Fiberoptic vs. DL

[toughlife]

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ok so i've had a couple of morbidly obese patients in the 300-400lbs range which required intubation for respiratory distress.

The question I have is, when do you decide to go DL vs awake fiberoptic. I know with morbidly obese patients ability to ventilate is always a concern but do you automatically jump to AFO without even considering DL, NPO status notwithstanding?

In the first patient, 350lb female, I was in my ER rotation at another hospital, the ER attending knew I was an anesthesia intern and asked, "do you think you can intubate this patient"? I took a look and noticed she was MP 3, TMD was 2finger breaths and I said, "I can give it a try'. So etomidate was pushed and I asked the RT for a MAC 4, suction and a little cricoid pressure and voila! I was in without any trouble. ER attending was impressed 😀

Second instance, have another obese patient, 380lbs male, in the CCU and we called the PACU resident to intubate patient. When he and attending showed up, they went straight for AFOI without even considering DL.

I have to admit I was pushing my luck with the first patient and given my intern status and inexperience with airways, I should have suggested they call the anesthesia resident on call.

However, I want to know if the residents and attendings here automatically go for the gusto without giving DL a try.

 

[jwk]

ok so i've had a couple of morbidly obese patients in the 300-400lbs range which required intubation for respiratory distress.

The question I have is, when do you decide to go DL vs awake fiberoptic. I know with morbidly obese patients ability to ventilate is always a concern but do you automatically jump to AFO without even considering DL, NPO status notwithstanding?

In the first patient, 350lb female, I was in my ER rotation at another hospital, the ER attending knew I was an anesthesia intern and asked, "do you think you can intubate this patient"? I took a look and noticed she was MP 3, TMD was 2finger breaths and I said, "I can give it a try'. So etomidate was pushed and I asked the RT for a MAC 4, suction and a little cricoid pressure and voila! I was in without any trouble. ER attending was impressed 😀

Second instance, have another obese patient, 380lbs male, in the CCU and we called the PACU resident to intubate patient. When he and attending showed up, they went straight for AFOI without even considering DL.

I have to admit I was pushing my luck with the first patient and given my intern status and inexperience with airways, I should have suggested they call the anesthesia resident on call.

However, I want to know if the residents and attendings here automatically for the gusto without giving DL a try.

We have a large population of gastric bypass and gastric bypass eligible patients. We rarely go the fiberoptic route. We'll often opt for the GlideScope as opposed to regular DL.

Some are really sold on "the wedge" position, but I really can't tell that it helps much, plus it's hard to to in an emergency situation.

 

[militarymd]

Gestalt....gained from experience.

and DL doesn't mean it can't be Awake.

 

[Intubate]

just cause they're fat, doesnt mean they're a difficult airway. they may be an aspiration risk and difficult to ventilate with a mask, but unless there are other red flags (no chin, MP3-4, etc), they can probably be intubated ok. positioning is key though...

 

[Planktonmd]

2 mg Versed, topical anesthesia, open your mouth sir, direct laryngoscopy, tell them to take a deep breath while you slide the tube in.
If they are crashing skip the Versed.
If they are unconscious skip the Versed and the topical.

 

[rmh149]

just cause they're fat, doesnt mean they're a difficult airway. they may be an aspiration risk and difficult to ventilate with a mask, but unless there are other red flags (no chin, MP3-4, etc), they can probably be intubated ok. positioning is key though...

Im with Intubate. I would venture to say most of the difficult intubations were on patients with less than BMI 35.

I dont think the MP assessement helps at all...I dont even look.

 

[Planktonmd]

Im with Intubate. I would venture to say most of the difficult intubations were on patients with less than BMI 35.

I dont think the MP assessement helps at all...I dont even look.

You don't examine the airway???
You must be really brave, I wish I had such confidence.

 

[urgewrx]

I had an attending tell me "Morbidly obese pt are easy airways because they have to breathe while eating since they are eating all the time."

Moral of the story : to be morbidly obese you have to have a good airway.


DL here

​

 

[rmh149]

You don't examine the airway???
You must be really brave, I wish I had such confidence.

