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.
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.
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!
Click the image to go to the article on Anesthesiology News
This month’s edition of Anesthesiology News features a worthwhile piece from Prof John Doyle, in which he poses 7 questions on the current state of airway management to 6 airway experts from around the world (Abdelmalak, Cooper, Frova, Rosenblatt, Spiegel and Doyle himself), and collates their responses into a dialogue. Definitely worth reading to determine what some (certainly not all) of the biggest names in the world are thinking on:
For what it is worth, here are my own answers, distilled into one-liners. I’m very willing to enter into discussions about them!
Place for DL in the future: Definitely; just look at the huge needs in the Third World and then ask if (even very cheap) VLs are a priority.
Use of bougies: Along with good positioning and mastery of face-mask skills, I think this is one of the most neglected parts of airway training.
What airway algorithm: The expert can do what they wish; the trainee should learn something appropriate (like ASA or DAS); the infrequent practitioner should use the Vortex.
Trache vs Cric: Cric all the way; scalpel-finger-bougie
Impact of VL in AFOI: Definitely reducing the use of AFOI, but a flexible scope remains an essential tool, and every airway master should be competent in it’s use.
Favourite SGA: Would love to say the 3gLM, but we need to publish the research first…
Favourite VL: Hasn’t been invented yet, but watch this space. The C-MAC with Pocket Monitor is my daily workhorse, but I have (and use) GlideScope, McGrath, AirTraq, King Vision, etc.
There are a lot of excellent (and complementary) views expressed in the article, which are worth reading. Check it out!
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:
https://www.youtube.com/watch?v=Ap18Dm_-6TE
Open access meducation for all aspects of airway management
