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Airway Techniques and Equipment

Dany Accilien, MD1*, Dexter C. Graves, MD1*, Nicholas Ludmer, MD2, Stephen Estime, MD3, Abdullah Hasan Pratt, MD2

1 UChicago Medicine, Emergency Medicine Resident
2 UChicago Medicine, Assistant Professor of Emergency Medicine
3 UChicago Medicine, Assistant Professor of Anesthesiology & Critical Care

* These authors contributed equally and are co-first authors.
These authors contributed equally and are co-primary investigators.

Abstract

This video abstract discusses airway management techniques in trauma resuscitation. It outlines the preparation and equipment used in patients with impending airway failure that require manual or mechanical ventilation. We discuss the innovative airway towers used in the University of Chicago emergency room as well as the general approach to airway management. We also go over the different types of laryngoscopy, assist devices, and cricothyroidotomy surgical airway procedures.

Introduction

Clinicians generally classify airway management techniques into two categories: noninvasive (passive oxygenation, bag-valve-mask ventilation, and noninvasive positive-pressure ventilation) and invasive (supraglottic airways, endotracheal intubation, cricothyroidotomy, and tracheostomy).1 Trauma airways are particularly critical airways as these patients have the ability to deteriorate quickly from airway compromise and hemodynamic instability due to their traumatic injuries. We will describe a systematic approach to the management of trauma airways. 

General Overview

In anticipation of an incoming trauma patient, preparation for airway management is a critical component of trauma resuscitation. In general, begin by assembling your team, identifying which individuals will be available and their roles (e.g, respiratory therapy, medical technicians) in helping you control the airway. 

Begin by ensuring that your patient display monitor is on and ready for the ancillary team to place necessary leads on the patient upon their arrival. Be familiar with what ventilation system your department and what equipment your respiratory therapist (RT) will bring along. Essential airway equipment is generally located on the ventilation system. This should have the material needed to secure the airway once established as well as key post-intubation equipment such as the end-tidal carbon dioxide monitor (EtCO2), suction, and a bag valve mask (BVM). Familiarize where your equipment is located, whether it’s a traditional Airway Tackle Box or a structure deemed most efficient at your department.2 A suggested approach is one used at the University of Chicago’s Trauma Center, which relies on an “Airway Tower” in order to ensure efficiency and quality control. Adjust your preparation as needed per your emergency medical services (EMS) reports if the information is provided prior to the patient’s arrival (e.g burn injury, extensive facial injuries, surgical airway intervention anticipation). Keep in mind that patients may appear stable on arrival yet quickly deteriorate during their clinical course during trauma resuscitations so it is suggested to always be prepared to manage a critical airway with all trauma resuscitations. 

Preparation and Equipment Check

Ensure that your patient monitor is on and ready for the ancillary team to place necessary leads on the patient upon their arrival and obtain key vital signs including your oxygenation levels. It is essential to check your equipment for any faults or deficiencies prior to the patient’s arrival. 

In anticipation of possible large-volume emesis or hemorrhagic airway, arrange the necessary components to suction the patient. Your suction canister and tubing should be checked to ensure they are working appropriately. Attach your Yankauer to your suction tubing and ensure all the valves and ports along the suction canister are closed and turn on the suctioning apparatus to ensure there are no leaks. Place the suction apparatus in a convenient location for you that’s easy to access when necessary. We suggest placing it within the suction packaging and tucked underneath the patient’s bed until it is needed. 

Please keep in mind that some Yankauers require you to cover a small safety vent hole at the base in order to provide high-quality suctioning (some providers place tape over this covering in order to assist in covering the small hole, or you can use your thumb or index finger while suctioning).3 

After assembling your suction equipment ensure all components of the bag valve mask are available, including the detachable mask, bag valve, and oxygenation tubing. Elongate the bag as most are compressed for packaging and attach the tubing to your wall oxygen and start with two-five liters. Attach the mask to the valve and compress the bag as a test to ensure air is being provided as expected with each bag compression. 

Consider an oropharyngeal airway or nasal trumpet to have available bedside if needed to augment oxygenation, but be cautious as significant (or suspected) facial or nasal injuries are a general contraindication to these airway adjuncts because of potentially worsening existing injuries or causing damage to the cribriform plate.1 

Videolaryngoscope and Quick Airways

Videolaryngoscopy has become the recommended first-line approach for trauma airways when available to provide increased chances of first-pass intubation. Become familiar with the video laryngoscope equipment available in your department, whether it is the C-MAC, Glidescope, or another brand. 