Well, I'm sorry you are not as confident. 🙂

Of course I examine the airway...I just could care less if the uvula is visible or not. The mallampati score has not proven to me to be an effective predictor of a difficult airway. I have had MPIII's that were easy, and MPI's that I couldnt intubate without the trusty eschemann introducer.

Things I look at:
teeth, specifically the upper
Mandibular Jaw position when their mouth is closed (underbite)
How wide they can open their mouth
Thyromental distance
Neck, ROM, length and thickness.
Any congenital defects that may compromise the airway (pierre-robin, downs's, etc.)
Lastly, any burns, hematomas, tumors, stenosis, etc.

Did I miss anything?

 

[urgewrx]

Well, I'm sorry you are not as confident. 🙂

I just could care less if the uvula is visible or not. The mallampati score has not proven to me to be an effective predictor of a difficult airway. I have had MPIII's that were easy, and MPI's that I couldnt intubate without the trusty eschemann introducer.

It's the Mallampati 4 you have to worry about. The other stuff you talk about you can probably see from 10 feet away.

 

[Planktonmd]

Well, I'm sorry you are not as confident. 🙂

Of course I examine the airway...I just could care less if the uvula is visible or not. The mallampati score has not proven to me to be an effective predictor of a difficult airway. I have had MPIII's that were easy, and MPI's that I couldnt intubate without the trusty eschemann introducer.

Things I look at:
teeth, specifically the upper
Mandibular Jaw position when their mouth is closed (underbite)
How wide they can open their mouth
Thyromental distance
Neck, ROM, length and thickness.
Any congenital defects that may compromise the airway (pierre-robin, downs's, etc.)
Lastly, any burns, hematomas, tumors, stenosis, etc.

Did I miss anything?

MP classification is the single most reliable predictor of difficult intubation from all the things you have mentioned.
Your confidence, sir, is obviously well founded.
😉

 

[rmh149]

Maybe thats what the literature says. I have lost confidence in the score. I may look in someone I am really worried about....but 95% of the time I dont.

 

[epidural man]

MP classification is the single most reliable predictor of difficult intubation from all the things you have mentioned.
Your confidence, sir, is obviously well founded.
😉

No, I don't think it is. Could you site your source? Actually, there are very many publications that have tried to answer this, and in fact - can't.

I was at another hospital and was asking one of the staff what drugs and techniques they use for awake fibers. He replied "awake fibers? We never do that any more since we have the glide scope."

I have used the glide scope once and was very impressed - but it was on an easy airway to start. The glide scope - as that gentlemen had indicated to me, may be the answer.

However, to answer toughlife's original question - I don't think an awake fiber is ever the wrong answer - and it is fun to do.

 

[epidural man]

1

 

[rmh149]

I have used the glide scope once and was very impressed - but it was on an easy airway to start. The glide scope - as that gentlemen had indicated to me, may be the answer.

I have used the glidescope on a patient in the ER that the ER docs were having trouble intubating. The glidescope was new and I have never used it...but I grabbed it anyway...in case my trusy eschemann didnt work.

When I got there I pulled out the glidescope and it made the intubation look extreamily easy...as it was.

Obviously, minimal learning curve.

I still used the eschemann as well to make it look more difficult than it really was.....just so everyone would think I'm cool. 😉

 

[Planktonmd]

No, I don't think it is. Could you site your source? Actually, there are very many publications that have tried to answer this, and in fact - can't.

I was at another hospital and was asking one of the staff what drugs and techniques they use for awake fibers. He replied "awake fibers? We never do that any more since we have the glide scope."

I have used the glide scope once and was very impressed - but it was on an easy airway to start. The glide scope - as that gentlemen had indicated to me, may be the answer.

However, to answer toughlife's original question - I don't think an awake fiber is ever the wrong answer - and it is fun to do.

Yes, it is!

Among the tools you have to evaluate the airway the 2 most reliable are:
1- MP classification.
2- Thyromental distance.
And you get the best results combining both.
MP classification becomes more specific when it shows MP class 4.
None of these tools is perfect but they are all you have, and you need to use them.
It's extremely reckless and arrogant for a mid-level who claims to be safe enough to practice independently, to say that he doesn't feel he needs to properly evaluate the airway or assess MP classification.
Now, Data about these evaluation tools is variable, but it seems the one most studied airway evaluation is Malampatti classification.
So, since you are a resident, why don't you tell us what data is out there?
I suggest that you start with your text books.

