All posts by Ross Hofmeyr

Should you use an introducer (bougie/stylet)?

While many of us would think this is a daft question, when we went hunting for high-quality evidence, it was not very forthcoming.  Hence:  science to the rescue!  Watch a brief (<120 second) overview of the study:

Kirsten Kingma and Ross Hofmeyr give a #litbit overview of their paper published open-access in Emergency Medicine Australasia comparing intubation with different introducers in a simulated easy and difficult airway.

What’s the bottom line?  We should always be using and introducer (bougie or stylet) when approaching a predicted difficult airway, and possibly for any emergency or rapid-sequence intubation… at least in manikins!  What’s needed next?  A robust RCT…

Capnography resources

Quick head’s up:  If you don’t know it already, capnography is one of the most powerful tools in airway management.  In the process of collating some pre-learning material for a workshop, I realised that I was gathering quite a few nice resources on capnography.  To save you the time, I’ve linked them together on a new Capnography page here on OpenAirway.  There are online tutorials, an interactive quiz, reference waveforms, and dynamic videos to be found. Please feel free to suggest further resources in the links!

AirwayHowTo: Clean a CMAC VL

If you work in an environment without constant access to staff to clean and process your video laryngoscopes, you need to know how to do it yourself. This quick video demonstrates pragmatic cleaning of the C-MAC VL (original and latest version) for low-risk patients. Where there is high infection risk, heavy soiling or blood on the blades, high level disinfection may be indicated.

Site updates: Courses & Lectures

Some updates to the site to improve your access and experience!  The various courses which are on offer in conjunction with the UCT Department of Anaesthesia and Perioperative Medicine have been added to a new ‘Courses & Lectures‘ page here on OpenAirway, which also now includes links to the content and resources available from many of our previous workshops, courses and congress meetings, as well as a collection of the lectures that are available online.  These are being added to steadily, but if you can’t find something, use the search function on the tool bar!  The menu has also been update to make the various items easier to find.

Airway topicalisation: How to make the GSH mix

There are many ways to adequately topicalise an airway, which depend on personal and institutional experience, and the available drugs in different parts of the world.   This is a step-by-step set of instructions on how to make the “GSH Mix” in use at Groote Schuur Hospital, Cape Town, South Africa.  Note that we don’t have access to certain ingredients which are commonly available elsewhere (such as viscous lignocaine or Moffett’s solution).

End product:  4 % (or 5%) lignocaine with 20 mcg/ml adrenaline.

You’ll need:

  • Three 10 ml syringes
  • Needles to draw up drugs
  • Syringe labels and marker pen
  • 5 ml 10% lignocaine (‘Remicard 10% in SA)
  • 1 mg/1 ml adrenaline (1:1000)
  • Two 10 ml normal saline ampoules to dilute
  • Nebuliser mask

Label the syringes clearly:  100 mcg/ml adrenaline (1:10 000) and 4 % lignocaine with 20 mcg/ml adrenaline:

Draw the adrenaline (1 mg/1 ml) into the adrenaline syringe, and dilute with saline to 10 ml (100 mcg/ml, or 1:10 000 solution):
Transfer 2 ml (200 mcg) of the dilute adrenaline into the mix syringe: Add 4 ml of the 10 % lignocaine solution to the mix syringe (use all 5 ml if you want to make a 5 % solution rather than the usual 4 %): Add saline to the mix syringe to a total volume of 10 ml.  You now have 4 % (or 5 %) lignocaine with 20 mcg/ml adrenaline: Put 5 ml of the mix into the nebuliser mask, ready to commence topicalisation by neb: Split the remaining 5 ml mixture into two 10 ml syringes (using your third syringe) to be used for spray-as-you-go through the scope if needed:
Put the rest of the adrenaline solution somewhere safe (or discard it), and draw back the plungers on the mix syringes all the way.  This introduces air which then blows the local mix through the scope when you do spray-as-you-go.  Don’t forget to give the neb plenty of time to work (15-20 minutes, until complete). Don’t forget to use adjuvant strategies to improve your topicalisation, such as gargling, atomised spray, or topical gel/paste, and enter your cases into a registry such as TheAirwayApp so that we can build worldwide experience with different techniques!

Nairobi Airway Course 2017: Photos

Some photos of the action at the Nairobi Surgical Skills Centre this week. Many thanks to the local faculty from the University of Nairobi and other institutions, the companies that supported use of the facilities and equipment, and the enthusiastic delegates!



Resources and notes from the course are available on the course page here

Airway Abbreviations

Herewith a collaborative effort from the airway Twitterati to establish a list of common airway abbreviations:

  • AFOI  –  Awake fibre-optic (or flexible optic) intubation
  • ApOX  –  Apnoeic Oxygenation
  • BB  –  Bronchial blocker
  • BVM  –  Bag/Valve/Mask device (see BVMR)
  • BVMR  –  Bag/Valve/Mask/Reservoir device (see BVM)
  • CICO  –  Can’t intubate, can’t oxygenate  (see CICV)
  • CICV  –  Can’t intubate, can’t ventilation (CICO now in use)
  • CL  –  Cormack-Lehane grade
  • DL  –  Direct laryngoscopy
  • DLT  –  Double-lumen endobronchial tube
  • DSI  –  Delayed sequence induction
  • ESA  –  Emegency Surgical Airway (see FONA)
  • ETI  –  Endotracheal intubation
  • ETT  –  Endotracheal tube
  • EtCO2  –  End-tital carbon dioxide
  • EXIT  –  EX-utero Intrapartum Treatment
  • FB  –  Foreign body
  • FETO  –  Fetal Endoscopic Tracheal Occlusion (or Fetoscopic EndoTracheal Occlusion)
  • FiO2  –  Fraction of inspired oxygen
  • FOI  –  Fibre-optic intubation
  • FONA  –  Front-of-neck access (see ESA)
  • LA  –  Local anaesthetic
  • LMA  –  Laryngeal Mask Airway (trade name, see SGA etc)
  • MAD  –  Mucosal Atomisation Device
  • MP  –  Mallampati grade
  • NPA  –  Nasopharyngeal airway
  • NODESAT – Nasal Oxygenation During Efforts at Secuing A Tube
  • OPA  –  Oropharyngeal airway
  • PLA  –  Perilayngeal airway
  • RSI  –  Rapid sequence induction
  • SAD  –  Supraglottic airway device (see SGA, EGA, XGA)
  • SGA  –  Supraglottic airway (see SAD, EGA, XGA)
  • THRIVE  –  Transnasal, Humidified, Rapid-Insufflatory Ventilatory Exchange
  • VL  –  Video layngoscopy
  • XGA  –  Extraglottic airway (see EGA, SAD, SGA)

Contributions/comments?  DM @openaiwayorg or @rosshofmeyr

Thanks to @AirwayMxAcademy for initiating the idea!

VLVids: Intubation in Spinal Immobilisation

Clinical video demonstrating a collection of techniques to facilitate elective intubation for a patient with an unstable cervical spinal injury in caliper traction.  Note the sideways introduction of the VL blade due to limited space for the VL handle, optimisation of the view (‘Rule of 3’), use of a coude-tipped bougie (introducer), and the 3-part technique to advance the endotracheal tube when it catches on the arytenoid cartilage (pull tube back to disengage, rotate 90 degrees counterclockwise, advance tube).