Difficult DL, need DLT

[Hork Bajir]

What do you all consider the best approach in patients who need a DLT, and have a grade 3/4 view upon DL? Assuming bronchial blocker isn’t an option (surgeon’s strong preference, need to flip back and forth between 2 lungs during OLTx, etc). I usually end up going single lumen —> tube exchanger (the long skinny one with a purple floppy end, vs one of the Cook airway exchange catheters). But, this isn’t always as easy as I’d hope. I’ve not had good luck at all with glidescope or CMAC - Usually get a good video view but not enough working space for the tube.

Any tricks up your sleeve? Always open to learning new things. Have heard McGrath is better for DLTs given the low profile, but don’t have them at my institution.

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[Hork Bajir]

Oops meant to post this in the main forum- @Arch Guillotti or @pgg mind moving it for me?

 

[Arch Guillotti]

Oops meant to post this in the main forum- @Arch Guillotti or @pgg mind moving it for me?

done

 

[Hoya11]

What do you all consider the best approach in patients who need a DLT, and have a grade 3/4 view upon DL? Assuming bronchial blocker isn’t an option (surgeon’s strong preference, need to flip back and forth between 2 lungs during OLTx, etc). I usually end up going single lumen —> tube exchanger (the long skinny one with a purple floppy end, vs one of the Cook airway exchange catheters). But, this isn’t always as easy as I’d hope. I’ve not had good luck at all with glidescope or CMAC - Usually get a good video view but not enough working space for the tube.

Any tricks up your sleeve? Always open to learning new things. Have heard McGrath is better for DLTs given the low profile, but don’t have them at my institution.

DLT placement is a true test of your laryngoscopy skills.

Try the Glidescope 4.

Form the tube so it looks like single lumen tube by molding the stylet to mimic the glidescope stylet (hockey stick).

Lube it well.

Push by any mild/moderate resistance when entering the trachea, sometimes it gets held up by a ring..

Don't choose a tube thats too big, I usually find a 37 left is my best fit

If you cant get in with DL or Glidescope 4, use the FOB you have in the room already for placement.

Put the scope down the bronchial lumen

On the Glidescope screen, use the FO scope with the DLT loaded to intubate the airway, then slide DLT in under Glidescope view.

 

[JiPo]

I know you said Bronchial blockers are not an option, but have you tried the EZ-Blocker? Just from my experience, I find these much better than regular bronchial blockers at isolating the lung, and it is much easier to use.

 

[vector2]

.

Put the scope down the bronchial lumen

On the Glidescope screen, use the FO scope with the DLT loaded to intubate the airway, then slide DLT in under Glidescope view.

This. Get an assistant to hold the best VL view possible and then slide the scope along the underside of the blade while watching VL screen until the tip of your scope appears. Once you get near/ under epiglottis then look at your scope screen and navigate through cords.

 

[ryanjmy]

 

[caligas]

Alternatively: place single lumen however, then double linen tube changer, then double lumen over changer WHILE VISUALIZING WITH GS.


....Or just use a blocker of choice.

 

[pgg]

Didn't know they had Glidescope stylets for DLTs.


I find any tube exchange over the Cook catheters, including SLT --> DLT, is much much easier if laryngoscopy is being done at the same time. Either DL or video.

I also use the smallest tube I think I can get away with. I see people choose 39s all the time for males and 37s for females and it usually just makes things unnecessarily harder.

 

[nimbus]

I’ve had pretty good luck putting an exaggerated bend on the preloaded DLT stylette and using the glidescope. Once I get the tube over the glottic opening, I have an assistant pull back the stylette while I simultaneously advance the tube with a counterclockwise corkscrew motion. The key is timing tube advancement and stylette withdrawal. You don’t want to let the DLT tip disengage from the glottic aperture.