 

[toughlife]

Yes, it is!

Among the tools you have to evaluate the airway the 2 most reliable are:
1- MP classification.
2- Thyromental distance.
And you get the best results combining both.
MP classification becomes more specific when it shows MP class 4.
None of these tools is perfect but they are all you have, and you need to use them.
It's extremely reckless and arrogant for a mid-level who claims to be safe enough to practice independently, to say that he doesn't feel he needs to properly evaluate the airway or assess MP classification.
Now, Data about these evaluation tools is variable, but it seems the one most studied airway evaluation is Malampatti classification.
So, since you are a resident, why don't you tell us what data is out there?
I suggest that you start with your text books.

Plankton, regarding the above claim, if you consider the source, then you know you can't have high expectations.

 

[epidural man]

It's extremely reckless and arrogant for a mid-level who claims to be safe enough to practice independently, to say that he doesn't feel he needs to properly evaluate the airway or assess MP classification.

I certainly agree with this.

So, since you are a resident, why don't you tell us what data is out there?
I suggest that you start with your text books.

Excellent Idea!
I will start with the textbooks and then move to the literature.

Miller 6th ed – "An increase in Mallampati score may occur during pregnancy and correlates with slightly higher rate of difficult laryngoscopy in this population." He says nothing more on the subject so this textbook is useless to answer the question about using the tongue size in predicting a difficult airway.

Barash 5th ed – …referring to the different parts of the airway exam "no individual measure proved both sensitive and specific." Later in the paragraph (pg 597), the book says that MP IV had a positive predictive value of 4 % when used alone.

Now to the literature….

Wilson ME: Predicting difficult intubation. Br J Anaesth 1993 – He says that no preoperative test has adequate sensitivity to identifiy most cases without substantial false positives.

Savva D: (1994) Prediction of difficult tracheal intubation. Br J Anaesth. – MP IV had a Sensitivity of 53%.

Wong SHS: (1999) Prevalence and prediction of difficult intubation in Chinese women. Anaesth Intensive Care – MP IV had sensitivity - 29%, Specificity - 98%.

Briefly some others (Positive predictive value of MP listed)
Arne (1998) – 19%, Oates (1991) – 4%, Butler and Dhara (1992) – 21%, Frerk (1991) – 17%, Voyagis (1998) – 37%, Brodesky (2002) – 8%, Juvin (2003) – 29%, Khan (2003) – 13%, Iohom (2003) – 27%, Yamamoto (1997) – 2.2%, El-Ganzouri (1996) – 4.4% (this trial had over 10,000 patients).

As far as it being the single best predictor, I guess you could be right. I always thought neck circumfrence, or ability to prognath was beter. I was just hoping that you had a reference since I have always wondered about this. You chided me as if I were challenging you.

1- MP classification.

2- Thyromental distance.
And you get the best results combining both.[

/quote]

There are many studies that agree with this.

 

[rmh149]

Thank you Epidural man for putting in the time to gather the information that shows that the MP score really isnt all that valuable.

You can call me arrogant Plankton...but I have done enough intubations to know what is a difficult or simple intubation. I am sometimes surprised...but I have yet to miss. Is that arrogant? Maybe.... but I dont put much value in a 4-20% prediction value when it comes to making clinical decisions.

You can if you want.

 

[Planktonmd]

Epiduralman,

Thank you for the data, as you see the MP score continues to be the most prevalent, the most studied, and the most widely used measure.
As I said previously, none of these tools is perfect, but they are important elements in airway evaluation, and until we have something better they are all we have.

 

[Planktonmd]

Thank you Epidural man for putting in the time to gather the information that shows that the MP score really isnt all that valuable.

You can call me arrogant Plankton...but I have done enough intubations to know what is a difficult or simple intubation. I am sometimes surprised...but I have yet to miss. Is that arrogant? Maybe.... but I dont put much value in a 4-20% prediction value when it comes to making clinical decisions.

You can if you want.

