What is your go to airway rescue device?

[ucsfgaspain]

So when you get into a can't ventilate, can't intubate situation...what device is your savior?

In my experience, I'm not a fan of the classic LMA...when the sat's are dropping to the floor, I don't want to have to futz with placing an LMA and worrying about the tip folding over etc...

I've been using either the king LT or the intubating LMA to rescue ...but anyone else finding better devices out there?

This question is directed more for airway rescue i.e. all I care about is ventilating not intubating. Thanks.

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[Planktonmd]

So when you get into a can't ventilate, can't intubate situation...what device is your savior?

In my experience, I'm not a fan of the classic LMA...when the sat's are dropping to the floor, I don't want to have to futz with placing an LMA and worrying about the tip folding over etc...

I've been using either the king LT or the intubating LMA to rescue ...but anyone else finding better devices out there?

This question is directed more for airway rescue i.e. all I care about is ventilating not intubating. Thanks.

Classic LMA because in the situation that you mentioned (unanticipated can't ventilate can't intubate disaster) it's very unlikely that you will have other devices ready to use.
LMA's are everywhere and they almost always work.

 

[ucsfgaspain]

Agreed about the ubiquity of LMA's. I'm thinking of how to stock our OB and offsite anesthesia sites. When I'm in these areas, I usually take a long my go to device as back up. They've bailed me out of ugly situations.

King LT- idiot proof. advantage is that you just ram it in and inflate. Hearing conflicting things in regards to how much aspiration protection it really provides. Would you use it for a c/s or any case with relaxant? Talked to the company and they told me to use like an ETT. Yet...not sure how safe this is.

Intubating LMA or Fast Trach: easy placement and can easily fiber through to intubate...finding that with the blind technique, goosing the tube too much, that i've resorted to fiberoptic confirmation

 

[militarymd]

If I can't ventilate...I like the flex lma


If I can't intubate....I go first to light wand.

 

[ucsfgaspain]

Milatrymd,

Why the flex LMA? Being someone with not the largest hands in the world, I often can't seat the LMA in the classic technique without using the shaft, to work it down. With the flex LMA, the shaft doesn't help with placement (by design of course) Also it prevents you from doing the 180 spin technique.

Would love to get more comfortable with the lightwand. Biggest obstacle is of course my lack of experience with it. Any tips or tricks with the lightwand that you can pass along?

Thanks

 

[coprolalia]

Assuming you looked with a GlideScope?

If not, I'd look with a GlideScope first. If you think it's gonna be a difficult airway, you should have that with you before you push the induction meds.

-copro

 

[pd4emergence]

There is an LMA made by cookgas that I like to use. Basically it is an intubating LMA without the metal piece. You can get a 7.5 ett through the 3.5 size LMA. They also have a 4.5 size that you can get a 8.5 ett through. The circuit connector comes easily out of the LMA and they have a stylet that will help you push the ett out of the LMA if you don't want to/or can't leave the lma in. Seems to work pretty well.

 

[dhb]

Assuming you looked with a GlideScope?

If not, I'd look with a GlideScope first. If you think it's gonna be a difficult airway, you should have that with you before you push the induction meds.

-copro

I don't understand the thing with the glidescope: maybe you get a better vision but it doesn't mean the tube is going to go where your looking. 7000$ seems way overpriced, this on the other hand is 50$ and is the most impressive tool i've seen (although i haven't used it on patients):

 

[militarymd]

we do all sinus cases with flex lmas....so I do more flex lmas than any of the other lmas......I go to what I use the most..

as for the lightwand....practice......my first year out of residency I didn't pick up a laryngoscope once for 6 months......only a light wand.

Milatrymd,

Why the flex LMA? Being someone with not the largest hands in the world, I often can't seat the LMA in the classic technique without using the shaft, to work it down. With the flex LMA, the shaft doesn't help with placement (by design of course) Also it prevents you from doing the 180 spin technique.

Would love to get more comfortable with the lightwand. Biggest obstacle is of course my lack of experience with it. Any tips or tricks with the lightwand that you can pass along?