 

[sethco]

That's great. I never knew these existed. Like @nimbus said, I usually just create my own bend with the DLT. A good solution that I use to use in residency was to place the DLT in a warm saline bottle for a couple minutes. This makes advancing a DLT over a tube exchanger past the cords easier. Haven't had to do this method in years though. For the rare difficult DL, I usually place a SLT via Glide and then keep the Glide in while I place a tube exchanger and then railroad the DLT. If I meet resistance, while maintaining visualization, I rotate 90 then 180 with a 37 FR. This almost always does the trick. For those very rare cases that it doesn't, I just use an SLT with a bronchial blocker and the surgeon needs to stop complaining

 

[ethilo]

I've intubated with a bougie then placed the DLT over the bougie blind on a difficult airway. It worked so well I almost didn't believe it. I know this isn't fancy but I'm definitely doing this as my difficult airway DLT strategy.

 

[abolt18]

We have these. They work great all of the 2 times I've used them. A little more bend than what is pictured. Also I found that it's more important that your helper knows how to remove this stylette (curling it out as opposed to just pulling straight up toward the ceiling) when you've got this massive, stiff DLT and its longer stylette.

 

[fakin' the funk]

What do you all consider the best approach in patients who need a DLT, and have a grade 3/4 view upon DL? Assuming bronchial blocker isn’t an option (surgeon’s strong preference, need to flip back and forth between 2 lungs during OLTx, etc). I usually end up going single lumen —> tube exchanger (the long skinny one with a purple floppy end, vs one of the Cook airway exchange catheters). But, this isn’t always as easy as I’d hope. I’ve not had good luck at all with glidescope or CMAC - Usually get a good video view but not enough working space for the tube.

Any tricks up your sleeve? Always open to learning new things. Have heard McGrath is better for DLTs given the low profile, but don’t have them at my institution.

Love the glide-fiber technique.

Load DLT on FOB, get glide view, then visualizing on the glide screen, use the FOB as a "steerable stylet" to get FOB into trachea. This can be really tricky - millimeters matter - so optimal sniff position and external laryngeal manipulation go a long way. Use some lube and twisting action to slip past the TVC.

 

[GassYous]

There's a fiberoptic scope that has a camera on the end which may be a viable option

 

[fakin' the funk]

There's a fiberoptic scope that has a camera on the end which may be a viable option

I would hope it has a camera

 

[caligas]

Another thing to think about: the DLT exchangers come in 2 sizes (11 and 14 Fr). The smaller is really too floppy but the bigger really needs lots of lube and probably a 41. 39 is tight. (Edited to correct sizes).

 

[Iso4ane]

Didn't know they had Glidescope stylets for DLTs.


I find any tube exchange over the Cook catheters, including SLT --> DLT, is much much easier if laryngoscopy is being done at the same time. Either DL or video.

I also use the smallest tube I think I can get away with. I see people choose 39s all the time for males and 37s for females and it usually just makes things unnecessarily harder.

However, too small increases youR risk of tube migration And over inflation of cuff (which makes the cuff no longer a low pressure cuff).

 

[Robotic Wis-Hipple]

All good tricks. The ones that I’m not sure I’ve found an answer for is the anterior combined with a small mouth/prominent incisors combo where even if you have a view with/without VL the issue is the inability to aim the end of the DLT anteriorly into the glottis before the tracheal cuff is grinding on front teeth. The warmed and pliable DLT with a FOB/exchange catheter as a guide may be the answer but I haven’t actually tried that, I just put in a blocker.

 

[Twiggidy]

All great responses above

Personally I think a 37 works for just about everyone. A key point is don't be afraid of resistance. I know we all don't tracheal injuries but I've seen and handful of otherwise excellent anesthesiologists look subpar just because they were afraid to use a little muscle and get the DLT in. Lube it real good and push it through.

Also, when I really anticipate difficulty I first just make sure I can secure an airway. Put in a single lumen tube and just take a pause and ventilate the patient. Ask your surgeon to be patient and go have a cup of coffee if needed while you and your friends (a second anesthesiologist) get the DLT placed. At this point if I have an airway secured I do everything else under direct visualization with either a glide or fiberoptic. I like to see the tube exchanger in the trachea and see the DLT go over the exchanger. Again, this is where the second anesthesiologist maintaining that good Glide view is helpful.

 

[vector2]

. Lube it real good and push it through.