I did not call you arrogant, I called you arrogant and reckless.
You said that you did not check the MP score which is similar to your statement about not worrying about MH in a patient with an unknown intra-op complication.
So I think you are arrogant, reckless and dangerous.

 

[rmh149]

I did not call you arrogant, I called you arrogant and reckless.
You said that you did not check the MP score which is similar to your statement about not worrying about MH in a patient with an unknown intra-op complication.
So I think you are arrogant, reckless and dangerous.

You are a closed minded individual. You can put value in whatever airway assessement you want. MP is #1 for you....good for you. I on the other hand dont put much stock into it. I prefer to look at more than just where the uvula is. Read my post.

You have your proper exam and I have mine. I can easily say you are being reckless if you only depend on the MP score.

 

[Planktonmd]

You are a closed minded individual. You can put value in whatever airway assessement you want. MP is #1 for you....good for you. I on the other hand dont put much stock into it. I prefer to look at more than just where the uvula is. Read my post.

You have your proper exam and I have mine. I can easily say you are being reckless if you only depend on the MP score.

You are just arguing for the sake of argument, I did not say you should only depend on MP classification, but it has to be part of the airway assessment.
I know I am wasting my time talking to you, but your ignorance is sometimes irritating.
Anyway, I am done with you.

 

[rmh149]

Sorry. Its the argumentative side of me. This morning I had a healthy 32 y/o female, 65kg. for DX laparoscopy. Even though it was plainly obvious her airway was going to be easy, I checked her MP classification anyway, and thought of you. I couldnt help it. 😉

 

[Gern Blansten]

Since I have read rmh's posts in the pain forums, I am done with him. He epitomizes all that we despise. Yet, he does not know what the triggers for MH are. Even non anesthesia providers at my hospital know what the triggers are. I certainly wish that he would stop posting a response to every clinical discussion as if he thinks anyone here cares to hear his opinion. For those newcomers to the forum, I am sorry to come across as harsh, but his act is tiresome. The arrogance is appalling.

 

[dhb]

his act is tiresome.

the data speaks for itself: 285 post in 2 months... 🙄

 

[rmh149]

the data speaks for itself: 285 post in 2 months... 🙄

Wow....didnt realize. You have a good point. I will chill for a while.

 

[epidural man]

Plankton, regarding the above claim, if you consider the source, then you know you can't have high expectations.

Meany!

 

[VentdependenT]

If youre a fatty and don't have an exceptional airway I'm bringing a scope in the room. Big friggen deal if you gotta use it.

Just make sure you have a decent assistant for the fiberoptic who can hoist that big phat tongue up and out and give a lil' bit o' jaw thrust at the same time.

All that big soft juicy pharyngeal tissue just loves to collapse when the propofol hits it. There goes yer stellar airway.

 

[toughlife]

Meany!

Are you a dude or a chick? Cuz calling me meanie, if you are a dude, is starting to make me wonder.

 

[BLADEMDA]

Whatever your opinion on this subject is today for those with less than 5 years of real world experience that opinion is likely to change dramatically.

In other words, Mil MD is giving you the right answer. After years in the trenches you develop almost a sense for the tough intubation cases. The FAT guy or girl is not the one that suprises you. For those you evaluate, take a careful history and prepare a good back-up plan.

It is the "normal" looking airway that will suprise you and catch you unprepared. That is when "cool as a cucumber" becomes paramount.
The difficult to ventilate/ difficult to intubate patient will make even the most seasoned provider sweat a little.

As for DL vs. fiberoptic I can tell you that one is completely over-kill most of the time. As a Resident use this over-kill to gain experience in various blocks/techniques for awake tube placement.

In my practice of over 20,000 cases per year we average less than 20 awake intubations per year. This is in a practice that does Trauma (busy), Neuro (very busy) and Bariatric surgery. In academia the fiberoptic is used much more frequently probably for "teaching purposes." Again, master the fiberoptic scope and learn ONE TECHNIQUE well because you will need it.

The invention of Intubating LMA's, light wands, Regular LMA's, Bullard type scopes and now the Glidescope has made the truly awake intubation "rare" in my practice. A nice development over the years.

