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.
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
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!
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!
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).
Demonstration of an unhurried intubation using a bougie preloaded in the reinforced endotracheal tube in an Airtraq optical laryngoscope with Airtraq Cam video adapter. You can note ideal positioning of the Airtraq (“Rule of 3”) and the steering ability of a coude-tipped bougie.
This real-life videolaryngoscopy example (RSI of a patient with a head injury for craniectomy) shows some commom errors, and room for improvement. Three major areas that could be better to spot here:
Less-than-ideal positioning of the VL blade. The tip is too deep (over the epiglottis, rather than in the vallecula), which reduces the available space to manipulate both VL and ETT, the field of vision, and the ability to perceive the approach of the ETT.
Quick suctioning of the secretions/saliva/mucus would reduce the risk of losing the view or the patient aspirating.
An introducer (stylet/bougie) would greatly assist passage of the ETT through the cords.
A classic example of good videolaryngoscopy technique being thwarted by not always using an introducer (stylet or bougie). Note the clinician performing the intubation gets perfect, optimised VL view (Rule of 3), but then struggles to pass the ETT anteriorly enough, losing time. Although this was no problem for the well-oxygenated patient in this case (and the intubation is still under 45 seconds duration), in a critical case it can lead to desaturation, frustration, and possible intubation trauma.
Another quick training video, on the basic techniques of driving a flexible scope (fibreoptic or video) for intubation. This was made specifically as a primer for people in our own department taking part in a training study, but hopefully it is useful to a larger audience!
Please put your comments and (hopefully constructive) critique below. As always, you’re welcome to use with attribution!
Technique for using the Aintree Intubating Catheter (AIC) to exchange between a supraglottic airway (SGA) and endotracheal tube (ETT). This is typically required when an airway has been ‘rescued’ with an SGA that is not designed for direct intubation, with a narrow internal diameter or obstructions. The Aintree has a length of 55cm, internal diameter of 4.8 mm (not 4.2 as stated in the video) and external diameter of 6.0 mm, allowing a paediatric fibrescope or flexible intubating vide endoscope (preferably 4 mm or less) to be passed through the AIC, into the trachea, and then an ETT railroaded after removal of the SGA over the AIC. If that sounds confusing, watch the video!
Tips/tricks/advice/critique? Leave a comment!
The Difficult Airway Society (DAS) have a nice poster guide to help you remember how to do this – click the image below to open/download. (Open access).
A description of the technique for intubating through a supraglottic airway that offers a sufficiently large internal bore to allow an appropriate-sized endotracheal tube using an adult fibreoptic or flexible video endoscope. Take note of the method of providing ventilation during the endoscopy!
As usual, this is an unscripted video, and constructive critique is welcomed to help us improve the educational offering.
Open access meducation for all aspects of airway management