Paging @SaltyDog to the room

 

[Twiggidy]

Paging @SaltyDog to the room

 

[drmwvr]

I've intubated with a bougie then placed the DLT over the bougie blind on a difficult airway. It worked so well I almost didn't believe it. I know this isn't fancy but I'm definitely doing this as my difficult airway DLT strategy.

Simple, quick and can be done with conventional DL without a lot of drama.

 

[GassYous]

I would hope it has a camera

Haha I meant the dlt has a built in camera near the end. VivaSight-DL

 

[Shimmy8]

Lot of good comments above. Have had this multiple times, and the glide/FOB combo is the best that we have. We've got the long floppy exchange catheters and I agree; just feel like they don't work well, often gets caught on the base of the cords/arytenoids.

With that said, I was working extra at another facility that has Mcgrath...saw this just this past week and it went awesome! Much lower profile and more room for the DLT. I was shocked. Going to push for these at my practice.

 

[ProwlerturnGas]

The updated McGrath VL is the bomb!

 

[GassYous]

We have a bunch of mcgraths which makes tubing very easy but I worry about my laryngoscopy skills.

 

[dchz]

A good solution that I use to use in residency was to place the DLT in a warm saline bottle for a couple minutes. This makes advancing a DLT over a tube exchanger past the cords easier.

I was about to post this too. I feel like we don't take advantage of this enough because of how much time it takes, but it's also much less traumatic if you have to go through bougie method.

 

[Ezekiel2517]

Lots of useful tips here. I'll probably try some of them. For a difficult airway, I typically would just do a glide and, when the DLT is just past the cords, place the FOB in the bronchial lumen.

 

[Ezekiel2517]

That's great. I never knew these existed. Like @nimbus said, I usually just create my own bend with the DLT. A good solution that I use to use in residency was to place the DLT in a warm saline bottle for a couple minutes. This makes advancing a DLT over a tube exchanger past the cords easier.

Whenever I hear about the warm saline, I'm reminded of the story my attendings used to tell me in residency. There was a case where a resident warmed the ETT in preparation for an intubation, may have been a nasal intubation. Not uncommon. Easy intubation, grade 1 view. After intubating, found that they were completely unable to ventilate. Checked to make sure the tube wasn't misplaced. Performed DL again, same grade 1 view with the ETT going right thru the cords. Still can't ventilate. Severe bronchospasm perhaps? Nothing they tried worked. Patient arrested, died. Long story short, the warm tube had folded upon itself past the cords. They never thought to take it out.

 

[MirrorTodd]

Whenever I hear about the warm saline, I'm reminded of the story my attendings used to tell me in residency. There was a case where a resident warmed the ETT in preparation for an intubation, may have been a nasal intubation. Not uncommon. Easy intubation, grade 1 view. After intubating, found that they were completely unable to ventilate. Checked to make sure the tube wasn't misplaced. Performed DL again, same grade 1 view with the ETT going right thru the cords. Still can't ventilate. Severe bronchospasm perhaps? Nothing they tried worked. Patient arrested, died. Long story short, the warm tube had folded upon itself past the cords. They never thought to take it out.

That sounds like one of those urban legend stories. But damn that sucks.

 

[Arch Guillotti]

Whenever I hear about the warm saline, I'm reminded of the story my attendings used to tell me in residency. There was a case where a resident warmed the ETT in preparation for an intubation, may have been a nasal intubation. Not uncommon. Easy intubation, grade 1 view. After intubating, found that they were completely unable to ventilate. Checked to make sure the tube wasn't misplaced. Performed DL again, same grade 1 view with the ETT going right thru the cords. Still can't ventilate. Severe bronchospasm perhaps? Nothing they tried worked. Patient arrested, died. Long story short, the warm tube had folded upon itself past the cords. They never thought to take it out.

Scary anecdote. Inability to ventilate can only be a handful of things and if it ever happens you better be able to run through the differential pretty damn quickly.

 

[vector2]

Here are the specs for Cook airway exchange catheters.