Blade

 

[CremeSickle]

I believe that is false.

Show me the reference for that?

The most reliable are inter-incisor gap and mandible luxation; thyromental distance; head and neck movement and past hx of difficult intubation. MP scores have proven over and over again to be the LEAST predictive of anything with the exception of grade 4.

1: Anesth. Analg. 2006 Jun;102(6):1867-78.

A systematic review (meta-analysis) of the accuracy of the Mallampati tests to
predict the difficult airway.

Lee A, Fan LT, Gin T, Karmakar MK, Ngan Kee WD.

Department of Anaesthesia and Intensive Care, The Chinese University of Hong
Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong. [email protected]

The original and modified Mallampati tests are commonly used to predict the
difficult airway, but there is controversy regarding their accuracy. We searched
MEDLINE and other databases for prospective studies of patients undergoing
general anesthesia in which the results of a preoperative Mallampati test were
compared with the subsequent rate of difficult airway (difficult laryngoscopy,
difficult intubation, or difficult ventilation as reference tests). Forty-two
studies enrolling 34,513 patients were included. The definitions of the reference
tests varied widely. For predicting difficult laryngoscopy, both versions of the
Mallampati test had good accuracy (area under the summary receiver operating
characteristic (sROC) curve = 0.89 +/- 0.05 and 0.78 +/- 0.05, respectively). For
predicting difficult intubation, the modified Mallampati test had good accuracy
(area under the sROC curve = 0.83 +/- 0.03) whereas the original Mallampati test
was poor (area under the sROC curve = 0.58 +/- 0.12). The Mallampati tests were
poor at identifying difficult mask ventilation. Publication bias was not
detected. Used alone, the Mallampati tests have limited accuracy for predicting
the difficult airway and thus are not useful screening tests.

MP classification is the single most reliable predictor of difficult intubation from all the things you have mentioned.
Your confidence, sir, is obviously well founded.
😉

 

[BLADEMDA]

Thats absolutely false.

Show me the reference for that?

The most reliable are inter-incisor gap and mandible luxation; thyromental distance; head and neck movement and past hx of difficult intubation. MP scores have proven over and over again to be the LEAST predictive of anything with the exception of grade 4.

Read that study and many others. Please be respectful to Plankton.

Blade

 

[CremeSickle]

I did not intend to come off as disrespectful, but ive been taught by all of my attendings that the MP is about as good as guessing. In my experience (as limitied as it may be) that seems to be quite true. While MP may be the most studied, it seems to have become entrenched for little reason.

I think plankton probably uses multiple tools to assess airway like we all do. I think tho that the MP is the least predictive of them and thats born out in the current literature.

 

[epidural man]

Are you a dude or a chick? Cuz calling me meanie, if you are a dude, is starting to make me wonder.

I'm a dude, but very sensitive.

 

[Planktonmd]

I did not intend to come off as disrespectful, but ive been taught by all of my attendings that the MP is about as good as guessing. In my experience (as limitied as it may be) that seems to be quite true. While MP may be the most studied, it seems to have become entrenched for little reason.

I think plankton probably uses multiple tools to assess airway like we all do. I think tho that the MP is the least predictive of them and thats born out in the current literature.

As I said previously on this thread, you use "all" the tools you have hoping you will be able to predict a difficult Intubation or difficult ventilation.
MP classification remains the most recognized and most studied, all the other predictors have not been studied or scrutinized enough, and when it's MP4 you have to think about your plan B and plan C before pushing that induction drug.

 

[CremeSickle]

Ah

We are on the same page 😉

As I said previously on this thread, you use "all" the tools you have hoping you will be able to predict a difficult Intubation or difficult ventilation.
MP classification remains the most recognized and most studied, all the other predictors have not been studied or scrutinized enough, and when it's MP4 you have to think about your plan B and plan C before pushing that induction drug.

 

[VentdependenT]

We do a gazillion awake FOI's here. So we get good at em, at least I think so. Sure, sometimes it may seem like overkill, but it doesn't take too much longer than a non rsi intubation, and if done right the HR and BP dont even budge.

We get purty darn good at the scope too, We had an attending here who was mr fiberoptic and mr lma. Scope can be quite useful at times.

