learning invasive difficult airway skills

sounds about right

 

Our program has an airway lab with all sorts of weird stuff in it, including some mannequins that allow us to practice the retrograde wire technique. Of course, it's not the same as doing it on a real person under stress, but I think there's some benefit to at least getting your hands to go through the motions. Like you, I/we do a lot of awake fiberoptic intubations and I haven't seen a patient yet (in 2 years of training, I'll grant you) who couldn't be intubated in this manner.

 

Combitube: No skill required, anyone can do it , not a very elegant device though.
Retrograde intubation: Not a good emergency procedure (if you have time to do a retrograde intubation you probably have time to do many other things that are less complicated).

 

OP--why cant you use a combitube? It's not really that 'invasive'.

Just make sure you inflate the correct pilot

retrograde---i agree...i dont know how to practice that on a real pt and get away. if you are close with an ent surgeon that's going to do a radical neck or trach,perhaps you can get away with doing it.

 

What kind of training do most residents get in making a surgical airway?

 

at my program we do an intern month on the ENT service and they are pretty aggressive about having us do trachs, either in the OR or the ICU. All the trachs here are open, so we don't get to practice those bedside percutaneous kits (which are actually a lot like doing a retrograde intubation...).

 

I wouldn't consider a trach a crash airway. A cric. would be but a trach is way too time consuming

 

I did a month of ENT my intern year. No trachs 'skin to skin' but did open up a few under very very close supervision. Helpful? Yes and no. It was 3 years ago. Nothing beats repetition for practice and I would never say I'm remotely comfortable with an open trach because I almost did one 3 years ago. What was most helpful was actually the scopes. Them guys scope darn near everyone in the office and that is something I HAVE actually practiced with regularity. If anything, OR trachs taught me that, as we all know, there's a lot of crap in the neck you don't want to cut with a scalpel if you don't know what you're doing.

ICU months had some bedside perc trachs in select patients. I helped out with everyone that I could, but that wasn't a ton over my required 2 months in residency. And that's a very controlled situation, again with close supervision.

We do practice with our cric kit on mannequins frequently enough. Since this is what I would actually grab in an emergency, it's nice to know what's in the kit, and how to use it. Our transtracheal block gives us a pretty intimate relationship with the feeling of a needle going through this membrane. From there on, hopefully the mannequin skills would kick in with the rest of the technique.

Side note: These guys Bair AE,Panacek EA,Wisner DH,et al.,“Cricothyroidotomy:a 5-year experience at one institution”,Journal of Emergency
Medicine(2003);24p.151–156.claim a 10.9% incidence of pre-hospital and 1.1% incidence of in hospital emergency cricothyroidotomies. Seems a bit high to me.

 

In reality,

an anesthesiologist cannot maintain competency with the esoteric (retrograde wire) or open trachs, and a failed airway aint the place for you to try something you've done twice.

In your life.

We have a backstage pass, though, to managing the failed airway via being comfortable with the transtracheal block thats commonly done for fiberoptics.

I'd say being able to perform the transtracheal block is a skill that'll enable you to handle a failed airway.

Most of us have done enough of them to be able to find, and cannulate the cricothyroid membrane fairly quickly.

It is my humble opinion that as an anesthesiologist, you should have one skill in the failed airway area that you're really good at, and I'd be willing to bet that cannulating the cricothyroid membrane is where the moneys at for most of us.

Can you find the membrane and stick it with something (21" needle/20"angiocath) in order to squirt in some lidocaine for a fiberoptic under controlled circumstances?

Sure you can.....and the cool thing is you can practice periodically.

So exploit that skill of yours, and make it your GO-TO step when everything else fails.

Refine it.

Start feeling cricothyroid membranes for a while again.

Pretend the ASA 1 knee scope you just threw an LMA #4 in just lost their airway.

Time yourself on how long it takes you to find the membrane.

Its gravy after you find it.

Take out the jet ventilator setup. Knock the cobwebs off of it. Hook it into the 02 thinghy.

Take out a 14" angio and hook up the setup to the catheter. Squirt it a cuppla times.

Now take it apart, and pretend youre gonna stick this ASA 1's cric with everything set up.....during the case.

You can do it.

I've done it twice in eleven years.

This is where the moneys at for most practicing anesthesiologists managing a failed airway.

JET VENTILATION.

 

For those who may not be familiar with this setup:
http://www.cja-jca.org/cgi/content/full/48/7/716-a/F
14 ga IV, 3 cc syringe, 2 15 mm connectors 1 each from a 4.0 and 7.5 ETT, oxygen tubing.

An interesting scenario is if you don't have a jet ventilator handy, then what? Is the common gas outlet good enough? Really depends on the specific machine. Can you even find that on a Drager Apollo? In any case, every difficult airway cart should have a jet ventilator apparatus attached to it along with a full O2 tank.

 

Anybody ever thought about or used a RIC line instead of an angiocath. Seems like it's a pretty decent perc-crich set - has a wire, knife, dilator, etc.

 

Hmm...Now that's a nice idea. Wire is pretty flimsy, but everything else is solid, and easy to find.