Learning new airway techniques

[Mokki]

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I really want to try new airway techniques on folks that are otherwise perfectly suitable for a straight DL and tube, but I feel some amount of internal pressure not to delay cases and not to rock the boat too much. Any other residents in this position? What did you do to get over this?

As a corollary, how many fiberoptics did you have to do before you felt confident you could get one if urgently needed on nearly any airway (i.e, i did about 150 DL's before I felt this way re: DL'ing in emergencies) I've done 5 FOI so far and I'm super nervous about having a difficult airway in a code requiring FOI and I'll be unable to do one...

Finally, what other airway methods are worth experimenting with now in residency? - lightwand, fast trak, FOI immediately come to mind. Others that you think are important?

 

[periopdoc]

You are always going to have pressure to keep things going on time, but you will rarely again have the opportunity to shrug that pressure off and do some learning (after you leave residency). My hints

1) Call your attending the night before and let him know what you plan to do so that he can facilitate it and give you advice on how to make things go quickly.

2) Don't expect your attending to be able to set everything up for you. He may be slammed with 2 rooms plus out of OR responsibilities. Have a anesthesia tech friend who can help with getting everything set up so that there are no equipment related delays.

3) Talk to a senior resident friend about their workflow for doing things efficiently.

4) Take your time, but don't flog a dead horse. There is a fine line between learning and fixating on a technique that is ultimately going to fail for a particular patient. Give it a go or two then revert to what you know.

Being facile with all airway tools is the same as being facile with DL. You need repetitions. Try doing one or two elective FOB's/ glidescope/ lightwand per day for a couple of weeks then keep doing at least one per week for the remainder of residency. Don't slack on the DL skills though. There is only one tool that is guaranteed to be in every place that you manage the airway and that is the laryngoscope. The other tools/ toys may or not be available when you need them. Which one turns out to be most important is unpredictable as you never know which utensils are going to be used by your ultimate practice.

- pod

 

[behindthadeuce]

My residency program has a dedicated AIRWAY month-long rotation where we learn almost every airway technique possible. Obviously, we don't perform procedures that are completely unnecessary (ie retrograde intubation or transtracheal jet ventilation) unless the patient actually has an indication for it....but we do 2-3 FOB intubations everyday for a month. We learn the bronchial tree anatomy, as well.

To answer your question, the most important things I would recommend learning are how to use a glidescope, how to use a FOB scope, and MOST IMPORTANTLY---get really ****ing good at intubating through an LMA. [And not the bull**** way of using a Fastrack LMA- I mean using a Cook-Gas LMA or another intubating LMA where you put a FOB scope down the LMA. This enables you to continue ventilating the patient the entire time you are using the scope and placing your ETT.]

This technique will be my go-to difficult airway maneuver for the rest of my career!!

And I wouldn't worry at all about the surgeons getting on your case for taking an extra 10 minutes at the start. It's a teaching hospital. Tell them next time they want a case to be 10 minutes quicker, they should stay in the room and finish suturing instead of letting their intern or med student do it.

-Deuce

 

[pjl]

I felt fairly comfortable with fiberoptics from a "driving the scope through the cords" standpoint after about 10-15 or so (asleep patients). As far as awake goes, it all depends on your local, and the overall indication. Learn different numbing techniques and make your own choices about what works for you. At this point if I have a cooperative patient I can normally get in with between 0 and 2 coughs. Some can be very easy, some quite challenging. Being able to do a reasonably competent bronch took about 5 or 10. You will get there, like everything else practice makes perfect.

As for finding time to practice, just grab a fiberoptic, put it in your room, and use it on your case. Pick your patient, and don't grab the last clean fiberoptic scope in the hospital. Doing an asleep fiberoptic to get some skills at driving it should take about 30 seconds longer than DL. Tell anyone who doesn't have 30 seconds to f off (generally more accepted later in your training).
For awake ones, you will run into that little devil on your shoulder asking if it is really in the patients best interest. I would encourage you to do enough glidescope/glidescope equivalents to be comfortable, then push for fiberoptics when you feel it is marginally indicated. It is the gold standard, but at many training institutions the numbers are dropping rapidly with the new airway toys. If your program is ammenable, I would recommend spending a week or two with the bronchoscopists, who electively fiberoptically intubate 15 or 20 patients before lunch. You will get very good very fast.
Doing intubations through an LMA is a GREAT skill to master. This will definitely add to your induction time, but very worth it to have practiced when it becomes necessary to do it in an emergency.

 

[Bertelman]

Are people seriously still using a lightwand for difficult intubations, or do we just talk about it so we can dust off that piece of equipment in the workroom?

 

[rsgillmd]

I agree with what Periop said. I started with the first case of the day (the easiest to have everything set up beforehand), and with an attending that I knew would be willing to teach me. When I grew more confident in myself and more involved in my own learning, I started calling the attending the night before. Nobody ever said no when they were called the night before.

As a CA-3 when I was working with my vice-chair, who was notorious for disappearing, I would call him the night before and say I want to talk about topic X. That way I knew I would get something educational out of the day. At first he was surprised, but he likes to teach and began to like it when I called him.

You are always going to have pressure to keep things going on time, but you will rarely again have the opportunity to shrug that pressure off and do some learning (after you leave residency). My hints

1) Call your attending the night before and let him know what you plan to do so that he can facilitate it and give you advice on how to make things go quickly.

2) Don't expect your attending to be able to set everything up for you. He may be slammed with 2 rooms plus out of OR responsibilities. Have a anesthesia tech friend who can help with getting everything set up so that there are no equipment related delays.

3) Talk to a senior resident friend about their workflow for doing things efficiently.

4) Take your time, but don't flog a dead horse. There is a fine line between learning and fixating on a technique that is ultimately going to fail for a particular patient. Give it a go or two then revert to what you know.

Being facile with all airway tools is the same as being facile with DL. You need repetitions. Try doing one or two elective FOB's/ glidescope/ lightwand per day for a couple of weeks then keep doing at least one per week for the remainder of residency. Don't slack on the DL skills though. There is only one tool that is guaranteed to be in every place that you manage the airway and that is the laryngoscope. The other tools/ toys may or not be available when you need them. Which one turns out to be most important is unpredictable as you never know which utensils are going to be used by your ultimate practice.

- pod