Your LMA and the ol' bougie can bail your ass outta almost any situation except for a subglottic disaster.

I would like to have a GlideScope here or a C-Trach. Never used, let alone seen a bullard in real life. Be nice to get my hands on that bad boy.

We have a light wand but I havent used it.

We also have that Sheckani (spelling) optical wand. That thing is solid man.


Alas, I am just young grasshoppa though.

 

[jetproppilot]

but it doesn't take too much longer than a non rsi intubation
.

HAHAHAHAHAHAHAHAHAHAHA

Where ya been buyin' your con-bud thats makin' you delusional, Venty??

Seriously.

Youre talkin' about night and day as far as time is concerned.

 

[thegasman]

HAHAHAHAHAHAHAHAHAHAHA

Where ya been buyin' your con-bud thats makin' you delusional, Venty??

Seriously.

Youre talkin' about night and day as far as time is concerned.

I agree with vent on awake foi, I can usually get the tube in pretty darn quick. Even faster in the patient with asleep foi. If I think airway might be a little tough or I dont want to crank on the neck too much but pt looks ez to mask ( like say a healthy acdf with neck pain or tingling in hands with neck movement), sometimes we put em to sleep, give em a few breaths, and slip the tube in with the scope - maybe takes 15-30 extra seconds if that😱. It is nice to have an intubating lma around too. If the airway looks truly difficult awake is the way to go - put I agree this is rarely necessary.

 

[The_Sensei]

We do a gazillion awake FOI's here. So we get good at em, at least I think so. Sure, sometimes it may seem like overkill, but it doesn't take too much longer than a non rsi intubation, and if done right the HR and BP dont even budge.

We get purty darn good at the scope too, We had an attending here who was mr fiberoptic and mr lma. Scope can be quite useful at times.

Your LMA and the ol' bougie can bail your ass outta almost any situation except for a subglottic disaster.

I would like to have a GlideScope here or a C-Trach. Never used, let alone seen a bullard in real life. Be nice to get my hands on that bad boy.

We have a light wand but I havent used it.

We also have that Sheckani (spelling) optical wand. That thing is solid man.


Alas, I am just young grasshoppa though.

Peter Murphy........fantastic endoscopist. Has he showed you his 2 finger intubation technique yet? Since I have become facile with the Glidescope, I do about 3 awake FOIs a year, now.

 

[dhb]

Since I have become facile with the Glidescope, I do about 3 awake FOIs a year, now.

Do you really like the glidescope?
We tested it for a week, the first day everyone wanted to have a shot at it then it stayed in a corner for the rest of the week.
I didn't like the plastic blade plus i don't see the point in having a screen showing you what your naked eye can see except if the patient has a small mouth.
If you have a McCormack 3-4 how are you going to see cords with the glidescope if you don't see then with DL?

 

[urgewrx]

Do you really like the glidescope?
i don't see the point in having a screen showing you what your naked eye can see except if the patient has a small mouth.

Disagree. The angle from the camera and yours is very different. Camera is lloking up, you are looking down. Comes handy for grade3-4 views.
Keep playing with it.

 

[VentdependenT]

Yo jet I'm serious. I start numbing the hell out of em in the holding area. S&%t I can get the nurse to start spraying benzocaine or 4% atomized in the oropharynx out there. Stick the tounge blade back there, give another heafty spray and GO to the room.

In room the scope's set up. Pt to bed, monitors, towel over eyes, takes about 10-20 seconds to do the trans tracheal and KABOOM in goes the scope and the tube. Push the white stuff, nix the narcs, and GO.

OR you can just skip the damn transtracheal and shoot 4% via the work port of the FO-scope through the cords.

May take 1-2 minutes longer than than pushing Vec and Pentathol. If your pushing Roc then fine, I'll give ya 3 minutes longer. Big deal. 3 minutes of stuff ain't nothen compared to struggling your ass off for 10-eternity for being careless.

Now that being said I don't have glidescopes and bullards and crap like that.

I would like to get more confident with your (jet's) technique of breathing down sevo and pushing a touch of prop and throwing down a DL or a FO-scope. That sounds tight brotha.