Thanks

 

[VentdependenT]

Can't ventilate = LMA classic reusable. King LT is ok. If I had one laying around I'd go for it. I don't think it affords much more than the LMA. I've had seating issues with the LT believe it or not.

Intubating LMA = P.O.S. I'd take a glidescope over that thing any day.

Cant intubate = Fiberoptic. I'm surgical with that b!tch.

 

[ucsfgaspain]

pd4 emergence,

Yeah I've got the blue intubating LMA thing as well. Haven't used that one much. It seems that the advantage of this blue one is that you are less worried of leaving the LMA in during the entire case. I'm always nervous about removing the fasttrack LMA after I've secured the airway with the tube. An accidental extubation after getting everythng copesthetic with the fasttrack and then losing it when you remove the metal hardware would blow.

Anyone use that new McGrath device? Seems sweet since it is so portable. In addition it is so much more ergonomic since you are in line of sight with the screen.

Would really be nice since you can take it up to OB, to the floor, etc. I guess problem would be that someone could end up taking it home. That would be pricey.

 

[coprolalia]

I don't understand the thing with the glidescope: maybe you get a better vision but it doesn't mean the tube is going to go where your looking.

If you use the stylet that comes with it, you're not going to fail the vast majority of the time. It's a great tool. I intubated someone the other night in the trauma bay with the c-collar still on and a ton of what-looked-like papillomas (obviously unknown at presentation in the trauma bay) around the vocal cords. If you practice with it, you can get pretty slick. This tool has gotten me out of many sticky situations. And, everyone around you can see exactly what you are doing as well.

That's the "thing" with the GlideScope. I don't consider them a "can't intubate/can't ventilate" until I've looked with the GlideScope.

-copro

 

[zippy2u]

UCSF, some thoughts about airway devices: You don't need to futz with the classical LMA. If ya can't put it in in 3 secs you're doing something wrong. The key is partial inflation, lubrication of the entire part that is inside the oral cavity, #3s for women and puny men like jockeys and #4s for men and amazonian women, #5s for horses and cows.( Oh, you don't anesthetize horses and cows? Me neither, so when ya find a #5, just throw it in the red garbage bag that gets incinerated and throw some more garbage on top of it-- you didn't pay for it). With your left hand on pt's head you tilt head back into sniffing position, the mouth typically opens at least a cm. Hold LMA in right hand like a pencil towards the end. No need to put your hand or fingers inside mouth! Ram her home with occasionally a 45 degree twisting motion until ya feel resistance. Ya don't need to put any more air in the cuff! Tape it. See, tip doesn't bend over in the oral cavity when LMA is partially inflated. No need for the 180 degree rotation manuever. Flexible LMAs? Put a stylet in them and do as above and once seated take out stylet. The blue ILA is better than the metal Fastrach. Never figured out why those British squirrels put the formed metal in the Fastrach--don't really need it. That's the gist of it all. Regards, ----Zippy

 

[ucsfgaspain]

zippy,

so if I understand your suggestion, I coat both sides of the LMA? Or just the posterior part against the hard palate? When you say partially inflate, do you mean only until the wrinkles come out of the LMA? Typically what volumes are you talking about 10 cc's or such?

Does this technique work with all the new generic LMA's out there? We've gone to some new version which I don't like as much but oh well. Also I do agree with you in regards to LMA #5's. Very little use for these. Thanks for the advice.

Another question for you all? Anyone using the King LT and where does it fit in your practice. Do you treat it more like an LMA or more like an ETT?

