Airway Management Rotation: Suggestions?

Discussion in 'Anesthesiology' started by VentdependenT, Feb 28, 2007.

  1. VentdependenT

    VentdependenT You didnt build thaT
    Physician Moderator Emeritus 10+ Year Member

    Joined:
    Oct 3, 2003
    Messages:
    4,010
    Likes Received:
    19
    Status:
    Fellow [Any Field]
    I have an Airway rotation comming up. We stress Fiberoptic use but do you guys have any rec's on other techniques which I should become familiar with?

    Things which I will do:
    Oral Fiberoptic awake and asleep
    Fast-trach LMA
    Light Wand
    That shikani optical stylette gizmo

    Things I wanna do:
    Intubate through a standard LMA with small tube or with a bougie.
    Blind nasal's
    Nasal FOI's (risk of epistaxis will limit any/all elective nasal intubations I assume)
    Retrograde (muhahaha)
    Jet ventilate (maybe if I snag a cadaver...)


    Off the above subject, a question for you all:

    For the "awake fiberoptic," the point is its more difficult to cause serious harm to an awake spontaneously ventilating than an asleep patient (even one who is spontanously ventilating). Well, if we do the standard series of airway blocks: glossopharyngeal, recurrent laryngeal, and superior laryngeal, along with oral topicalization, and we keep the guy awake and he vomits what did we really do for him? How did all that prep work help?

    Now the guy is going to aspirate all that stuff through his "reflex-less" airway and it is now going to be an emergency intubation.

    When chosing fiberoptic how do YOU choose between awake n' numbed up, vs asleep n' paralyzed, vs taking a look while asleep and still ventilating, etc?
     
  2. Note: SDN Members do not see this ad.

  3. Mman

    Mman Senior Member
    10+ Year Member

    Joined:
    Mar 22, 2005
    Messages:
    4,042
    Likes Received:
    1,625
    Status:
    Attending Physician
    what would be the point of an asleep and paralyzed fiberoptic? I mean I've done them several times with attendings just for the sake of practicing with the fiberoptic so I've got some more skillz when I really need it awake.

    The only time I can see a reason to do asleep and paralyzed fiberoptic is if it's an unrecognized difficult airway and you've already pushed the paralytic and can't get the tube in via other means. I would certainly never plan it ahead of time, except for teaching purposes.

    The fast track is one of my favorites because of it's versatility, although I do like the shikani as well and think of it as a much smaller and more maneuvarable bullard.
     
  4. fval28

    fval28 Junior Member
    10+ Year Member

    Joined:
    Dec 1, 2005
    Messages:
    91
    Likes Received:
    0
    The "awake" FOI is (IMHO) a misnomer. I agree with you Vent- once you obliterate the reflexes you essentially have a unprotected airway and increased risk of aspiration. Where I think the AFOI is useful is in patients who may desat quickly (obese, COPD, etc) and keeping them as a self ventilating organism is in their best interests- until the tube is in. In this scenario, the option to back out,wake them up and regroup is a much shorter wait than if fully induced and paralyzed.

    I typicaly do my AFOI's with just some versed, robinul, fentanyl, topicalization (aerosolized 4% lido) and transtrach block (4 cc's 4% lido), oral airway, flowmeter at 10 L/m thru aspiration port, put the tube in. Most times after the tube is in the patient will reach up and scratch their nose (fentanyl) before breathing themselves off the sleep. The guys I learned this from are very slick with an FOI and use this as their primary means of dealing with a potentially difficult airway- I'm still on the steep end of the curve but they are definitely a nice way to manage a tenuous airway without setting any bridges ablaze.
     
  5. dhb

    dhb Member
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Jul 12, 2006
    Messages:
    3,500
    Likes Received:
    697
    Status:
    Attending Physician
    what for?
     
  6. Arch Guillotti

    Arch Guillotti Senior Member
    Administrator Physician Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Aug 8, 2001
    Messages:
    7,383
    Likes Received:
    1,046
    Status:
    Attending Physician

    to dry them out
     
  7. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Nov 2, 2006
    Messages:
    6,796
    Likes Received:
    1,752
    Status:
    Attending Physician
    Awake fiberoptic is not for a full stomach patient.
    An awake fiberoptic intubation is ideal for an anticipated difficult intubation with anticipated difficult mask ventilation.
    It also could be a good choice for an unstable neck where you need to document the neurological status after intubation and before induction.
    Now if you have a full stomach patient who you also think is going to be difficult to intubate, and you choose to do an awake fiber optic, you need to empty the stomach before you start.
    When it comes to which gadget to learn, you need to try as many as you can, and get yourself familiar with all of them, but you also need to choose a technique that you like most and become an expert in that technique, and in my opinion fiberoptic is still the gold standard.
     
  8. Noyac

    Noyac ASA Member
    SDN Advisor 10+ Year Member

    Joined:
    Jun 20, 2005
    Messages:
    7,509
    Likes Received:
    2,062
    Status:
    Attending Physician
    Dude, see if you can get your hands on the glide-scope. Its pretty sweet.
     
  9. VentdependenT

    VentdependenT You didnt build thaT
    Physician Moderator Emeritus 10+ Year Member

    Joined:
    Oct 3, 2003
    Messages:
    4,010
    Likes Received:
    19
    Status:
    Fellow [Any Field]
    We had the glide scope rep at Rush earlier this year. Missed him. Used it at Harborview and thought it was bad asss.

    PlanktonMD: As I understand it, even if you empty a patients stomach out with an NG that still doesn't mean they can puke up whatever is in their duodenum/small bowel/residual stomach junk.
     
