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).
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.
Herewith a quick tutorial on the use and placement of the bifurcated, dual-balloon ‘EZ-Blocker’ bronchial blocker. More videos on the DLT vs BB debate, the other blockers, and troubleshooting advice to follow. Comments welcomed as always!
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.
Despite making a previous post and video to explain the way to make sure the device switches on, I regularly get told that the Pocket Monitor (PM) for our C-MAC video laryngoscope is not working/charging/switching on. This is in fact a design feature to prevent accidental activation or discharge. Watch here to find out more:
Thanks to the lovely Sam Adams for playing along…good career in acting if anaesthesia were to ever become boring!
Folks are frequently reporting that our C-MAC Pocket Monitor is not switching on when they plug it in to a blade and want to use it, without realizing that it automatically goes into a hibernation mode if left in the open position for more than 15 minutes. Check out this quick AirwayHowTo video on solving this problem:
Rigid endoscopes are very valuable tools for intubation in certain difficult scenarios, but are not commonly used in most centres. The techniques and learning curve differ significantly from normal direct laryngoscopy, requiring independent practice to become proficient. Pictured here are (left to right) a rigid bronchoscope, Bonfils, Levitan and Shikani optical stylets (rigid intubating endoscopes).
This is the set-up for basic training on an UCT Anaesthesia Airways course. Which of these devices have you used? Do you have tricks or comments to share?
Open access meducation for all aspects of airway management