Many institutions might only have an 11 fr which is still pretty floppy and doesn’t occlude much of the glottic opening which makes railroading a tube that much more difficult. If you can use a 14 fr. Also, the 19 for might only fit the bronchial lumen of a 41 fr DLT, and only in a couple manufacturers.

 

[vector2]

Scary anecdote. Inability to ventilate can only be a handful of things and if it ever happens you better be able to run through the differential pretty damn quickly.

Ya done messed up if running a suction catheter down the tube to assess patency and suck out potential mucous plugs isn’t one of the first things done after empiric bronchospasm treatment fails.

 

[Arch Guillotti]

When the bag feels like a brick your options are limited. Severe bronchospasm, obstruction, pneumo, displacement should all be considered.

 

[Twiggidy]

Ya done messed up if running a suction catheter down the tube to assess patency and suck out potential mucous plugs isn’t one of the first things done after empiric bronchospasm treatment fails.

I would also add that if this situation occurs, if someone isn't throwing betadine on the neck and grabbing a scalpel they're going to have some explaining to do.

Ventilate by any means necessary

 

[pgg]

I would also add that if this situation occurs, if someone isn't throwing betadine on the neck and grabbing a scalpel they're going to have some explaining to do.

Ventilate by any means necessary

I don't think I'd make the call to cut the neck if I could see a tube through the vocal cords on DL or VL. Folded tube? That's wacky. But like vector says, you should clue in to something being wrong when you attempt suction and hit a wall. Obstruction is high on the differential.

 

[Twiggidy]

I don't think I'd make the call to cut the neck if I could see a tube through the vocal cords on DL or VL. Folded tube? That's wacky. But like vector says, you should clue in to something being wrong when you attempt suction and hit a wall. Obstruction is high on the differential.

In a “Can’t Ventilate” situation it should at least cross your mind

 

[pgg]

In a “Can’t Ventilate” situation it should at least cross your mind

I'm just saying it would cross my mind and be ruled out after confirming the tube is in the trachea.

 

[Twiggidy]

I'm just saying it would cross my mind and be ruled out after confirming the tube is in the trachea.

But that's just the issue, right? Tube is in the trachea and you're still not ventilating. You look on video and see tube going through cords and you've done all the medicinal routes possible and you're still not ventilating........meanwhile the O2 sat and 32% and the code is starting. This is just basic airway algorithm. The oral examiner just keeps saying, "Okay but you're not ventilating. Now what do you do?"

I guess what I'm getting at is I'd rather explain to the patient who has a trach that the tube curled in his airway instead of explaining to his widow that the tube curled in the airway.

 

[nimbus]

Whenever I hear about the warm saline, I'm reminded of the story my attendings used to tell me in residency. There was a case where a resident warmed the ETT in preparation for an intubation, may have been a nasal intubation. Not uncommon. Easy intubation, grade 1 view. After intubating, found that they were completely unable to ventilate. Checked to make sure the tube wasn't misplaced. Performed DL again, same grade 1 view with the ETT going right thru the cords. Still can't ventilate. Severe bronchospasm perhaps? Nothing they tried worked. Patient arrested, died. Long story short, the warm tube had folded upon itself past the cords. They never thought to take it out.

Never heard of it. Not sure I would even have considered that diagnosis. Glad I read it here to add to my differential. That case should have been written up.

 

[Ezekiel2517]

Scary anecdote. Inability to ventilate can only be a handful of things and if it ever happens you better be able to run through the differential pretty damn quickly.

Agree. I mean, the reason algorithms (like ACLS) exist is bc they know people aren't great at thinking critically in those situations. Everyone knows the difficult airway algorithm but there isn't really a clear cut algorithm everyone reflexively recalls for inability to ventilate after intubation. Not uncommon for ppl to get flustered. I remember a case from residency I had of severe bronchospasm right after intubation. Couldn't ventilate at all. The attending I was with was experienced, smart/skilled, and trained at one of the best programs in the country. Yet it completely caught him off guard. Despite me telling him it was an easy intubation and a grade 1 view, he obviously assumed I screwed something up so he pulled the tube, did a DL, and intubated himself. Still nothing. And I'm not kidding when I say this, he was in such disbelief he literally pulled the tube and reintubated the patient 3 more times after that. Still nothing. It was only after I told him that, given the history and context, I thought this was severe bronchospasm, did it register in his brain. Luckily, epi and mask ventilation finally allowed us to escape. I just remember him and his scrubs being completely drenched in sweat lol.

