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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.

Transcription

CHAPTER 1

Hello, My name is Abdullah Hassan Pratt. I'm an emergency medicine physician and I am an assistant professor of emergency medicine at the University of Chicago Medical Center. Today, we will be covering quite a few things. The first of which are airway techniques for trauma patients in the scenario most likely of level one traumas, but many of these techniques can be used in any airway situation and especially the more difficult airway.

CHAPTER 2

So, if you are ready to begin, let us start with a general overview. The setup is the most important part of any airway situation. Always being able to anticipate what kind of trouble you may get yourself in or the patient may decompensate in a certain situation is crucial to being able to prepare for that and respond in a timely manner rather than being retroactive. So, to first start out with, the initial setup as you all see behind me, you all have a monitor.

You all have a ventilation set up for our respiratory therapist. On that ventilation set up, when we first walk in our trauma bays, includes all of the equipment to secure an airway to also test the entitled CO2 like we've talked about before in this video, as well as other methods such as suction, securing, end-tidal, capnography, those of the like. Also hanging on the respiratory therapist's ventilator, happens to be a bag valve mask, which is a crucial component to any airway. Always remember that if you have nothing else, a bag valve mask, oxygen, and possibly an oral pharyngeal airway or a nasal trumpet, it may be all you need with good technique to maintain oxygenation and ventilation in any situation. Oftentimes, many residents, many physicians may end up in sticky situations as we would call it because of trying to intubate, trying to establish a definitive airway, or even a surgical airway, like we'll talk about, without the need when they have a bag valve mask and good techniques such as jaw thrust, okay? So, done are those components.

Other things that we will cover in this video, happen to be one of our unique novel setups for airway equipment that happens to have worked best for our residents, for our attendings, and overall in specifically trauma situations. We have taken what we've learned as a new trauma center having opened in may of 2018, and we have perfected a model for us that we feel like is pretty standard now in terms of where equipment is located and the ease of access in reaching that equipment, especially when time is of the essence. So as you see to my left, you have an intubation tower that ranges from everything from a map of what should be set up prior to an intubation, all the way to the difficult airway methods - all of those things in chronological order. But, if you also notice, if you might be asking yourself: "What's that red box doing over there?" This red box is what we all in airway and in emergency medicine refer to as tackle boxes. This used to be one of the standards, the mainstays, of airway management, but as you'll see pretty soon, there's quite a big difference between a very unorganized tackle box with just a number of different things. Many times residents and attendings just dump this thing out, look for what they need, and then there's a big mess. May not find it at all. But, what we have learned is that when dealing with very, very high acuity patients, such as what we see here on the south side of Chicago, with the high rate of penetrating traumas, that a much more organized and efficient method was what was required to have consistency and a high standard of care when trying to establish an airway. So we'll talk about those things today, okay?

So, as we move, just to kind of set a little bit of better basis for you all, the first things that usually happen when a trauma comes in is that we get an alert that that trauma is coming in. We get a story about what's going on. And sometimes we're able to extrapolate from that story whether this is someone who is going to need an airway, whether this is someone who's going to be a difficult airway. And that allows us to prepare a little bit better. But, at the bare minimum, we are always prepared just due to the systemic safety net that we have in place, in terms of efficiency, to be able to handle whatever happens. Many times patients may come in, they may look stable, they may look like their airway's intact. and they may deteriorate very, very rapidly, which may cause us to shift in terms of our course, and then go ahead and establish a more definitive airway. So that's what we're going to talk about today, okay?

CHAPTER 3

So the first thing, when we talk about preparation, as you look behind us, we have a monitor trying to make sure our monitor is on, working, hooked up, so that we can get a good oxygenation is very important. But prior to even that step, before the patient even rolls in the trauma bay, oftentimes the first things that I will do is check my equipment.

I do a dry run. I check my suction. I make sure that my suction canister and tubing is hooked up properly. And as you can see, sometimes it's kind of jumbled. You have to kind of untangle that. Once you untangle it, the next step is finding a Yankauer, and that Yankauer is used to establish a more strong suction flow. Okay? Sometimes we use it without that, but many times we use it strictly with the Yankauer, okay? Once that Yankauer is there, we go ahead and we make sure that the suction is hooked up, that all of our valves and ports are closed, And then we turn on the suction. Last thing we do is, we test it to make sure that the suction is working properly. Now oftentimes, just for convenience so that I know where it's at, I'll usually put my suction right here under the patient's bed until further notice. Right now, we'll leave it on top. Okay?

Next thing that I usually do is open a bag valve mask. As we talked about, if all you have is a bag valve mask, oxygenation equipment, and the ability to test with your monitor to see if you're properly oxygenating and ventilating, that is all you need in that situation. So we'll go ahead and open up our bag valve mask. So we have the actual mask, we have the bag valve, and then lastly, we have the oxygenation tubing. Okay? We will set that off the side. The oxygenation tubing is just usually attached with a quick rubber band. We usually pop that rubber band. Take the oxygenation tubing. We then elongate the bag. It's up here. Okay? Once that bag is elongated, we make sure that it will inflate. We hook up the oxygenation tubing directly to oxygen. You want to turn it on. We usually put it on two liters. Okay? And then from that point, you want to make sure that your actual mask is attached, and you want to make sure that it's functioning, okay? You want to make sure that this actually gives air every time, okay? So, that's our bag valve. That's our suction.

