Friday, April 7, 2017

See also:

Adult Airway Day (August 22, 2017)

Annual conference with hands-on experience with faculty led stations - as below. "The difficult airway is simply one that cannot be quickly obtained" (Burgess 2022)

Station #1: Direct Laryngoscopy, Fiberoptic Intubation with Mannequin

  • ENT direct laryngoscopes
    • First-line laryngoscopes: Dedo & Lindholm (most H&N staff), Kleinsasser (DVD)
    • Lindholm Adolescent Scope
    • Hollinger anterior commissure scope - use for better exposure anteriorly
    • Weerda laryngoscope - useful for supraglottic laryngectomies
    • Not shown: Jackson “sliding” laryngoscope - has removable component to facilitate insertion of endotracheal tubes
    • Not shown: Rudert laryngoscope - triangular shape (used in past by Dr. Trask)
  • Station objectives
    • Recognize the different types of laryngoscopes and their uses.
    • Be able to set up a direct laryngoscope (Dedo) with light source and jet ventilation (also discussed in table 3)
    • Appreciate the relationship of the anterior commissure scope with a cuffed 5-0 MLT ET tube
    • Understand the proper technique for a flexible fiberoptic intubation
    • Difficulty airway management- adult awake fiberoptic intubation

Station #2: Rigid Bronchoscopes, Telescopes, and Foreign Body Removal

  • Rigid bronchoscopes
    • Storz bronchoscopes (2): adult (6.5 & 7.5 x 43 cm; 8.5 available but in separate location), adolescent (5.0 & 6.0 diameter x 40 cm)
      • If you can, try to use at least a 6.5 bronchoscope, because your optics will be much better (with the corresponding 5.5 mm telescope); if you need to use a 6.0 or smaller bronchoscope, you will unfortunately be forced to use a 2.8 mm telescope.
    • Adult Pilling bronchoscope (7.0 & 8.0 diameter x 40 cm)
      • Mostly used for airway dilatations
      • Key maneuver: At level of vocal cords, rotate bronchoscope clockwise 90 degrees, so that longer edge of bevel is on the right.  Advance scope w/ bevel tip in center of larynx and shorter edge of bevel sliding against left cord, to avoid catching and traumatizing right cord with bevel tip.
  • Two methods to place rigid bronchoscope
    • Directly
    • Use Jackson sliding or anesthesia laryngoscopes to guide bronchoscope to level of vocal cords
  • Sample rigid bronchoscope set-up:
    • (Direct view) Bridge adaptor for endoscope vs. glass eyepiece vs. rubber telescope adaptor (for quick transfer b/w endoscope & optical forceps)
    • (Top) Prism with connection to light cable
    • (Oblique) Instrument guide for flexible suction catheter vs. jet ventilation cannula (though we usually don’t jet through bronchs)
    • (Bottom) Adaptor for respirator
  • Foreign body instrumentation
    • Storz optical forceps (preferred): adult or adolescent
    • Nonoptical forceps- rarely used
    • If there is concern about the foreign body fitting through bronchoscope, you should brace the foreign body against end of bronchoscope and remove both together as one unit.  You do not want to shear the foreign body off the end of the bronchoscope.
  • Station objectives
    • Be able to put together all the different parts of a bronchoscope and to use optical forceps and rigid endoscope with the bronchoscope.

Station #3: Advanced Techniques - Jet Ventilation and Endotracheal Tubes

  • Jet ventilation:
    • It is important to note that there are 2 different proximal jet cannulas (adaptors that connect the laryngoscope to the jet ventilator), one for the Dedo laryngoscope and one for the Kleinsasser laryngoscope
    • If the one you are given doesn’t seem to fit, ask for the other one!
  • Special intubation techniques
    • Flexible fiberoptic laryngoscope for intubation
  • Types of ET tubes
    • Standard, MLT, oral RAE, nasal intubation, laser-safe, EMG laryngeal monitoring, cuffed vs. uncuffed
  • Laryngeal mask airway (LMA)
  • Anesthesia direct laryngoscopes = MacIntosh, Miller, Wisconsin/Wis-Hipple
    • In kids, the Wisconsin 1.5 blade provides a nice intermediate size blade between the more commonly available Miller 1.0 and Miller 2.0 straight blades.
    • Glide scope
  • Station Objectives
    • Understand the proper setup of a Dedo scope for Jet ventilation
    • Recognize and understand when to use the different types of endotracheal tubes, so that you can appropriately communicate with your anesthesia colleagues
    • Understand the role of the LMA and different anesthesia laryngoscopes in airway management

Station #4: Adult Emergency Airway Cart

Emergency Tracheotomy Tray Emergency Tracheotomy Set

  • Station Objectives
    • To familiarize oneself with the role of the airway cart in the various settings
    • To become familiar with the content of the cart and how best to utilize it.

    • To recognize the necessary equipment for achieving a surgical airway

       

References

Burgess MB, Schauer SG, Hood RL, De Lorenzo RA. The Difficult Airway Redefined. Prehosp Disaster Med. 2022 Dec;37(6):723-726. doi: 10.1017/S1049023X22001455. Epub 2022 Nov 9. PMID: 36349956.

Benjamin B, Lindholm CE.Ann Otol Rhinol Laryngol Systematic direct laryngoscopy: the Lindholm laryngoscopes  2003 Sep;112(9 Pt 1):787-97.

Langvad S, Hyldmo PK, Nakstad AR, Vist GE, Sandberg M. Emergency cricothyrotomy--a systematic review.

Scand J Trauma Resusc Emerg Med. 2013 May 31;21:43. PMID: 23725520

Nemeth J, Maghraby N, Kazim S. Emerg Med Clin North Am. 2012 May;30(2):401-20. PMID: 22487112