Tag Archives: difficult airway

Endoscopy, Equipment, Rigid scopes, Video laryngoscopy

VLVids: Dual endoscopy intubation with compressive thyroid mass

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Here’s a great example of using a dual endoscopy technique not only to manage a potentially difficult airway, but also to give more insight into the pathology itself. This short video shows the intubation of a patient who presented for thyroid surgery with a large mass compressing the trachea, as well as some other predictors of difficult intubation: slightly limited mouth opening, a short neck, and potentially challenging dentition. We wanted to see the position and degree of tracheal compression present before advancing the tracheal tube, but also to place the modified tube with nerve monitoring sensor precisely at the right depth.

Video laryngoscopy with a Mackintosh-style blade provided good access to the airway, and allowed us to spray the vocal cords and trachea with local anaesthetic, avoiding neuromuscular blockers. We could then place the tip of the tube through the vocal cords and observe the trachea and subglottic space using the Bonfils optical stylet. Both images are displayed side-by-side to coordinate view. It’s a good tip to put the device in your left hand on the left side of the screen (and corresponding right-handed device on the right) to promote good orientation.

If you’ve tired dual endoscopy for a clinical case, pop a description or brief story in the comments!

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Algorithms, Equipment, Guidelines, Intubation, Lectures, Paediatric, Video laryngoscopy

NAPEM’17: Paediatric Difficult Airway in the ED

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!

Airway Assessment, Algorithms

Difficult Face Mask Ventilation – ATOTW 321

The newest edition of the Anaesthesia Tutorial of the Week (ATOTW #321) covers the much underestimated but critically important topic of predicting and managing difficulty in face mask ventilation.  Irish anaesthetists Jonathan Holland and Will Donaldson have created a useful resource for anyone studying or performing airway management, or refreshing for exam purposes.

ATOTW is a free resource created and hosted by the World Federation of Societies of Anaesthesiologists.  You can sign up to receive the weekly mails here, and download this edition on mask ventilation here:

ATOTW 321 – Difficult Mask Ventilation

The authors discuss the predictors of difficult mask ventilation and report/propose another two mnemonics, to add to the existing stable (MOANS, BONES, etc):

Two mnemonics for prediction of difficult face mask ventilation
Two mnemonics for prediction of difficult face mask ventilation.  Source: ATOTW 321

I’ve always used MOANS for mask factors (like I use LEMON for laryngoscopy), but all these mnemonics cover the same ground.  MOANS, for instance, stands for

  • M   Mask seal factors, like beards, NGTs, odd shaped faces
  • O   Obesity and causes of Obstruction, like tumours/angioedema
  • A   Age extremes (the elderly and very young)
  • N   No teeth (or nasty dentition)
  • S   Snoring and Stiff lungs (the latter being issues like inhalation burns and acute bronchospasm, where the higher pressures required increase the risk of gastric insufflation and Splinting of the diaphragm)

As you can see, they are all much the same, although there are a few things that are not covered by every algorithm.  The purist would point out that obesity is defined as a BMI of >30 kg/m2, not 26 as stated in the table.

Difficult_Mask_Algorithm
Hollan & Donaldson’s flowchart for management of difficult face mask ventilation. Source: ATOTW 321

The authors then present a useful flowchart for addressing unexpected difficulty, which is quite sensible.  It is much in line with the DAS guidelines and other algorithms for general airway difficulty, and useful for instruction.  Of course, in a dire emergency, using a cognitive aid such as the Vortex would be  effective.