In this episode I review the ABA topic of airway management. This is obviously a huge topic but in this episode I highlight key points about the components of airway management recommended by the ABA including identification of a difficult airway, management of a difficult airway, the difficult airway algorithm, different tools and adjuncts, and different types of tubes. This will be the final post of 2016. Thanks so much to all of you for listening and being a part of ACCRAC’s inaugural year in 2016. Here’s wishing you a wonderful start to your 2017!
Outline by April Liu: Episode 27
5 thoughts on “Episode 27: Airway Management”
Another tip for men with beards: You can apply a layer of Ioban or a Tegaderm over the patient’s beard and cut a small hole for the mouth and nose to facilitate mask ventilation.
Great point. Also I’ve seen ioban used. It may well be worth trying this stuff first if you have time before shaving the beard!
As I am re listening from pod-cast 1 again, this was meant to be for the nr 6 podcast (paraglossal approach) but it is probably better here as I added some things I have found useful.
I did not know it was called paraglossal approach but after watching the video It is very similar to the way I was taught a variant (Dr.Van G I am eternally thankful) of this technique but with a mac blade. I was just starting out as a bright green doc on an ICU and was not having much luck with the mid-line /sniffing position initially thought by an attending with glove size 9 and forearms like my legs. I just was not able to lift hard enough with a larger patient to do it that way. Then Dr Van G ( whose hobbies included difficult airways) showed me a different way using three fingers on the scope and absolute minimal force and got a grade 0 view where I got a 2b at best and a muscle ache in my arm. Still use this for pretty much every intubation (also works with glide scopes and such) .
Some random ideas and tips
I adopted is using a bigger blade as this is standard at my current German institution (always a mac 4 unless for paediatrics , sometimes a mac 5 for >195cm plus size patients especially if they have huge heads). The mac 4 blade is slightly thinner at the same length than a mac 3. At first it feels huge but I think it only has advantages
Additionally I tend to do a thumb transfer/fulcrum from a cross grip, where you move your thumb from the lower teeth to the back of the blade. By doing this you can much more effectively manipulate the blade as you move from a mechanically unfavourable configuration to a much more sensible link configuration and reverses any loss of mechanical advantage due to a longer blade into an advantage (it’s applied St. Venants principle, Prof. Alexander Slocum of MIT gives an excellent (and funny) lecture that is available on you tube). I have never seen anybody else do this but surely somebody must have thought about this before.
I always use double or triple gloves so you can quickly shed a layer and not smear everything with yukk and you still have protection on. Re-glove when you still have 1 layer left , because it is really hard to get gloves on with sweaty hands but not on a gloved hand).
Double lumen tubes:
When the patient can tolerate it I found it useful to decouple the patient from the ventilator momentarily to deflate the lung that is operated on. Once the lung has collapsed it will now have a higher opening pressure than the still expanded lung and it will stay out of the way better (The physics are somewhat related to the two balloon experiment) . To re-inflate the operated lung I switch off the other lung and inflate only the collapsed lung, that way you don’t hyper-inflate the other lung before you can get volume into collapsed lung and you can better feel what the lung is doing on the bag (I found a single line in the Morgan textbook that mentioned this).
When the tube just does not want to pass the cords in the usual way, it is worth trying to reverse the tip 180 degrees (i.e. let it points backwards, pass the cords and gently rotate it while advancing). It is counter-intuitive but in people with a pronounced hunched back the the spine will bend quite acutely dorsal and I have had Bechterew patients where I just could not see anything resembling cords with a fibre scope until I flexed it 90 degrees downwards.
I now always ask for an added 2nd back support for the patient with DLT cases as you can tilt the table all the way to one side without the patient falling down, as to have a halfway manageable 45 degree patient position in case of airway problems instead of fully sideways. We had a case where this would have made the management of the airway a lot less stressful than it was (repositioning a patient with an open thorax to re-intubate).
For people with beards I know that are hard to mask ventilate I have a very low threshold to put in a LMA.
In Europe we tend to be more liberal with the use of LMA’s but I don’t do prone cases or beach-chair as I think that is not safe, I have read a case report of problems with extra articulation of fluids in shoulder arthroscopy where they lost the lma airway due to swelling.
That said, I like to at least try an LMA for morbidly obese patients when the case is shortish and does not involve weird positioning. I have found that the extra tissue in the neck makes for a really good seal and I have done cases with patients so far up to 260kg without problems and I like not having to worry about muscle relaxants and as LMA’s are well tolerated and most very obese people have OSAS you can leave it in until they are really awake.
for cases where there is minimal manipulation of the patient but the operation takes ages ( foot surgery) I use an LMA a lot.
And as a closing tidbit. No body told me and It’s really obvious once you think about it, but If you never thought about it: you can have a laryngeospasm with an LMA.
Hopefully this is of use to somebody
Thanks for sharing your tips!
Excellent lecture and appreciate your positive approach and comments at the end!