Point 1: I cannot agree more that different approaches to laryngoscopy have different pros & cons and that high fluid situations put indirect or image based laryngoscopy (IL) [includes VL, AirTraq etc] at a distinct disadvantage: the optics are in the airway where the fluids are with IL(VL)! This is opposed to direct laryngoscopy where the optics are outside and so will not get blinded by fluid.

In both cases, multiple suctioning is required with consideration to control the source of fluid (e.g. direct pressure to stop airway bleeding, foley the epistaxis, NG decompress the belly full of blood). One advantage of IL(VL) is that it allows multiplayer airway management (HT @emupdates and @emcrit I believe: there can be two “suctionists” in addition to the intubator looking at the airway and managing fluids soiling the airway while simultaneously trying to secure the airway). This goes back to what is the best approach, knowing what difficulties will pose to it and addressing those difficulties in plan A. If that fails then plan B must be different to try to solve the problem!! As must plan C and plan D!!

Point 2: If the first attempt failed, doing the same thing will likely also fail. Multiple attempts lead to airway trauma, leading to a more difficult airway to manage whether intubating or rescue ventilating/oxygenating: more swelling, bleeding and disruption. I feel it is important to assess after each failed attempt as to why the failure occurred, and address the difficulty encountered. It is crucial to know how to deal with difficulty when encountered; subsequent attempts must always change something. Changing operator may not be change enough if one does not know the difficulty and get around it.

Point 3: Minh, I absolutely agree about the SGA. I think of BMV as your first backup parachute and SGA should be one’s automatic secondary backup chute (and of course with initial denitrogenation if time and ongoing apneic oxygenation). I like to think of these as the rapid “have no time” rescue airway/oxygenation tools. Whenever the sats are down [and the Roller Coaster oxyhemoglobin dissociation curve (HT @robjbryant13) as well as the pulse ox lag (HT @emcrit) suggests that this should be triggered at around 93%], one should rapidly move to reoxygenation first with BMV and if that does not work, move to rescue SGA and consider prepping for the final backup of cric. If SGA does not work immediately and one has already multiple attempted intubation or the airway is too difficult (surgically inevitable?), one should move to the rapid surgical airway that is readily available: as you know my favourite is scalpel bougie open cric which is rapid, reliable, can work in high BMI, gets a secured airway and only needs the scalpel, bougie, 6.0 ETT and your finger!

@ Jimmy D: wow, thanks for that perspective on what could have happened to the airway.

Thanks again for the chance to think (and obsess) more about airways!

Yen

Let me go over a part of this case just a little bit to parse out some interesting tidbits:

Following successful cricothyrotomy and ventilation, efficiency of ventilation falls through the Melker catheter over a 5 minute period. The Melker catheter is uncuffed, and the leak is noticed to come from the oropharynx. Combined BVM-Mask and BVM Melker is successful in reestablishing adequate ventilation. Videolaryngoscopy is subsequently successful.

Ok, here we go: Despite adequate medication for RSI, the patient was in complete and total laryngospasm–to the point that experienced endoscopists could not find the larynx. This happens in patients with long term OSA–they develop (functionally) folds of tissue that act like a second epiglottis, and no matter what you do, you can’t find the larynx (I’m speaking from experience here).

Following the successful cric, ventilation began to fall off because the vocal cords finally began to relax and let the ventilation gases out. Then they found the larynx and intubated.

1. The Melker catheter was efficient at providing ventilation, despite the lack of a cuff. An obstruction at the level of the vocal cords, or the base of tongue, allows this catheter to seal and ventilate. The loss of this seal 5 minutes later points to a relaxation of pharyngeal/laryngeal anatomy, thus allowing the ventilation gases to pass out of the larynx/trachea and into the oropharynx.

2. I have seen reasonable doses of succinylcholine fail to relax the vocal cords. I have seen reasonable doses of rocuronium fail to relax the vocal cords. What we all must come to terms with is that sometimes, the drugs do not work as advertised.

3. The use of an SGA could simplify ventilation in the above case, and provide a conduit for repeat oropharyngeal endoscopy (through the mask) during ventilation with the Melker. This gives you another avenue to examine and treat the airway.

4. Those Melkers are short catheters–they are VERY temporary airway solutions. They are used to save lives, and then they need to be transitioned out in a timely manner.

Here’s an analogy: In the “old days”, when houses were built using fuses for electrical safety (instead of circuit breakers like most of us have now), it was possible to replace a burnt-out fuse with a coin to complete the electrical contact–an expedient, but tenuous maneuver. This was intended as a temporary measure if a new fuse was not immediately available, but let’s consider now the next question–how long are you going to leave the coin in the slot intended for an actual fuse? If you leave it in there too long, you risk an electrical fire, and the whole house burns down. I offer that you consider the use of a Melker with the same considerations as the above analogy. The Melker is short, thus it can come out easier–and unless you have done the work of working on a better airway (a tracheostomy below the Melker, for instance), you will not have a plan to maintain the airway beyond that Melker Cric.

5. Should these practitioners have gone to an SGA earlier? Maybe not–I believe that the complete airway obstruction was at the level of the vocal cords in this case–the SGA would have failed to ventilate. Placing the SGA and continuing to attempt to ventilate while the Cric is in progress is an extremely good idea, however. These physicians did the right thing–they kept the patient alive with a surgical airway until the patient’s vocal cords relaxed enough for them to find the larynx with videolaryngoscopy and intubate him.

I just wonder if they followed the DAS failed RSI guideline, if that would have let to the SGA quicker. This may have bought some time with oxygenation to try to prepare for a surgical airway.

We have a new difficult intubation trolley in Albany, modelled on the Joondalup Hospital one where each drawer corresponds to the next step in the DAS guideline. Excellent for brain freeze moments.