  10. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Nov 2, 2006
    Messages:
    6,796
    Likes Received:
    1,752
    Status:
    Attending Physician
    That's true, you can never be a %100 sure, but if you have no choice: anticipated difficult intubation and difficult ventilation + full stomach, what else can you do?
     
  11. VentdependenT

    VentdependenT You didnt build thaT
    Physician Moderator Emeritus 10+ Year Member

    Joined:
    Oct 3, 2003
    Messages:
    4,010
    Likes Received:
    19
    Status:
    Fellow [Any Field]
    Plankton: true.

    Tried the asthetically challenged Fastrach Intubating LMA today (electively tried it). Not impressed. I couldn't get that tube to pass. Tried lifting the head off the table with the lever, couldn't pass the tube. Tried fidgiting, wiggling, wobbling, kaboblling, spraying, noodling, nada...

    I could ventilate with the lma though, which is what really counts in an emergency. I could've nabbed the fiberoptic and tried to intubate through the Fastrach with that but I was done messing around by then.

    Any tips on this device?
     
  12. cchoukal

    cchoukal Senior Member
    Moderator 10+ Year Member

    Joined:
    Jul 10, 2001
    Messages:
    2,009
    Likes Received:
    153
    Status:
    Attending Physician
    yeah, use the C-trach instead (with the fiberoptic LCD monitor). That way you can see where your tube is going and direct it toward the cords. I've never had great success with the plain iLMA, but the video iLMA (c-trach) is pretty great.
     
  13. johankriek

    johankriek Membership Revoked
    Removed 2+ Year Member

    Joined:
    Jul 19, 2006
    Messages:
    920
    Likes Received:
    1
    Status:
    Post Doc
    I never understood why people do asleep fiberoptics.. Defeats the purpose.

    The following statement speaks volumes. If you dont think you can intubate, DONT PUT THE PATIENT TO SLEEP.

    this does not mean if you dont think you can intubate, but you think you can ventilate its ok..
     
  14. Gasboy07

    2+ Year Member

    Joined:
    Jan 29, 2007
    Messages:
    61
    Likes Received:
    0
    Status:
    Resident [Any Field]
    The asleep patient tolerate the trainee much better!

    I think if someone has been documented as difficult to intubate but easy to ventilate it could be a reasonable approach... though I'd still do them awake or go for a regional.
     
  15. Mman

    Mman Senior Member
    10+ Year Member

    Joined:
    Mar 22, 2005
    Messages:
    4,042
    Likes Received:
    1,625
    Status:
    Attending Physician
    I've had times with the fast track where you need to grab the handle with your left hand and sort of use a levering action (down on the handle, up on the business end) which is counterintuitive to intubating somebody to get the tube to pass through the cords.

    The other thing I've had happen is that sometimes a different size will work better. For example, I had one lady with a big goiter and no chin to speak of. We knew she would be difficult but looked like she'd be decent to ventilate. Induced and started with a size 4 fastrack. We could ventilate like a charm with it, but the ETT ended up in the esophagus. Took it out and grabbed a size 3 which was a little harder to place and not quite as easy to ventilate through, but the ETT went in like a charm.

    Sometimes you just have to fiddle, but I do like the fact it can really aid ventilation and give you time to figure out how to get the tube in.
     
  16. supahfresh

    supahfresh un paradis du gangster
    10+ Year Member

    Joined:
    Dec 30, 2003
    Messages:
    462
    Likes Received:
    11
    Status:
    Attending Physician
    you really need to try a retrograde. they're dope

    also, check out the mcgrath 5. its phat and I like it better than the glidescope.

    http://www.lmana.com/mcgrath.php
     
  17. VentdependenT

    VentdependenT You didnt build thaT
    Physician Moderator Emeritus 10+ Year Member

    Joined:
    Oct 3, 2003
    Messages:
    4,010
    Likes Received:
    19
    Status:
    Fellow [Any Field]
    We dont have that thingy.

    Id like to try a retrograde but I don't think my attending is going to let me whip a 14gauge angio in my patients cricothyroid membrane and feed a central line guide wire up into their mouth/nose.
     
  18. dhb

    dhb Member
    Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Jul 12, 2006
    Messages:
    3,500
    Likes Received:
    697
    Status:
    Attending Physician
    Doesn't your attending like coffee? :D
     
  19. serenity

    serenity Senior Member
    5+ Year Member

    Joined:
    Jun 7, 2004
    Messages:
    132
    Likes Received:
    0
    We had an airway workshop recently, where we did retrograde intubations,cricothyrotomy and fibro-optic on goats,actually their airway anatomy was pretty close to humans.
    It was sad to see them desaturate while we were learning the techniques.
    It was a cool experience
     
  20. serenity

    serenity Senior Member
    5+ Year Member

    Joined:
    Jun 7, 2004
    Messages:
    132
    Likes Received:
    0
    We had an airway workshop recently, where we did retrograde intubations,cricothyrotomy and fibro-optic on goats,actually their airway anatomy was pretty close to humans.
    It was sad to see them desaturate while we were trying to intubate
    However it was a good learning experience
     
  21. VentdependenT

    VentdependenT You didnt build thaT
    Physician Moderator Emeritus 10+ Year Member

    Joined:
    Oct 3, 2003
    Messages:
    4,010
    Likes Received:
    19
    Status:
    Fellow [Any Field]
    How much does a goat cost and where can I get one. Or can I just tube the goat at the petting zoo?

    Do you think the kids will be upset when I break out the LMA and the fiberoptic scope right there on the cedar chips?
     
  22. Planktonmd

    Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Joined:
    Nov 2, 2006
    Messages:
    6,796
    Likes Received:
    1,752
    Status:
    Attending Physician
    I think every resident should be provided a free goat to improve their airway skills.
     

Share This Page