Airway Management Rotation: Suggestions?

[VentdependenT]

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?

 

[Mman]

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.

 

[fval28]

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.

 

[dhb]

robinul

what for?

 

[Arch Guillotti]

what for?

to dry them out

 

[Planktonmd]

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?

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.

 

[Noyac]

Dude, see if you can get your hands on the glide-scope. Its pretty sweet.

 

[VentdependenT]

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.

 

[Planktonmd]

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.

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?

 

[VentdependenT]

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?

 

[cchoukal]

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.

 

[johankriek]

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.
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.

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..

 

[Gasboy07]

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.

 

[Mman]

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.

 

[supahfresh]

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

 

[VentdependenT]

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.

 

[dhb]

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.

Doesn't your attending like coffee?

 

[serenity]

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.

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

 

[serenity]

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.

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

 

[VentdependenT]

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?

 

[Planktonmd]

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?

I think every resident should be provided a free goat to improve their airway skills.