Like I said, I still have a TON to learn. But smooth mo-fo's like you all help me get there.

 

[VentdependenT]

Sensei, Peter Murphy is a wicked laryngoscopist. That guy could intubate a friggen cricket with OSA. I've heard, but havent witnessed, the intimate "I FEEL cords" technique.

Jet, No weed for me. I just snort STERNO. Its cheaper and lasts longer. When I really wanna fly I huff spraypaint with a sock and a motorcycle helmet.

 

[CremeSickle]

When I really wanna fly I huff spraypaint with a sock and a motorcycle helmet.

Classic 👍

 

[epidural man]

Do you really like the glidescope?
We tested it for a week, the first day everyone wanted to have a shot at it then it stayed in a corner for the rest of the week.
I didn't like the plastic blade plus i don't see the point in having a screen showing you what your naked eye can see except if the patient has a small mouth.
If you have a McCormack 3-4 how are you going to see cords with the glidescope if you don't see then with DL?

More and more case reports keep coming out about glidescope misadventures. Some have placed the tube THREW the soft palate. Ouch!!!

Very handy tool, nonetheless.

 

[Laurel123]

I really like the glidescope! I have used it for people that can't open their mouth that wide, or can't crank back their neck at all. I also have had good luck with the fasttrack LMA with some people that are easy to mask but for some reason turn out to be Grade 4+.

Anyways, I do have a question for my private practice folks here... In residency, we did plenty of awake FOI. I felt pretty good about them. But after a year in private practice - I have done none. It just doesn't come up. I have had about ten difficult intubations, but they were all easy ventilations so I have used glidescope and fasttrack and one asleep FIO to get the airway. My concern is that my skills will become rusty. And I can't justify doing awake FOI for practice in private practice because of time constraints and patient comfort.

How do you guys keep your skills sharp?

 

[Miamirex]

Glidescope is the bomb, not perfect, but sure beats holding that eye piece and wiggling around with all that equiptment. Just slide in, look at the screen(100X visualization compared to looking through eye-piece) and slide ETT or boogie into the trachea. It is better technology.

 

[OldManDave]

I think that several papers clearly demonstrate that FAT does NOT equal difficult intubation - I intentionally used the phrase difficult INTUBATION because there are profound differences in the depth of the $hit you are standing in between difficult intubation vs difficult bag/mask (BVM). And that is a key factor in how I choose to proceed when my pre-op exam portends of a potentially difficult situation.

If available, records of prior intubations (esp if know how experiences the intubator was at the time) are especially valuable. If my airway exam only has 1 or 2 elements that suggest concern, but I know from a relatively recent intubation that BVM was easy or successful, then I have a lot more levity in planning my induction.

If the pt was difficult to BVM & their airway exam 'concerns' me. I will generally go straight to AFOI. Of course, we all know that our "awake" FOIs frequently - to encourage pt cooperation - veer more toward sedated & even deeply sedated FOIs (why is it that challenging airway folks always have the damnest of gag reflexes AND an inability to adequately topicalize with lido?).

If I know the BVM will be OK, I tend to do what I call a staged induction (combination of conservatively titrated IV agent + inhaled Sevo) allowing them to sustain spont resp until I have them sufficiently deep that I can take over respirations by BVM & "know" how well/not well I can BVM. If I can BVM w/o issues, then I will either proceed with an FOI or attempt a DL - tangent upon what my pre-op airway exam indicated. If BVM ain't cool, since they are still spontaneously ventilating, I simply turn off the Sevo & let them wake up to try plan 'B' - an AFOI. Sometimes I will go ahead & topicalize these pts with lidocaine prior to sedating them to aid in intubating them by either DL or FOI.

Another adjunct I have found to work very well with AFOIs is an infusion of dexmetatomidine. It is amazing how sedate, yet maintain the capacity to follow instructions pts under dex can be. However, the downside is it takes a good bit of time to load & titrate the infusion to get the desired effect. I have done a few LARGE folks with known histories of difficult BVM &/or intubation in a very controlled fashion with dex. But, you must have a pre-op area capable of monitoring & personnel comfortable in caring for someone getting a dex-load + infusion to prevent long turn-over times.