The last thing that I usually look for is what we call an oral pharyngeal airway. What that oral pharyngeal airway allows you to do is it allows you to maintain a patent airway. It allows better oxygenation and ventilation for that patient. So right now we're going to go ahead and go to our tower, so that we can see some of these things in the exact order that we hook them up in.

So as you see, these clips - these ensure quality control. Many of our technicians who restock this after every single use, they make sure that these clips are all full and that they haven't been tampered with. That lets them know that they do not need to restock that. Any of these clips that are popped off, just me popping one of these clips, means that our technicians in the emergency department need to go back and restock that, even if it's full, it needs to be checked. There's a roadway map, just like for us physicians that shows what all equipment that we need prior to an intubation, that roadway map. They also have a similar one that allows them to stock. And if you take a look at that roadway map, this is just a series of images along with checklists that lets them know each and every drawer what should be in there, okay?

CHAPTER 4

When speaking about now, setting up for your airway. Prior to the patient coming in, we have that bag valve mask. We have our suction with the Yankauer that we've tested. The bag valve mask is hooked up to oxygen. We also have our video laryngoscope, here. And if you can see, we have regular video via CMAC. On our tower, what we've also noticed is that for very very quick airways, we like to keep a few of our materials that are normally stocked in our towers on the CMAC machine itself. The reason for this is that there are some times when an airway needs to be established, that's not exactly in our trauma or resuscitation bay, but I know that prior to starting an airway, I'm going to grab my video laryngoscope. And sometimes if you have a good quality control, where our technicians also restock this tower with the bare necessities, you can just take this and run. And so you can go outside with this. You can go into a hallway and intubate with this if you need it. And so as you see here, what we have are our MAC 4 video laryngoscope. Okay? We have our actual camera module that slides in, okay? And we can go ahead and hook that up. Put that aside. This slides in just as such. You want to do a quality control test right here on your screen. Make sure I can see my hand, make sure it's focused. Make sure it's not too cloudy. I usually set that aside to my left because I'm right-handed so I want to go ahead and intubate with this in my left hand and a tube on the right. We also have ET tubes here as well, usually a 7.0, also a 7.5, as well as an 8.0, okay? The last thing, we have a 10-cc syringe that we will hook up to inflate. And we also have bougies that we can use in the place of a stylet. The top shelf has endotracheal tubes. It also has 10- or 12-cc syringe for inflating our balloon. It has a bougie that's here that we normally use in place of a flexible stylet because of the versatility of the bougie, and as well as, if we can't visualize an airway, we can always give an attempt with a blind intubation with a bougie. Okay? Next drawer down, We have our rigid stylet, which is normally used with a hyperangulated D-blade as we call it, but it's just another variant of our laryngoscope blades, which gives you a tighter angle that you're going to be able to make for a more difficult airway. And this rigid stylet has its own specific technique. And we're going to talk about that a little bit later. Last thing you have a smaller MAC 3 size, similar to the MAC 4, but usually for smaller women, even teenagers. Lastly, you have that hyperangulated D-blade as we talked about, which as you can see, if we compare that to the MAC blade, has a more acute angle. Okay? So the D-blade has a more acute angle than the CMAC 3 or 4. It gives you a little bit better utility. Sometimes it's an option if you have a difficult airway.

CHAPTER 5

For standard airway techniques, all the way to the more difficult airway, where we keep all of our supplies happens to be in this airway tower. As we mentioned before, this airway tower has gone through a number of reiterations that we've done internal studies on and found that the best iteration happens to be one where it's convenience first. So in terms of convenience, for us residents at the time, when I first started on trauma when we first initially opened, what we found is that the most common things that one was going to need for an intubation was a quick tube, the laryngoscope, whether it's a direct visualization laryngoscope or the video laryngoscope, the 10-cc syringe, a flexible stylet, as well as a nasal trumpet or an oral pharyngeal airway. So those are the things that we most commonly use. So we placed those at the top drawer. So now as you see, we're going to pop our clip. This is going to mean that this needs to be restocked. It's going to indicate for our technicians that it's used, but we'll go ahead and give it a shot.

