Recent intubation experiences

[Inertia123]

---

Members do not see this ad.

Current Emergency Medicine PGY-1 on Anesthesia rotation. I have been lucky to work with nice anesthesiologists and CRNAs during the rotation and have gotten to intubate about 30 patients in two weeks. Probably from a combination of luck, easy airways and developing skill, my hit rate has been ~95%. I had 2 cases today that did not go as smoothly as possible and I'm not sure why. The first one was a tall young man who needed a NIMS tube. Got a grade 1 view but as I was placing the tube, I completely lost my view with the epiglottis flopping down over the glottic inlet. I regained the view but was having a hard time getting the tube anterior to the arytenoids. My only guess is that maybe I should have used a mac-4 rather than a mac-3. The second case was a middle aged woman. Again, grade 1 view, but as I was trying to pass the tube I was not able to get anterior enough and the tube kept bending posteriorly away from the cords. Thinking back on it I maybe could have used more tongue sweep. Both of these I was able to get after some struggling but not without inflicting some airway trauma - which I was not happy about. Also, if these cases were ED RSI cases they would have surely been taken from me long before the point I succeeded in these cases. Weirdly enough, I had a 3rd case with a known difficult airway who I intubated with the glidescope with almost no difficulty at all.

I dunno - I guess it's scary to me to have a streak of about 25 very smooth and uneventful intubations and then come up against 2 that I had difficulty with in the same day. It's also scary to me that I was able to get a grade-1 view in <15 seconds in each case but then had such difficulty placing the actual tube especially since I have placed tubes with a lot more ease in people who I have had lesser quality views.

Thoughts???

 

[ryanjmy]

If you're having trouble passing the tube use a stylet. Make it mostly straight with a slight bend at the end. Occasionally, you may have to adjust the bend more anterior. Also tip of the tube is beveled. Lead with the point.

 

[deleted9493]

If you do enough intubations with the glidescope, you'll realize that a clear view of the cords does not mean that the patient will be easy to intubate. The fiberoptics are of course giving you an indirect line of sight and with a less than optimal mouth opening, you may have difficulty maneuvering the tube anteriorly enough.

Bougies can be hugely helpful when you don't have a good view, but as rynajmy has pointed out, using a stylet is probably all you needed to make these two cases easy on yourself.

 

[Inertia123]

Both had a stylet...

I must've been doing something wrong who knows...

 

[deleted59964]

try holding the ett further back toward the connector, it allows you to use the curve in the tube to direct the tip more anteriorly

 

[wee eng]

Current Emergency Medicine PGY-1 on Anesthesia rotation. I have been lucky to work with nice anesthesiologists and CRNAs during the rotation and have gotten to intubate about 30 patients in two weeks. Probably from a combination of luck, easy airways and developing skill, my hit rate has been ~95%. I had 2 cases today that did not go as smoothly as possible and I'm not sure why. The first one was a tall young man who needed a NIMS tube. Got a grade 1 view but as I was placing the tube, I completely lost my view with the epiglottis flopping down over the glottic inlet. I regained the view but was having a hard time getting the tube anterior to the arytenoids. My only guess is that maybe I should have used a mac-4 rather than a mac-3. The second case was a middle aged woman. Again, grade 1 view, but as I was trying to pass the tube I was not able to get anterior enough and the tube kept bending posteriorly away from the cords. Thinking back on it I maybe could have used more tongue sweep. Both of these I was able to get after some struggling but not without inflicting some airway trauma - which I was not happy about. Also, if these cases were ED RSI cases they would have surely been taken from me long before the point I succeeded in these cases. Weirdly enough, I had a 3rd case with a known difficult airway who I intubated with the glidescope with almost no difficulty at all.

I dunno - I guess it's scary to me to have a streak of about 25 very smooth and uneventful intubations and then come up against 2 that I had difficulty with in the same day. It's also scary to me that I was able to get a grade-1 view in <15 seconds in each case but then had such difficulty placing the actual tube especially since I have placed tubes with a lot more ease in people who I have had lesser quality views.

Thoughts???

There is a well heeded principle in endotracheal intubation to "make your first attempt your best attempt". The number of endotracheal intubations needed to develop proficiency is estimated to be anywhere from 35-100, mostly dependent on the definition of 'proficiency'. Many of us in practice who intubate daily year in and year out are still from time to time surprised by unanticipated difficult intubations. In a true emergent intubation in the Emergency Department, I would suggest using the GlideScope if available. I also use a stylet in keeping with the "make your first attempt your best attempt" mantra. A proper positioning of the head and perhaps some ramping in some patients is also frequently overlooked in the heat of the moment. It is also important to keep in mind that clinical situations are almost always multifactorial, so it may take more than one adjustment to facilitate success.

 

[cleansocks]

Current Emergency Medicine PGY-1 on Anesthesia rotation. I have been lucky to work with nice anesthesiologists and CRNAs during the rotation and have gotten to intubate about 30 patients in two weeks. Probably from a combination of luck, easy airways and developing skill, my hit rate has been ~95%. I had 2 cases today that did not go as smoothly as possible and I'm not sure why. The first one was a tall young man who needed a NIMS tube. Got a grade 1 view but as I was placing the tube, I completely lost my view with the epiglottis flopping down over the glottic inlet. I regained the view but was having a hard time getting the tube anterior to the arytenoids. My only guess is that maybe I should have used a mac-4 rather than a mac-3. The second case was a middle aged woman. Again, grade 1 view, but as I was trying to pass the tube I was not able to get anterior enough and the tube kept bending posteriorly away from the cords. Thinking back on it I maybe could have used more tongue sweep. Both of these I was able to get after some struggling but not without inflicting some airway trauma - which I was not happy about. Also, if these cases were ED RSI cases they would have surely been taken from me long before the point I succeeded in these cases. Weirdly enough, I had a 3rd case with a known difficult airway who I intubated with the glidescope with almost no difficulty at all.

I dunno - I guess it's scary to me to have a streak of about 25 very smooth and uneventful intubations and then come up against 2 that I had difficulty with in the same day. It's also scary to me that I was able to get a grade-1 view in <15 seconds in each case but then had such difficulty placing the actual tube especially since I have placed tubes with a lot more ease in people who I have had lesser quality views.

Thoughts???

In your first case I agree a mac4 might've helped but it seems the 3 was long enough to get a grade 1 for a bit of time at least so it's probably just a matter of learning to keep the view subconciously while doing things with your other hand.

Sometimes a stylet can hurt you too. If you use stylets you develop the techniques for bending them correctly and twisting them in the mouth properly over time. I'm a no stylet, fast to bougie sort of guy but you just have to find what works for you.