Potential Difficult Airway

[militarymd]

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Ever try this technique?

18 gauge iv into cricothyroid membrane.

guide wire into iv.

Vessel Dilator (from any central line kit) into trachea via Seldinger technique.

connect vessel dilator to jet ventilator.

put patient to sleep.

jet ventilate.

tiva.

figure out how to intubate afterwards when you have ALL the time in the world.

 

[numbmd]

Why not just do retrograde? Pass the tube over the guidewire and forget about the jet ventilator.

 

[militarymd]

Why not just do retrograde? Pass the tube over the guidewire and forget about the jet ventilator.

retrogrades have not worked well for me...unless using a very specific kit and wire.


the above described technique works very easily every time with a regular central line kit.

 

[numbmd]

I guess my hesitation to use the jet ventilator is that you have to personally ventilate the pt, taking you away from other tasks. Plus, I have seen patients who have had bilateral pneumos from the jet ventilator (pressing the button just a little too long).

You can thread the guidewire thru the suction port of a fiberscope and use that to guide in the tube, with vision. Sweet technique.

 

[Planktonmd]

I can't think of an indication to do elective jet ventilation to handle an anticipated difficult airway.
There are so many things to try before attempting such a dangerous intervention.
And before MMD reacts to my statement I need to clarify that this is not a personal challenge to his abilities nor is it an evidence based statement 🙂.

 

[militarymd]

I can't think of an indication to do elective jet ventilation to handle an anticipated difficult airway.
There are so many things to try before attempting such a dangerous intervention.
And before MMD reacts to my statement I need to clarify that this is not a personal challenge to his abilities nor is it an evidence based statement 🙂.

I've been the OR director for 2 different 16 OR suites/hospitals....with and without residents.

I've seen more than my share of airway mishaps in my tenure in these 2 different OR suites...

"covered"/ reviewed mishaps from somewhere in the neighborhood of 100,000 cases in the last 9 years.

I've seen MORE airway trauma from traditional approaches to the difficult airway than I have seen with the technique I've described...

Jet ventilation is dangerous only in the hands of people who don't know how to use it.

The same applies to all of our equipment and drugs......if you don't know what you're doing....a Miller 3 is a weapon.

 

[Planktonmd]

I've been the OR director for 2 different 16 OR suites/hospitals....with and without residents.

I've seen more than my share of airway mishaps in my tenure in these 2 different OR suites...

"covered"/ reviewed mishaps from somewhere in the neighborhood of 100,000 cases in the last 9 years.

I've seen MORE airway trauma from traditional approaches to the difficult airway than I have seen with the technique I've described...

Jet ventilation is dangerous only in the hands of people who don't know how to use it.

The same applies to all of our equipment and drugs......if you don't know what you're doing....a Miller 3 is a weapon.

OK

 

[Noyac]

I can't think of an indication to do elective jet ventilation to handle an anticipated difficult airway.
There are so many things to try before attempting such a dangerous intervention.
And before MMD reacts to my statement I need to clarify that this is not a personal challenge to his abilities nor is it an evidence based statement 🙂.

I can.
I posted this one a few yrs back. i was a resident when a lady came to the ER with ACEI angioedema. I ran to the Er to see her as the ambulance brought her in. Her lips were bulging out of her face and she was saying help me. I took her to the OR directly. It took me just a few minutes to get her in the OR. I didn't have any time to set up anything. My attending was poor to say the least and I don't really remember but he probably said something like call me if you need anything. Which obviously means, this one is yours. It was about midnight. I planned an awake FOB but like I said I hadn't had time to set anything up. As we were riding the elevator to the OR which was a direct connection b/w ER and OR she began to lose her voice and really struggle to get air. 🙁 When I tell you she was changing in front of my eyes, I can't emphasize this enough. I was the Chief resident in my last year (obviously) with very good airway skills and I felt very comfortable with all the airway tools. B/4 I could get her into the OR her tongue was sticking out of her mouth like it was being squeezed out from behind. She couldn't say a word any longer and had the look of shear terror in her eyes. We were probably looking at each other with the same face, something like this 😱 I had told her I was going to put a tube in her awake. Now I was running out of time. The surgeon held her down sort of trying to comfort her. I grabbed a 16g angiocath and did a trans tracheal local injection thru the cath and left it in place in the trachea. Had the jet vent ready to go (in hindsight I would have hooked it up and given a breath) and pushed about 100mg propofol. Stuck the favorite MAC4 in and saw something that looked familiar. Pushed the ETT and gave a breath. BINGO My attending walked in a few minutes later and said, "everything go alright?"😡

So this is sort of an elective Jet Ventilation scenario. But in the future I will ventilate first with the Jet. I didn't have time for anything else.

 

[Apollyon]

Please forgive my ignorance (just a dumb ER doc that used to be a paramedic): since I've never had to jet ventilate someone, I only know in the abstract that jet ventilation is time-limited - I thought it was about 30 minutes, due to inadequate CO2 exhalation (mechanically) and gradual hyperinflation. At the same time, we were taught to put a 14g Angiocath in and hook the jet vent up to it. As I was taught, the TTJV bought you time to either secure the airway, or get the pt to someone who could. Is there something in the kit that facilitates the exhalate? Alternately, am I just simply way off base?

Threads like this, though, again reinforce why you guys in this forum are the BOMB!

 

[numbmd]

You don't have to worry about exhalation primarily because the obstruction is extra thoracic as opposed to intra thoracic. Sometimes (rarely in my practice) you have to use a jet ventilator because of the procedure, as in tracheal surgery.