So, as you see, in the first drawer, we have direct visualization laryngoscope blades. We have everything from MAC 4's to a MAC 3, smaller. We also have one of the things that I'm very fond of, which is a Miller blade, though this is something that has lost favor amongst anesthesiologists and emergency medicine physicians, you never know when you need it for the patient who has the larger tongue or an airway where more in-line visualization is needed. And it's something that we encourage our residents to learn actively,so as not to lose those skills. So as you see, we have four different types of blades. Put those back. We have our oral pharyngeal airway, which is always something that I reach for whenever I'm going to think about bag valve masking someone. This helps so many times in many situations where everybody's asking for a tube, and you say, you know what, we're doing a good job, because we've got an OPA, oral pharyngeal airway, or a nasal trumpet, either one can be used. Sometimes we use both to, if someone has a big habitus, or they're losing their airway pretty fast, and that bag valve mask. So this is also something that we keep here. We keep it in a number of sizes ranging from the small white to the slightly larger green, to the yellow, and then, to the big one, the red one, okay? The 12-cc syringe for inflating the balloon is also in this drawer. The handle that attaches to your direct laryngoscope is also in here, okay? Common size endotracheal tubes ranging from a 6.5 to a 7.0 to a 7.5, and an 8.0 are also in here. And lastly, 60-mm syringes are also in here. The 60-cc syringe is in this top tower primarily because it allows us to deflate and anticipate a patient coming in with a supraglottic airway from EMS or from our paramedics. And that balloon can be deflated with the 60-cc syringe. If you don't have the 60-cc syringe, you can also cut that supraglottic airway, the king or the LMA but the standard way of doing things will be to hook it up. And when you're ready to swap out airways you can go ahead and draw off with a 60-cc syringe effectively deflating that balloon. Lastly, but most importantly, before intubating you need to have a stylet of some sort. And here we have the commonly use flexible stylet. This stylet can be bended to conform to any situation. If you need a little bit more curvature, a little less curvature, everybody has their style. This is the most commonly used stylet in intubations both in anesthesiologists as well as emergency medicine physicians. So that's here as well. All of these things, if you can see, are labeled. They're labeled not only for us to know where they are but also for our technicians to know where to place things. Most of this, as you can imagine, becomes muscle memory meaning that I'm not even usually having to look for something. You do this enough times, I know exactly where things are. I know a handle here. I know a blade's here. I know OPA is here. I know my syringe is here. A tube is here, and a stylet is there. So you can effectively move from left to right and grab everything you need in the correct order. The same way you go top to bottom. So you can grab OPA, nasal trumpet for when you're ready to bag. As you progress forward, you can grab your blade first, then your handle, which will be hooked up. And now you're ready to intubate on the fly in the moment, if you have a bloody airway, or if you do not have a video laryngoscope. Lastly, you have your tubes and then your stylet. That's the last step. Just in case you have an assistant, you can be working on these maneuvers, bagging with the oropharyngeal airway, direct visualization, while someone else is progressing through setting up your ET tube for definitive airway intubation. I'm glad these things are disposable. So they're meant for one use. As you can see, one good use, sometimes not even one use. All right, you want to make sure that works. Set that aside. Now that we have our direct visualization as a backup, we also have a video laryngoscope as well. You have an OPA as well as the bag valve in order to just bag with a good jaw thrust and good positioning and a sniffing position.

We can now progress forward to some of the other things that you may have in your airway cart, specifically for us, because we now assume that we've intubated with these equipments, right? The next thing is going to be post-intubation. So the care for someone who's intubated does not stop just once a tube is in, right? You can place that tube in. You can have an end-tidal CO2, all of those things, but let's talk about some of the things that may be in a post-intubation. So post-intubation, you have a reiteration of the things that our respiratory therapist may have. We have our anchoring, securing strap method that secures an ET tube in place for a patient. The last thing you want is to get a great airway, definitive airway, and then it slip out when you're heading to CT, or up to the operating room, or even if a patient's not well sedated and they rip it out themselves. So this thing will buy you a lot of time and save a lot of trouble. Okay. You also have our CO2 detector, which is one of the three most important confirmative actions that allows us to know that a tube is properly placed in the trachea and not in the esophagus. This is commonly known as the color change. So we'll open that up and let you see that. All right. So this would hook straight directly up to the tip of a tube, okay? Once you've fully intubated, and you're bagging someone up, okay? So that's our color change. All right? This will change from purple to yellow if you have CO2 that's being exhaled as someone ventilates. And if you can see, right here, there's a perfect slot for this right up there on top, as there is a perfect slot for our laryngoscope, our blade, and handle, okay? As well as our tube - there's a perfect slot for that as well - endotracheal tube right here. All right. There's a slot for our oral airway, right here. There's a slot for the stylet, which is in there, okay? There's also our bag valve mask, suction Yankauer, okay? But also things that are in here - once a person's fully intubated, we want to continue to measure the waveform of our CO2. And we use that through capnometry, okay? This would plug directly into our monitor, okay? And then it plugs directly in to one of our connection devices that goes immediately on the bag. This detaches, so you detach your mask from your bag. You have an empty bag once this person has been intubated. You can take this, okay? This plugs directly to the bag. That's our stylet there. And once someone is intubated, and we'll demonstrate this later, this plugs there. So now as you bag, you should be getting CO2 off of this. This will be red on the monitor. This is another way of confirming that your tube is in place, as well as measuring the patient's ventilation. As this decreases, you can assume that their ventilation is decreasing as well. There may need to be adjustments. Your tube might be out of place, or that patient may actively be in a code situation and may be going into shock and not perfusing their tissues as well, okay? So we'll detach that for the time being until we fully demonstrate this later. Okay. We'll place our tube back here, stylet where it needs to be, our capnography cord, right there. Okay? As well as our suction.