The GlideScope video laryngoscope and the C-MAC have key design differences, and thus slightly different techniques may be needed to achieve glottic exposure. The C-MAC has a blade shape much like a standard Macintosh curve, allowing for a conventional approach similar to direct laryngoscopy. In contrast, the GlideScope video laryngoscope blade has a 60-degree curvature. Although the hyperangulated curvature affords improved glottic exposure in difficult airways, it also requires the use of a specially designed curved rigid stylet (GlideRite stylet) to facilitate the direction of the tracheal tube to the laryngeal inlet.4

Establishing a quick airway is essential in securing the airway in many cases, but particularly emergent in traumatic airways. In order to facilitate efficiency during the process, consider placing a few key pieces of airway equipment (Bougie, MAC 3 or 4, 7.0 or 7.5 endotracheal tube, 10-cc syringe, and Flexible Stylet) on the tower holding the videolaryngoscope in order to provide ease of access. Place the camera modulator into the laryngoscope blade you have chosen and test it to ensure the output is clear and focused. The bougie, rigid stylet, and hyperangulated D blade should be considered to be placed nearby for quick access as well, but these adjuncts are discussed in more detail in later sections.

Standard Intubation and Difficult Airway Equipment Overview

Based on our experience at a high volume level 1 trauma center, our airway tower is constructed based on efficiency and most commonly needed intubation equipment. We will discuss the intubation process in subsequent sections, but first, we will go over what equipment to have and manners to arrange it. The most commonly used equipment and necessities observed during trauma airway resuscitations generally consist of quick and easy access to the following:

  • An endotracheal tube (ETT)
  • Laryngoscope (direct visualization laryngoscope or the video laryngoscope)
  • Video laryngoscope
  • 10-cc or 12-cc syringe
  • Flexible stylet
  • Nasal trumpet and/or oropharyngeal airway
  • Bag valve mask

Therefore, the equipment listed above is placed within our top, most accessible drawer in the airway tower.3 

The first drawer consists of direct visualization laryngoscope blades as well as the attachable handles, oropharyngeal airways, nasal trumpets, 10 or 12-cc syringes, various-sized endotracheal tubes, a flexible stylet, and a 60-cc syringe (to allow inflation and deflation of supraglottic airways placed in the field via EMS prior to their removal). This first drawer is designed to provide assistance in a stepwise progression of airway management from top to bottom and left to right, with adjuncts becoming more advanced alongside increasingly necessary advanced airway management (e.g., the adjuncts for bag valve mask assistance such as the oropharyngeal airway (OPA) are available on the left, followed by the equipment needed to intubate in a stepwise fashion as you go towards the right of the drawer). For example, if you have an assistant, you can ask them to start from the right and organize your ETT and stylet while you set up your laryngoscope equipment. 

The second drawer consists of equipment needed postintubation such as an ET tube holder (strap method) and CO2 detector (color change), capnography.1 

The third drawer consists of various-sized ET tubes and extra direct visualization laryngoscope blades. 

The fourth drawer consists of the supraglottic airways, which include the laryngeal mask airway (LMA) and the King airway. Ultimately an ETT will provide the best physical barrier to protect from aspiration and should be the provider’s main goal.5

The fifth drawer contains extra supplies such as suction canisters, suction tubing, Yankauers, nasal cannulas, and masks. 

The sixth and final drawer consists of equipment needed for anticipated difficult airways. Anticipate the use of difficult airway equipment for those you suspect have had crush injuries to the neck, expanding hematomas, extensive facial injuries, or known foreign bodies obstructing the airway. This drawer contains items such as surgical scrub cap, headlamp, sterile gloves, number 10-blade scalpel, a cricothyroidotomy tray, tracheostomy tube, nasal ETT, and atomizer. 

Direct Visualization with Intubation

Preoxygenation is a process that displaces nitrogen with oxygen in air spaces to extend the safe apnea time.1 It should be initiated in all patients as soon as it is determined a patient will require intubation. Using a BVM or non-rebreather (NRB), administer 100% oxygen delivered at 15 L/min. A nasal cannula can also be used with BVM or NRB to maximize oxygenation.1 Additional adjuncts including OPA, nasopharyngeal airway (NPA), jaw thrust, and the chin lift maneuver may be used to optimize preoxygenation. 