 

[Noyac]

Apollyon, remember CO2 won't kill. Lack of O2 however will.

Many of us here do ENT cases that require jet ventilation. Therefore, we jet to practice it from time to time in a very controlled situation.

By the way, dumb is only relative. I don't think you want me setting a shoulder or working up belly pain. Even though I have done these things and could probably do them if need be, I'm sure you are much better. Dumb is only those who don't know their limits.👍

 

[rsgillmd]

....For the unanticipated difficult airway I think the LMA with fiberoptic/Aintree combo is great and highly reliable. The intubating LMA was a major letdown.

I'm curious, why was the intubating LMA a letdown? Lack of success in intubating? Difficulty placing it? Something else?

Before I got comfortable with the fiberoptic scope, and before we got the glidescope, I reached for the LMA Fastrach several times. Once I had to stick a FOB through it to guide the tube more anteriorly, but other than that I have a 100% success rate with it.

 

[Planktonmd]

I can.
I posted this one a few yrs back. i was a resident when a lady came to the ER with ACEI angioedema. I ran to the Er to see her as the ambulance brought her in. Her lips were bulging out of her face and she was saying help me. I took her to the OR directly. It took me just a few minutes to get her in the OR. I didn't have any time to set up anything. My attending was poor to say the least and I don't really remember but he probably said something like call me if you need anything. Which obviously means, this one is yours. It was about midnight. I planned an awake FOB but like I said I hadn't had time to set anything up. As we were riding the elevator to the OR which was a direct connection b/w ER and OR she began to lose her voice and really struggle to get air. 🙁 When I tell you she was changing in front of my eyes, I can't emphasize this enough. I was the Chief resident in my last year (obviously) with very good airway skills and I felt very comfortable with all the airway tools. B/4 I could get her into the OR her tongue was sticking out of her mouth like it was being squeezed out from behind. She couldn't say a word any longer and had the look of shear terror in her eyes. We were probably looking at each other with the same face, something like this 😱 I had told her I was going to put a tube in her awake. Now I was running out of time. The surgeon held her down sort of trying to comfort her. I grabbed a 16g angiocath and did a trans tracheal local injection thru the cath and left it in place in the trachea. Had the jet vent ready to go (in hindsight I would have hooked it up and given a breath) and pushed about 100mg propofol. Stuck the favorite MAC4 in and saw something that looked familiar. Pushed the ETT and gave a breath. BINGO My attending walked in a few minutes later and said, "everything go alright?"😡

So this is sort of an elective Jet Ventilation scenario. But in the future I will ventilate first with the Jet. I didn't have time for anything else.

Noy,
This was great thinking but this was in no way elective jet ventilation to manage an anticipated difficult intubation.
You were managing a patient that was about to die and had you used the jet and ended with bilateral pneumo no one could blame you because you were trying to save a life.
The elective jet ventilation for an anticipated difficult intubation I was referring to goes like this:
Oh, I think I am going to have trouble intubating this patient... I think the best thing I can do is insert a vessel dilator in his neck then induce GA and jet ventilate while I think what my next step should be!

 

[militarymd]

some people like to limit themselves when it comes to being facile at different techniques....and that's OK.



If you tend to cause bilateral pneumo's when you jet ventilate, then you shouldn't do it.

I personally don't cause pneumo's when I jet ventilate.

 

[Planktonmd]

some people like to limit themselves when it comes to being facile at different techniques....and that's OK.



If you tend to cause bilateral pneumo's when you jet ventilate, then you shouldn't do it.

I personally don't cause pneumo's when I jet ventilate.

Yeah 👍

 

[dA pilot]

Ever try this technique?

18 gauge iv into cricothyroid membrane.

guide wire into iv.

Vessel Dilator (from any central line kit) into trachea via Seldinger technique.

connect vessel dilator to jet ventilator.

put patient to sleep.

jet ventilate.

tiva.

figure out how to intubate afterwards when you have ALL the time in the world.

Is there a reason why you use the vessel dilator to jet ventilate? In my experience, the vessel dilator does not have a luer lock and the distal tip is slightly larger than a 18 guage.

 

[militarymd]

Is there a reason why you use the vessel dilator to jet ventilate? In my experience, the vessel dilator does not have a luer lock and the distal tip is slightly larger than a 18 guage.

vessel dilators don't kink like an angiocath....also they are long enough to reach into the trachea as opposed to angiocaths which are short...and may easily slip out of the trachea and have you shooting air into the subcutaneous tissues

 

[Noyac]

vessel dilators don't kink like an angiocath....also they are long enough to reach into the trachea as opposed to angiocaths which are short...and may easily slip out of the trachea and have you shooting air into the subcutaneous tissues

True that

I like your technique. No surprise.

 

[militarymd]

True that

I like your technique. No surprise.

it's not MY technique....It's something that I learned from an "academic" anesthesioloist.🙂

 

[proman]

I'm curious, why was the intubating LMA a letdown? Lack of success in intubating? Difficulty placing it? Something else?

Before I got comfortable with the fiberoptic scope, and before we got the glidescope, I reached for the LMA Fastrach several times. Once I had to stick a FOB through it to guide the tube more anteriorly, but other than that I have a 100% success rate with it.

I've found the intubating LMA to be more difficult to place, the epiglottis has sometimes occluded the flap, and the whole process of actually placing the tube (with that rod thing) to be cumbersome. Maybe I haven't done enough, but with a fiberoptic scope and Aintree catheter, you can accomplish the same thing with a regular LMA.