Now, as we move forward, going down our airway cart, we want to talk about the next drawer, which just represents endotracheal tube sizes of all sizes. Sometimes you need a much larger endotracheal tube. If this is a 9.0 for a certain person when you normally may use the 7.5, if they may have aspirated a lot of secretions, blood, food particulates, a number of things, that larger tube size will allow you to suction that much easier to evacuate the lungs, and allow for better ventilation, okay? All the way to smaller tubes. Sometimes you have someone with a very, very narrow airway. They may have had vocal cord stenosis. They may have all kinds of scar tissue, cancer patients, people who have received radiation, or in the rare situation, even though this is an adult ER, we also work in the children's ER, sometimes you may get a child, and you may need a much smaller ET tube. So, going from left to right, the smallest we have is a 3.5, this would be for an infant. Okay? All the way to the coveted 6.0. So the 6.0 tube can be used normally with cricothyrotomies as well as narrow airways during a cricothyrotomy, as we'll talk about, we'd like to use a Shiley tracheotomy tube, but in the case of not having that trach tube, you can use the 6.0 ET tube to maintain an airway that we call a surgical airway if need be. But we'll talk about that as we go. All the way to an 8.0 tube, and then sometimes we may have a 9.0 too. We also have extra blades in this draw as well. So this is kind of an extra supply draw.

Moving down, you also have what we talked about before, which are supraglottic airways. These are airways that would be used in a case where either an EMS personnel couldn't get an intubation because they were moving too fast. They had to hurry up and get a patient or they couldn't bag well enough. And so they placed the supraglottic airway as a way to ventilate and oxygenate a patient when the time does not allow, or the skill level may not allow, someone to establish a definitive airway via intubation. So we'll take a look at those. So here, as you can see, we have our laryngeal mask airway. We commonly refer to that as an LMA. This is a very simple procedure. You just tuck that, place it in the airway. And this allows you to bag directly from this end, up someone, until you can establish a definitive airway, or if you're preparing for a surgical airway in that situation. Okay? We also have our King airway. This king airway is a second type of supraglottic airway, different users use different ones. We hope that we never have to use them but we all train on both of them just in case we need to use them at different times. I've used both.

As we go down our airway pathway, we have a few extra supplies in the second to last drawer. Those extra supplies include extra suction canisters, extra suction tubing, extra Yankauers for suction, extra oxygenation tubing, nasal cannulas, as well as extra masks if you're delivering in-line meds or if you're placing someone on a non-rebreather prior to intubating.

Last but not least is our difficult airway drawer. We all hope that we don't have to reach for that drawer. This is the drawer that has surgical equipment. This is if you can't get any of these other airways established, or if prior to someone coming in, you can anticipate that it's going to be a difficult airway. In the context of trauma, this means someone who's had a crush injury to their neck. This can also be, if someone has had penetrating trauma to their neck, where they have an expanding hematoma or collection of blood, that's starting to occlude their airway due to the pressure. In those situations, you want to have these supplies ready just in case you have to establish a surgical airway or a more difficult airway pathway. In this drawer, as you can see, you have surgical preparation from your bouffant, you have a headlight just in case things are getting very, very messy, okay? You have surgical gloves, so that you can remain sterile if you need to establish a surgical airway. First thing at the top, you'll see a blade. In this case, we're using a 10 blade. Some people also use an 11 blade as well. I find that the 10 blade is a little bit more sturdy. It helps you get through thicker tissues of the neck, as well as if someone has a larger habitus, and you're already going through multiple layers. This is a good blade to have. Many surgeons and emergency physicians carry one of these in their front pocket. Okay? You have the actual cricothyrotomy tray. So this cricothyrotomy tray is in preparation for that surgical airway. This does not actually have the tracheostomy tube. This doesn't have a Shiley in it or a trach tube. This has just the tools that you'll need to actually cut down, open up, dilate that trach. Okay? And we'll look at some of those contents in just a second. You have your sterilization prep as well. Okay? You also have a nasal endotracheal tube. Other considerations when dealing with a difficult airway is what happens if you can't pass the tube through the throat. Certain issues where it may come up whether someone has soot in their airway, maybe there's been a fire. Maybe they've had what we call an inhalation injury. And in those situations, if they're still awake we would prefer to nasally intubate. What this means is that we place a tube through the nostril that allows us to intubate. At times this was done blindly. Sometimes you use a laryngoscope in the mouth to help open the airway and then you place the tube through the nose and you watch the tube pass. But nowadays we've moved to fiberoptic airways, meaning that we can look directly at the cords through the nose, and then that allows us to pass a tube over that camera, which allows us to pass that through the cords, establishing an airway. Now, if you're wondering why this has a funny shape as compared to our other ET tubes. Okay? This is a standard endotracheal tube. This is the nasal endotracheal tube. The difference is the length. As you can imagine, if you're going through someone's nose to intubate them - in this way - going through their nose to intubate through the curvature, that's a further distance. And sometimes it's not long enough or it places the end of the endotracheal tube right at the nostrils, which allows for easy disconnections, you know, if the patient moves, it's a very aggressive procedure, it can dislodge many different times. So we use the nasal endotracheal tube that has this slight Z-bed to it, okay? And we'll talk about how to set this up and we'll go through that a little bit later. Also, we have an atomizer. Now this atomizer is a device that can be hooked up to a syringe. And this allows us to anesthetize someone's airway prior to placing that nasal intubation tube. If you can imagine - to have a tube placed down your throat can be very uncomfortable, but more importantly it causes a gag reflex that may allow you to vomit slightly and then aspirate what you vomited. That's a horrible situation for us. If we can prevent that, we can. One of the main ways is by using an atomizer to spray. It creates a mist of of anesthetization medications such as Lidocaine, effectively removing the gag, making that person a little bit more comfortable because we don't want to put them under or to induce any kind of paralytics while that person is asleep because then the airway may close, and you may not get a better shot at it. So being able to atomize allows them to stay awake, while we prepare and actually attempt an intubation. It's a good tool. I recommend many people to have it. Lastly, we have the tube that one would use when they actually perform a cricothyrotomy. Now, we call it effectively the Shiley. It's just the brand name. What it really is a tracheostomy tube. And it has the cuff. It has an inner cannula. It also has straps to secure it as well as other different tools within it. And we'll take a look at that a little bit later as well. Okay?