Position the patient in the “sniffing” position with the lower neck flexed and the head extended for the optimal angle. A neck roll may be placed under the patient’s neck to help.

Remove any dentures or foreign bodies from the oropharynx that may obscure your view and suction any visible secretions with your Yankauer.

With the laryngoscope (Mac or Miller blade) held in the left hand, use the right thumb and index finger to scissor open the patient’s mouth. Insert the laryngoscope into the mouth scooping the tongue underneath the blade in a right to left direction and advance into the larynx. Once the arytenoids are in view, lift the epiglottis. Using the right hand, insert the ETT/stylet following the curve of the blade and visualize the end of the ETT going through the cords until the cuff is below the cords. An assistant should be available and ready to remove the stylet. Remove the laryngoscope while holding the ETT in place and inflate the balloon. Secure the ETT and connect to an oxygen source (i.e., BVM or ventilator).

Check for the ETT placement by auscultation, tube condensation, visualizing chest equal and bilateral chest rise, visualizing color change on colorimeter from purple to yellow. An end-tidal CO2 detector should eventually be connected to the circuit.1

C-MAC Video Laryngoscope

Video laryngoscopy allows transmission of the view via an external monitor for enhanced and shared visualization. It provides an advantage in patients with difficult airway anatomy. The Glidescope and C-MAC are two of the most commonly used devices. 

First, check to make sure all equipment and wires are connected and working properly to ensure smooth intubation. The technique used in video laryngoscopy is similar to that of direct laryngoscopy; however, once the blade is inserted into the oropharynx, direct your attention towards the external monitor. Visualize the ETT going through the vocal cords just as in direct visualization and confirm the placement. 

Video-assisted laryngoscopy also has the added advantage of allowing the use of a hyperangulated blade. The sharper, more acute angle of the blade allows the user to visualize more anterior or displaced airways. Masses, trauma, hematomas, or anatomic variations are some of the causes of displaced airways. When using a hyperangulated D blade, you must use a rigid stylet that follows the angle of the blade.1

Bougie Intubation

The gum elastic bougie is an important adjunct for difficult intubations in which the glottis cannot be adequately visualized. It is found on the side of all of our airway carts readily available. Its design allows it to be used with any of our laryngoscopes. The plastic introducer is long and flexible with an angulated tip. The angulated tip allows the bougie to maneuver to locate anteriorly located cords. Once inside the trachea, the operator should be able to find the tip of the angulated bougie moving against the tracheal rings confirming the correct location.6 The ETT can then be loaded onto the proximal end of the bougie and into the cords blindly. The ETT can also be preloaded onto the bougie. The bougie can be bent to follow the curvature of any of our laryngoscopes and used as a backup adjunct.

Laryngoscopes

Three common laryngoscope blades that we use are the Macintosh, Miller, and the hyperangulated D blade. Each blade contains a light source connected to a handle. The Mac and hyperangulated blades can be used with video laryngoscopy, while the Miller blade is to be used exclusively for direct laryngoscopy. 

The Mac blade is a curved blade designed to be inserted into the vallecula and indirectly lift the epiglottis upward. The Miller blade is a straight blade designed to be inserted posterior to the epiglottis in the larynx and directing the epiglottis upward. The hyperangulated blade has a 60-degree curvature designed to give better visibility with more anterior airways.7 

Fiberoptic Flexible Scope

The fiberoptic A scope allows for direct visualization and intubation in an awake trauma patient with anatomy or pathology that would make standard intubation challenging. Several patient populations in which awake intubation may be the best approach include burn victims with inhalation injury, penetrating neck injuries, expanding hematomas, and limited neck mobility. If you anticipate a difficult endotracheal intubation or rescue oxygenation with BVM, fiberoptic awake intubation should be considered. The fiberoptic scope allows for the visualization of the airway to assess for swelling, bleeding, or pathology and also for nasal intubation to avoid unstable oropharyngeal pathology.1

First, anesthetize the nasopharynx and the oropharynx to inhibit the gag reflex. You may also need to use glycopyrrolate to dry up any secretions that may inhibit the view. Once properly prepped, insert the tip of the scope into the nasal canal guiding it along the floor of the canal. Follow the pharynx down until the cords come into view. If you anticipate airway swelling or smoke inhalation, the ETT may be preloaded on the scope. Advance the tube through the vocal cords visualizing on the Ambu screen. Fiberoptic intubation will usually require a smaller ETT.