 

[zippy2u]

Yeah, spooge the side that goes against the hard palate and spooge the rim. Yeah, until the wrinkles are out which is typically less than 10 ccs. Yeah, all versions. Regards, ---Zip

 

[Planktonmd]

UCSF, some thoughts about airway devices: You don't need to futz with the classical LMA. If ya can't put it in in 3 secs you're doing something wrong. The key is partial inflation, lubrication of the entire part that is inside the oral cavity, #3s for women and puny men like jockeys and #4s for men and amazonian women, #5s for horses and cows.( Oh, you don't anesthetize horses and cows? Me neither, so when ya find a #5, just throw it in the red garbage bag that gets incinerated and throw some more garbage on top of it-- you didn't pay for it). With your left hand on pt's head you tilt head back into sniffing position, the mouth typically opens at least a cm. Hold LMA in right hand like a pencil towards the end. No need to put your hand or fingers inside mouth! Ram her home with occasionally a 45 degree twisting motion until ya feel resistance. Ya don't need to put any more air in the cuff! Tape it. See, tip doesn't bend over in the oral cavity when LMA is partially inflated. No need for the 180 degree rotation manuever. Flexible LMAs? Put a stylet in them and do as above and once seated take out stylet. The blue ILA is better than the metal Fastrach. Never figured out why those British squirrels put the formed metal in the Fastrach--don't really need it. That's the gist of it all. Regards, ----Zippy

This post ladies and gentlemen is simply the best LMA tutorial I have seen any where.
Good job Zippy

 

[Jeff05]

that thing sucks. you can't guide the tip of the tube and it's impossible to intubate when pt is anterior.

i have NEVER had a case where i couldn't intubate with a glidescope. you can ALWAYS see something. you can fold a regular stylette in a particular way that allows one to get the most anterior patients. if i can't intubate and can't ventilate - LMA goes in immediately. i put in LMAs partially inflated.

I don't understand the thing with the glidescope: maybe you get a better vision but it doesn't mean the tube is going to go where your looking. 7000$ seems way overpriced, this on the other hand is 50$ and is the most impressive tool i've seen (although i haven't used it on patients):

 

[Gator05]

What do you all do for difficult airways where a DLT is needed?

 

[Planktonmd]

What do you all do for difficult airways where a DLT is needed?

Do fiberoptic, place regular ETT, place tube changer through ETT, Take tube out, place DLT on changer (through bronchial side), put laryngoscope in mouth to lift soft tissue, slide DLT down trachea, adjust placement with FOB as usual.
Voilà!

 

[Jeff05]

difficult airway with DLT.

1. get regular tube in and mainstem it, either blind or fiberoptic.

2. use a blocker.

 

[fastosprintini]

if it's not totally surprising i have the bullard ready, warmed and loaded (behold THE BULLARD!) , if taken by surprise i'd put in an nasal airway,followed by a classical LMA. fasto

 

[urge]

I have never been in a cannot ventilate, cannot intubate situation. It's always one or the other but not both(granted the difficult looking airways get done awake). I know of such an event but the details were so bizarre that I'm not sure what to think about it.

Has anyone here experienced a cannot intubate/cannopt ventilate scenario personally?

I guess I'ld try an LMA, then the jet ventilator, then holler like a ho at the surgeons.

 

[Planktonmd]

Has anyone here experienced a cannot intubate/cannopt ventilate scenario personally?

I have, and ended doing the C Section with an LMA.
Patient did well.

 

[ucsfgaspain]

Urge,

I've got one for you. Happened during my CA-3 year. Remember every second to this day. and it's been a while. And no there was no glide scope or anything like that back in the day. The LMA was the new fangled thing back then. And remember the days of those big a+S+S thiopental jugs?

Thin old gomer for a bowel obstruction. Had my Med student, junior resident with me. RSI. Give it to my med student to do.

Student states can't see anything. -Yeah whatever-

Junior resident...can't see anything. -Damn...i got a weak junior-

I take a look with the straight blade. Lift the epiglottis...nothing...and I mean nothing there. -WTF?-

We've got him positioned optimally blah blah blah. I hockey stick the tube up and try to go blind. Squeeze the bag...air out of the NG. -Motherf+er!-

Sat's start fall. No worries thin guy I can ventilate. Nothing zilch...nada...Oral airway...nasal airway...two hand ..still nothing.

Sat's really playing the base tones...