CHAPTER 6

So, bag valve mask. OPA. Bag. OPA goes in, right side up, swivels around. Here, goes there. Good jaw thrust. You want to make sure you got a great jaw thrust. Bag. You want to watch for chest rise. Okay. Once you're ready to intubate, take that aside, set up, direct, ET tube. I already have one set up here. Here, here. OPA out. Scissor. Good position. Here, Sweep the tongue. Airway. You want to get a good look. Good in-line. I'm going to pass the tube. Once you think that's in, take out. Here. Inflate. Bag. A little bag, you see good air. At that point, you can also use your color change, here. That goes on there. And this would turn colors - will change the yellow. Disconnect. We'll do another iteration. Lets see, deflate. Okay, all right. What you all just witnessed was a standard direct visualization with a MAC blade intubation using a flexible stylet and a 7.5 ET tube. That's the most common way that many people intubate.

CHAPTER 7

For our next technique, we will use the video assisted laryngoscope via the CMAC. We'll always want to make sure that you can see clearly, this detaches from here as such, that goes in. You want to make sure that's nice and snug, hold that with your left hand. You want to be able to scissor the mouth open, slide in. You want to first take a look via direct visualization the same way you normally would with a non-video assist, and then I will only look to this video assist if I absolutely have to. But in this case, just for demonstration purposes, already got a great airway. Okay? Going to take our ET tube. You want to gently slide it right through the cords. Okay? Once that's through the cords and at a depth of about 23 at the teeth, we're going to take out, we're going to remove the stylet, we're going to inflate our balloon. Once that's inflated, twist it off. We'll take our bag valve mask again. We're going to attach. We'll look for color change. Look for chest rise. Take a listen with our stethoscope to make sure we have good bilateral breath sounds. Okay?

For the next technique that we will show, we will use the hyperangulated D-blade. Now remember, the D-blade for video assisted laryngoscopy or laryngoscope has a sharper, more acute angle, which allows you to push the airway a little bit more anterior, or it allows you visualization if a person's airway is slightly displaced anteriorly just due to natural causes or things like masses, trauma, hematomas, etc. This allows you a slightly different look and view. If your standard Mac or Miller will not achieve the view that you would like. Oftentimes, we will lead with this with pre-knowledge of the case of the patient. If you know it's a larger patient, if you know there's a lot of blood in the airway, sometimes this is your first go-to, but oftentimes this is your secondary backup, if your initial technique doesn't work. If you try to visualize initially with a Mac or a Miller, you can't see, you go ahead bag the patient back up with that oral pharyngeal airway, getting them to a hundred percent oxygenation. And then you go ahead while you set up, you go ahead and try again once you're comfortable, once things are kind of at a calm and steady state. As you can imagine, sometimes it's never a calm, stable state, and you have to prepare this pretty fast, okay? So we'll take a look at how that works. This is our D-blade. Take our camera. It goes in again, want to make sure that we can see. The difference for the D-blade is that you also have to have a stylet that matches this curve. So this curve that we have is specially formulated to use a rigid stylet with this. Okay? So we will use our rigid stylet. So this stylet does not allow you to bend it in a similar way that the flexible stylet does. The flexible stylet can be made to any shape: straight, curved, anything that you'd like to accommodate your airway. But when you're forcing this stylet with a tube over it through an airway, this can oftentimes bend on you and it can straighten out when you don't necessarily want it to, allowing you to not be successful in your initial attempt. So we'll try it with the rigid blade, okay? Here, so now this is prepped. As you can see, this angle matches the angle of the blade. This is going to become important. When you understand the difference in techniques between a standard intubation with a flexible stylet and the rigid stylet. The flexible stylet - once you're going to take your look, you can hold very gently between your first, second, and third digits. For the rigid, it will only work if you follow the curve of the blade in a similar way as if this blade was a train track, and this was the car wheels of your tractor. So you want to hold it in your palm as such, not like you held the flexible style. The reason why is because if you hold it this way, you will never fully follow the curve. It's harder to get your wrist to turn that curve. So we hold it as such with our thumb in place ready to pop the stylet when you need to. So we'll gently place it in there. You'll go ahead and scissors one more time. Once you get the airway view that you need, you're going to go ahead holding your stylet and tools as such. And you're going to just follow the curve. You want to just follow that curve through the cords. So as you all can see, we're through the cords. Once you get through the cords, you're going to go ahead and pop the stylet and you're going to simultaneously advance your tube while pulling out the stylet. You're going to place it at a depth of your comfort. For this person, we're going to say 24. We're going to go ahead and inflate. We're going to take our bag valve mask again. We're gonna hook up. And then I'm going to watch for chest rise. And we're also going to listen for bilateral breast sounds. Lastly, we're going to check our color change to make sure that we've got good end-tidal, okay?

