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.
Here’s the poster by Kingma, Hofmeyr, Zeng, Cooramasamy and Brainard that has generated a fair amount of interest (>10k impressions on Twitter). Full analysis hopefully coming soon to a journal near you. Bottom line? In a difficult airway, you’d best be using a bougie or stylet, no matter who you are. As far as bougies go, preloading rather than railroading is faster and seems better. Click on the image for a full-resolution PDF (2Mb).
Want to talk about this? Comment below or ping @surferkirst @rosshofmeyr @TheSharpEndCrew on Twitter!
A video example of performing a straightforward intubation using the AirTraq optical laryngoscope, here coupled with the WiFi-enabled camera unit to allow image capture. Note the optimal positioning (“Rule of 3”):
Epiglottis visible at the top of the screen
Vocal cords central in the vertical axis
Interarytenoid cleft in the lower half of the screen.
This intubation is using a reinforced (“armored”) endotracheal tube, which is sometimes more difficult than a standard ETT, as it is a little floppier. The AirTraq makes it simple in this instance. The reinforced ETT was used to facilitate patient positioning for a neurosurgical case.
Over the past two weeks, I have been involved in three cases where all means of laryngoscopic intubation failed – including multiple different blades, introducers and highly skilled hands – and the airway could only be intubated with a flexible fibreoptic ‘scope. These three cases illustrate the type of pathology that can make even video laryngoscopy (VL) difficult or impossible:
A morbidly obese patient in traction with a high spinal injury
A patient presenting with late-stage, advanced laryngeal carcinoma with both supra- and infraglottic involvement and masses
A child with Pierre-Robin Sequence presenting for mandibular distraction surgery.