Throw in the LMA...nothing...pt. is beginning to f...ing brady.

Grab the cric kit...and I sh+t you not, did my one and only cric faster than I though humanly possible.

Attending comes running in all frazzled from being woken up from a stat page, you should have seen his face!

What did I learn...do all your crazy sh+t and F*ups during residency...cuz it's someonelse's license on the line.
I used to be one of the most aggressive residents ...now when it's my license...man am I way more conservative

 

[jwk]

What did I learn...do all your crazy sh+t and F*ups during residency...cuz it's someonelse's license on the line.
I used to be one of the most aggressive residents ...now when it's my license...man am I way more conservative

Worried about your license?

 

[MTGas2B]

On the list of options there is always the blind eschmann stylet. Run it around the corner, feel it bump bump over tracheal rings and stop, time to intubate, or feels smooth and keeps on going into the stomach. Pretty cheap, and gets you out of a lot of jams.

I have to say its my first line go to device. Number two is an LMA, whatever kind we have around. We have a few different types depending on which hospital I'm working at the time.

 

[huktonfonix]

I also love the intubating stylets. It depends on the situation though. For those able vent cant tube I like the LMA (classic, intubating, ILA, whatever). I can always tube or FBO through that. For those cant vent/cant intubate Ive never had to go to a cricothyroidotomy and hopefully never will. There are those situations that you just cant see anything (gushing blood, puke) in which case its either gonna be an intubating stylet or a light wand or just intubation by feel. I feel that this last category (cant see) should be added to the algorithm since a lot of our rescue devices are still based on direct vision and not feel.

 

[jetproppilot]

On the list of options there is always the blind eschmann stylet. Run it around the corner, feel it bump bump over tracheal rings and stop, time to intubate, or feels smooth and keeps on going into the stomach. Pretty cheap, and gets you out of a lot of jams.

I have to say its my FIRST LINE go to device. Number two is an LMA, whatever kind we have around. We have a few different types depending on which hospital I'm working at the time.

Me too.

The eschmann has nearly eliminated FOI for me.

 

[epidural man]

pd4 emergence,

Yeah I've got the blue intubating LMA thing as well. Haven't used that one much. It seems that the advantage of this blue one is that you are less worried of leaving the LMA in during the entire case.

If you haven't used it much, you should. The ILA by CookGas is the bomb. It KILLS the fastrach in my mind. It works and looks just like an LMA, but it is shorter and larger diameter so you can use a regular tube. It gives you and incredible fiber optic view every time, or seems to work with a blind pass almost every time.

At ASA a while back, I spoke with the guy who invented the ILA and he said that if you have any problems, it can only be 1 thing - that is the epiglotis is folder down so you can make proper adjustments to fix that. The stupid intubating LMA (fastrach) has a two page instruction that comes with it for troubleshooting and it seems very complicated. There are so many things that can go wrong with that thing.

Here is the two page instructions to "adjust" the fastrach if you are having trouple. Tell me if you are going to get this thing out if you are in an emergency airway situation?
http://www.lmana.com/docs/Fastrach_Maneuvers_Guide.pdf

Here is a link to the ILA for anybody interested in learning more about a great emergency airway device better than an LMA.
http://66.77.149.134/index.cfm?fuseaction=act_getpagecontent&page_id=243&FirstLineHorizontal=1

 

[buckhorn]

that thing sucks. you can't guide the tip of the tube and it's impossible to intubate when pt is anterior.

i have NEVER had a case where i couldn't intubate with a glidescope. you can ALWAYS see something. you can fold a regular stylette in a particular way that allows one to get the most anterior patients. if i can't intubate and can't ventilate - LMA goes in immediately. i put in LMAs partially inflated.

I agree, "that thing (Airtraq) sucks. you can't guide the tip of the tube and it's impossible to intubate when pt is anterior" We had the rep show up and gave us a few free samples, It was difficult to use in easy airways, worthless in a slighlty challenging airway.

I have used the glidescope a few times in very difficult airways and have always been successful in intubating the patient quickly.