CHAPTER 8

Last considerations before we get into some more of our fiberoptic techniques are what if you don't have a flexible stylet or a rigid stylet, and what if they don't work for you? If you get in a situation where you've tried the flexible stylet, it straightens out on you, it becomes something that doesn't work and it doesn't allow you to pass your tube through the cords. What if you try now you're rigid and you can't follow that angle. Now what's the next go-to? Before you go reaching for that 10 blade, or that 11 blade, I want you to take consideration of what we have right here on our tower, which is the gum elastic bougie. The bougie, which we find on our cart - it's just on the side of the cart. They're normally hanging right here. This bougie can be used with any of our laryngoscopes. So the bougie comes straight. It can be used with a Mac. It can be used with our straight Miller. So with the Miller blade, it can also be used. And we'll demonstrate how it can work in each of these situations, slightly differently. So as you can notice, our Miller blade is straight. As opposed to our previously talked about Mac blade. The Miller has a completely different technique of intubating as well. It allows you direct in-line visualization. As you can see here, it almost creates a straw, or a tube, that you can look directly through. It allows you, if the tongue is large, if there's a lot of habitus, neck masses, once you get a view with your Miller, that's it. You can go ahead and intubate. The bougie can be used for that situation, but a flexible stylet can also be used. I typically like to use the bougie here in these situations. So to demonstrate a Miller intubation, we'll take our - make sure our light is working just as such. The technique of Miller intubation is also slightly different. So we can take our bougie, and we like to quick load our bougie by backing it up through the front of the ET tube so as not to catch the tip that comes pre-bent for the bougie. Once you get a portion of this that comes out the back, you can rotate that around, and you place it directly through the eye of the ET tube. Once there, you want to eliminate as much of that end as possible by pulling on the longer end. And you want the longest portion possible because you're going to pop this. You'll still attach your 10-cc syringe as such, in preparation. And oftentimes, this is how we'll prepare. For Miller, I may leave this amount of bend, but as you see when we do our next blades we're going to add a little bend to that. Okay? You want to hold it with your index finger, or your second digit, right here on the inside of this Q shape. Your middle finger, or third digit, right on the outside. And then your thumb stabilizing this whole junction. This gives you an added advantage when using a bougie because if you can imagine, if you were only holding a bougie by itself, like it can be used. It's hard to tell if you're rotating or not because it's slippery, there are secretions, you have different amounts of gloves on, surgical or standard gloves, but the only different directions you have to move with the bougie is deep or superficial, left/right, and then you have rotation of the tip. To give you an added advantage, by holding here, it allows you better manipulation, as well as it allows you to know whether your bougie is rotating or not. And so we'll see that right now. When you Miller, you go ahead and scissor like you normally do. But for a Miller, you can hug. You can go as deep as you'd like to, knowing that this is probably going to end up in the esophagus. The standard technique for the Miller is then to find your airway as you back out. And we're going to practice that. So I'm in, I see esophagus. I back out, I see my airway. I take my bougie and I gently thread it through the airway. I should feel tracheal rings at this moment. So I can feel the ridges of the trachea, which further confirms that I'm in. I can go ahead and take my blade out. I'll pop - with these two fingers, that will pop off. Always hold the bougie. Now you can go ahead and slide, catch it from the other end. And now, without even looking, I can go ahead and advance this tube, knowing that the bougie is already in the trachea. Okay. All right. Once in, I can take the bougie out. I'm now at a depth of about 24 at the teeth. All right, same standard technique. We're going to inflate here. We're going to attach our bag valve. And then you're going to confirm - same thing. You're looking for chest rise. You're listening bilateral breath sounds. Looking for color change. We'll go through a few more bougie techniques to prove that you can use this with any blade. The utility of the bougie is that you can use it with any different blade from the Miller to the Mac, to the hyperangulated. It's really the universal tool.