Cricothyroidotomy

When all adjuncts have failed to establish a secure airway, a surgical airway must be established. You should be prepared for a cricothyroidotomy as a last resort backup for any intubation. The most important step of any procedure is preparation. Equipment needed for cricothyroidotomy includes a 6.0 ETT or size 6 Shiley tracheostomy tube, bougie, 12-cc syringe, and a cricothyroidotomy tray kit (includes 11 blade scalpel, dilator, skin hooks, curved hemostat, scissors, and forceps).

Locate the cricothyroid membrane between the thyroid and cricoid cartilage and stabilize the two cartilages with the non-dominant hand. Using a number 10 or 11 scalpel, make a 1–2-inch vertical incision in the midline through the skin and subcutaneous tissues. Now make a horizontal incision through the cricothyroid membrane. Place the back end of the scalpel handle through the incision to widen it. You can also use a skin hook and hemostat to open the incision. Place a bougie through the opening aiming inferiorly. Place a size 6 ETT or tracheostomy tube over the bougie through the opening sliding it inferiorly. Remove the bougie. Secure the tube and confirm the placement. The alternative option is to use the Shiley tube with the attached stylet instead of the bougie.8

Closing Remarks

Airway management is the first step in trauma resuscitation. In general, airway management always begins with preparation and anticipating the worst-case scenario. At the University of Chicago, our airway carts allow us to always have all of our supplies readily available for emergent and trauma situations. After you have located all of your equipment and decided which medications to use, we move on to preoxygenation with the techniques discussed. There are several intubation techniques that can be used for any scenario you find yourself in. Be sure to familiarize yourself with direct laryngoscopy, video laryngoscopy, awake fiberoptic intubation, and when all else fails, cricothyroidotomy surgical airways. Lastly, always confirm the placement of your airway device.

Supplementary Materials

Figure 1: Mainz Universal Algorithm for In-Hospital Airway Management. Ott, T., et al. Algorithm for securing an unexpected difficult airway: User analysis on a simulator. Anaesthesist. 2018. Jan;67(1):18-26. doi: 10.1007/s00101-017-0385-2.

  

Table 1: Rapid-Sequence Intubation Induction Agents. Tintinalli, JE, et al. (2020) Tintinalli's emergency medicine: a comprehensive study guide (9th edition). New York: McGraw-Hill Education.

   

Table 2: Rapid-Sequence Intubation Paralytic (Neuromuscular Blocking) Agents. Tintinalli, JE, et al. (2020) Tintinalli's emergency medicine: a comprehensive study guide (9th edition). New York: McGraw-Hill Education.

  

For further information on rapid-sequence intubation agents, please see the Pharmacology for Rapid Sequence Intubation (RSI) Airway Management in Trauma Patients article by Laura Celmins, PharmD, BCPS, BCCCP.

Citations

  1. Tintinalli, JE, et al. (2020) Tintinalli's emergency medicine: a comprehensive study guide (9th edition). New York: McGraw-Hill Education.
  2. Flint, LM (2008) Trauma: contemporary principles and therapy. Wolters Kluwer Health/Lippincott Williams & Wilkins.
  3. Cox, R, et al. Yankauer suction catheters with "safety" vent holes may impair safety in emergent airway management. Am J Emerg Med. 2017;35(11):1762-1763. 
    https://doi.org/10.1016/j.ajem.2017.04.009
  4. Mosier, J, et al. A comparison of the GlideScope video laryngoscope to the C-MAC video laryngoscope for intubation in the emergency department. Ann Emerg Med. 2013;61(4):414-420.e1. https://doi.org/10.1016/j.annemergmed.2012.11.001
  5. Hagberg, CA, et al. (2013) The difficult airway: a practical guide. United Kingdom: Oxford University Press.
  6. Hess, DR, et al. (2011) Respiratory care: principles and practice (2nd edition). Jones & Bartlett.
  7. Kaul, V. "All That 'Bladerdash.'" Critical Care Now, 17 Aug. 2020. Access: criticalcarenow.com/2020/08/17/all-that-bladerdash/. Accessed 21 Jan. 2021.
  8. Cameron, P, et al. (2011) Textbook of adult emergency medicine e-book (3rd edition). Churchill Livingstone.