 

[abolt18]

Agree. I mean, the reason algorithms (like ACLS) exist is bc they know people aren't great at thinking critically in those situations. Everyone knows the difficult airway algorithm but there isn't really a clear cut algorithm everyone reflexively recalls for inability to ventilate after intubation. Not uncommon for ppl to get flustered. I remember a case from residency I had of severe bronchospasm right after intubation. Couldn't ventilate at all. The attending I was with was experienced, smart/skilled, and trained at one of the best programs in the country. Yet it completely caught him off guard. Despite me telling him it was an easy intubation and a grade 1 view, he obviously assumed I screwed something up so he pulled the tube, did a DL, and intubated himself. Still nothing. And I'm not kidding when I say this, he was in such disbelief he literally pulled the tube and reintubated the patient 3 more times after that. Still nothing. It was only after I told him that, given the history and context, I thought this was severe bronchospasm, did it register in his brain. Luckily, epi and mask ventilation finally allowed us to escape. I just remember him and his scrubs being completely drenched in sweat lol.

If someone else put the tube in and I could not ventilate at all, you can bet I would pull that tube and reintubated... Once.

 

[coffeebythelake]

If someone else put the tube in and I could not ventilate at all, you can bet I would pull that tube and reintubated... Once.

Agree. I would do it myself to see with my own eyes that it passed the cords.
However it begs the question -- what kind of routine intubation scenario other than severe bronchospasm would exist where you have massive airway resistance? bagging the esophagus shouldn't feel that way.

 

[DrN2O]

If for lung transplant, SLT->ECMO->whatever you want. The OP asked about difficult intubation. If you had trouble getting the SLT in, the DLT is going to be harder. Surgeon preference for DLT is not an acceptable indication in a true difficult airway. Get your airway and ventilate first.

The problem I see most people have is not getting the tip to the cords, but be able to advance the tube after the stylet is pulled back, or even with the double lumen tube exchanger in place. The direction of the your force is making the tube bend, so the tip actually points more anterior. You need to stop pushing down. The key is rotate the DLT axially, and it will naturally go down the hole after 180-360 degrees. Fiber after.

 

[drmwvr]

Nothing they tried worked. Patient arrested, died. Long story short, the warm tube had folded upon itself past the cords. They never thought to take it out.

I wouldn't consider that a warm tube...that's a melted tube...makes me wonder how they were "warming" the tube if the story is as advertised. As much as a cautionary tale for obstructed airway dx as after market alterations in tubes...

 

[Ezekiel2517]

I wouldn't consider that a warm tube...that's a melted tube...makes me wonder how they were "warming" the tube if the story is as advertised. As much as a cautionary tale for obstructed airway dx as after market alterations in tubes...

I was told the ETT was warmed by placing it in one of the typical bottles of warm saline found in the OR's, as is commonly done. They can become quite pliable.

 

[drmwvr]

I was told the ETT was warmed by placing it in one of the typical bottles of warm saline found in the OR's, as is commonly done. They can become quite pliable.

Right...there's warm saline and then there's warm saline that's too hot. Just seems so odd...whatever...carry on...

 

[Ezekiel2517]

Right...there's warm saline and then there's warm saline that's too hot. Just seems so odd...whatever...carry on...

Right...and since I trained at the same institution where this took place and have also used the warm saline "trick" multiple times during my training, I am familiar with the temperature of the warmers and the warm saline bottles in the ORs.

 

[Arch Guillotti]

Agree. I would do it myself to see with my own eyes that it passed the cords.
However it begs the question -- what kind of routine intubation scenario other than severe bronchospasm would exist where you have massive airway resistance? bagging the esophagus shouldn't feel that way.

Kink in tube or massive airway booger. Some type of obstruction.

Tension pneumo will also cause incredible obstruction but is incredibly unlikely in this scenario.