We've seen the Miller intubation utilizing the bougie, loaded with the 7.5 ET tube on it. At this point, we'll now try to do that and demonstrate that using a Mac video assistant laryngoscope. So again, camera goes in, lock it in. Have your bougie with your tube. And so for this iteration, we're going to scissor here, sweep our tongue. Now we're taking a good look. And so, as you can see, this is my tongue above. This is the epiglottis. I'm going to slide my blade right in that vallecula. I've got a great view. Holding in a manner that we talked about with our three fingers, we're just going to gently place the bougie right through the cords. Okay? Once I feel those rings or the cords, I'm going to go ahead. I can leave my blade in the mouth, it's a plastic blade. I'm going to go ahead - if I'm one handed, I can pop it off with just one hand. Holding the bougie, grab it from the back end, And then you're going to advance, advance. I'll take a look, make sure that that went through the cords. It did, as you can see, we confirm. The blade comes out. I go to the depth of my choosing, either 23 or 24 centimeters. Remove the bougie. We inflate once more. We attach. Bag up. We make sure that we're inflated all the way. Bag, and you're in, okay? So, we will try other technique as well.

Now we've seen utilizing the bougie with an ET tube loaded over it for a Miller blade, direct visualization, as well as a video laryngoscope, utilizing a Mac 4. Now we will attempt that same technique utilizing that hyperangulated blade. Again, this all comes into consideration when you're down a stylet, either the rigid or the flex, or if neither one has worked in that situation. The beauty of a bougie is that I can bend this bougie into whatever shape that I want it to be, similarly to how we needed to use the hyperangulated, rigid stylet. In this case, I will give extra angle to my bougie. I want to match it to the angle before I go to intubate that's similar to here. As you can see, that's not the same angle right now. So what we would do is we would curve this to the proper angle that I'm comfortable with. Perfect there, we're going to lock our bougie back in place through the eye. Just as such. I only want a little bit there so that I can pop it off. Try to check my angle a little bit - it's similar, it needs a little bit more. Okay, this looks pretty good. That looks like that will follow that angle very well. Okay? Same technique. I will scissor the mouth open. Go ahead and place my hyperangulated. As you can see, we've got a pretty good view. I want to hold our bougie with our three fingers, and then just gently follow the curve, straight in through the cords. Once you're through those cords, you can give a little bit of advancement, you can take our blade out. Okay, we pop. And from that point on, we just follow that curve. Okay. We inflate once more. And then you can bag up, okay? Same deal, bag up, okay? All right.

CHAPTER 9

So now I will set up for the last thing that I want to talk about, which is just very difficult airways utilizing the A Scope. For special considerations when evaluating someone for the need to intubate them, if they've had airway injury, expanding hematoma, inhalation injury from a fire, oftentimes we will utilize a fiberoptic viewing mechanism to not only look at the vocal cords to see if there's swelling around the cords or the arytenoids, but also if we needed to, it would also allow us to quickly intubate that person nasally and then establish that definitive airway, therefore averting danger. The worries with that is that oftentimes with inhalation injuries, expanding neck masses, the time until someone loses their airway is very slim. That kind of reaction, those kinds of things, we anticipate. And so we do this earlier, rather than later if you were just viewing, the proper mechanism for establishing your A scope - because of the ambu-scope, we call it an A scope. We first want to anesthetize the patient with Lidocaine. You can use 4% Lidocaine in that situation to anesthetize the oral pharynx and the nasal pharynx. This allows the loss of gag. Once that person is properly anesthetized and has been prepped and consented, you would then go ahead and start by inserting the tip of the A scope. Once you establish orientation, up/down, left/right, twist/turn. You have rotational axis, up/down axis, and deep and superficial. So as we've talked about, we're going to first enter the nose. This patient's already anesthetized. We've already established what the best nostril is. And the goal in this situation is just to view the cords. So we're going to start by going in. We're going to ride the floor of the nasal pharynx. Okay? So at this point, we've established a great view of our vocal cords, which are right here in the center of the screen, as well as the epiglottis, which is about at your 11 o'clock position. We can rotate to get a better view. And now we will attempt to determine if there is swelling, if there's occlusion, or other type of soot damage to that area. if there is, then we may make the decision at that point to go ahead and intubate. Now in that situation, if you've already loaded an ET tube, that's perfect. You can go ahead and intubate. In this person's case, we haven't. So we will back out, we will use our nasal ET tube. We will go ahead and load it fully up. And many times people go ahead and start. You can either fully load as such - this oftentimes can affect your ability to manipulate. So what many people do instead of this technique is that they pre-load into the nose, okay? So they take the tube, they go ahead, place it in the nasal pharynx. Okay? Once in there, they go ahead and take their camera. They slide it through. Until you don't see anything else. And so you're seeing tube, tube, tube - and you may have a second hand in these situations - tube, and the first thing that I see out of the tip of my tube are the vocal cords. Those same vocal cords we saw before, we're seeing again. You also see the epiglottis. And at this point, you can go ahead and advance through the vocal cords, okay? You can go ahead and give a little bit of a bend. Okay. All right, now we're through the vocal cords. We're seeing the rings of the trachea. The mannequin trachea in this situation, okay? And now we can go ahead and advance our tube. Okay, sometimes it takes a little bit of twisting. You can also use a skinnier tube in different situations. This is often the most uncomfortable portion of the procedure for the patient. Once I feel like that my tube is fully in, okay? Okay, so there it is. My tube is now fully in. I think it's in the cords, okay? I'm going to back my camera out and confirm that it's through the cords. If I do not see vocal cords on my way out, then I know that my tube is deep enough and it's passed through the cords. And so we will take a look at that at this point. So we'll slowly back out. I don't see cords. I'll try again. No cords. So we'll go straight into the trachea. That means that this intubation is a successful one. I can go ahead and remove my camera at that portion. We'll go ahead and inflate. Inflate it. We'll attach, and then we'll inflate.

