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…
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.
As promised, my presentation from the 9th National Assembly on Paediatric Emergency Medicine currently being held at the Apollo Institute of Medical Sciences & Research in Hyderabad, India. There is much more content in the audio, which I will try to add to the post later when it is available.Thoughts? Comments? Post them below!
As promised/per usual, here’s my presentation from the current National Assembly on Paediatric Emergency Medicine, being held now (16-19 Feb 2017) at the Apollo Institute of Medical Sciences & Research, Hyderabad, India. Much of the content is in the audio, of course…which I will post if/when available.
Comments welcome below as usual!
One of the greatest influences on my understanding of the geometry of the airways, and thereby the technical skills and processes required to place airway devices of all types, has been the work on publications of Dr Kenneth Greenland. Greenland’s publication in the BJA in 2010 should be required reading for anybody who performs intubation. However, if you want to really understand theories of the airway curves and columns, I highly recommend getting it from the horses mouth. Here below are several videos in which can Greenland explains his thinking and theories. While they are a little longer than your average #FOAM material, I cannot recommend them strongly enough.
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.
Ross’s talk from the 2015 SMACCdub meeting, with credit to #SMACC and the Intensive Care Network.
This and many other talks available on the SMACC home pages.
Click here for the slides, podcast and original abstract on ICN.