CHAPTER 10

We have now learned all of our standard airway techniques ranging from preparation all the way to a bag valve mask with an oral pharyngeal and airway, all the way to direct intubating with a laryngoscope on the DL, Miller, Mac. We've also done video laryngoscopy. We've also used fiberoptic laryngoscopy and nasal intubation. At this point, if all of those methods have failed, supraglottic airway has failed, you should now be in the position to make a decision to establish a definitive airway via a surgical airway. In our context for trauma and emergency medicine, that means specifically a cricothyrotomy. The procedure of a cricothyrotomy should always start like any other procedure with prep, making sure you have all of the utensils that you need. There are a couple of different iterations that people usually use with this, but they both start with prepping, right? You want to make sure that your site is prepped clean, Betadine, chlorhexidine, all of those may work. You want to make sure that there's a wide, well-draped area. Sometimes that's not always available, and you might have to establish this airway sooner rather than later. That's understandable. The next things to do are to familiarize yourself with the two different types of tubes that you may use - a 6.0 tube can be used. If you also are lucky and you have a Shiley 6.0 tracheostomy tube, you can use that as well, okay? Next step, you're going to want to make sure that you have a bougie. You can use this. Some people may not necessarily need this if you get good visualization, okay? You need your 12-cc syringe. And lastly, you need your cricothyrotomy tray, okay? Within that cricothyroidotomy tray, you have 11 blade, you have a dilator, or a spreader. This actually spreads to allow you to visualize the surgical field. You have hooks. This is a hook that hooks the skin. You have curved hemostat, you have scissors, and you have forceps. From start to finish, once you've prepped someone, you want to make sure you can identify landmarks. So you have the thyroid cartilage, just below that you have the cricoid cartilage. Between that large prominence, which is known as the Adam's apple, which we've just referred to as the thyroid cartilage, between that and the cricoid cartilage, is the cricothyroid membrane. Once you stabilize a patient's thyroid cartilage, with your first and third fingers, your middle and our thumb, you want to go ahead and use that index finger, and you want to palpate that membrane. Once you've felt that membrane, you're going to go ahead then, and use your blade. You're going to make a vertical incision. We can bluntly dissect out this patient's neck, okay? Down until we actually see the membrane. You can then use hooks to remove that skin on the top and bottom. And now once you see that membrane, you're going to want to make a horizontal incision through the membrane. You want to go one way, turn, make it the other way. At this point, you should feel air or you should be able to see bubbling. Once you actually have incised that cricothyroid membrane, the first technique, if you have very low resources, would be literally to just place the bougie into your trachea, feel the rings. Then you want to place the 6.0 tube over that. This should easily go down within. Once you go in a few inches, you can remove the bougie, and you can bag up. The second method, once you've now gotten to that cricothyroid membrane, you spread out. You've got a good look at that membrane. You do your horizontal incision at that point. And then instead of going ahead and using the bougie, you can take your Shiley out. You're keeping that finger in place to make sure that you're not losing your airway. You can insert this sideways, and then you want to rotate it downwards and into the patient's trachea. Okay? Once it's in the trachea, you remove the stylet. There's an inner cannula here. This goes within. It snaps into place, and you can bag up. The modified method of this would be once you've gone ahead and incised, you can still use a bougie to get within the airway. You can use your bougie as a stylet to then back it through your Shiley all the way until it's within the trachea. At that point, the bougie can come out, and you can still bag up. Those are the different mechanisms for establishing a surgical airway via cricothyrotomy.

CHAPTER 11

So today, the things that you have gone over should have been preparation, all the equipment that you need, proper preoxygenation. You've also gone over the pharmaceuticals that we use in terms of rapid sequence intubation via induction paralytics and post-intubation care. But, the techniques that we've learned have ranged from bagging with an OPA or a nasal trumpet, to all the way to using proper suction technique, to direct DL visualization using a laryngoscope blade, Mac, Millers both can work, but remember, there's a different technique. The different stylets that you use from flexible, to bougie, all the way to a rigid. Remember with the rigid you have to use that hyper-acute blade. And you can do that via video or direct laryngoscopy. You've learned fiberoptic techniques. And now you've also learned how to establish a surgical airway. Thank you all for your time.