In between retrieval missions, when I am on shift at the base, I try to do airway research and experiment with new devices and techniques.
What I show here is a series of demonstration pictures from my latest round of testing of a novel hybrid intubation technique via a supraglottic airway device. Kudos to Dr DuCanto for showing me the technique via his videos.
Equipment used during demonstration :
1.Simulaids CPARLENE Torso mannikin
2. LMA Supreme #3
3. Cook Frova intubating bougie
4. Suction swivel connector
5. King Vision Video Laryngoscope with #3 standard blade ( non channeled)
In the first two photos above, I have demonstrated two examples of how to insert a bougie via a LMA Supreme. Firstly using a suction swivel connector, or if that is not available then directly down the ventilation channel of the Supreme. The suction connector allows continuous ventilation to occur via the LMA during passage of the bougie. If passage of the bougie is difficult then apply some lubricant to the bougie and pass this down the ventilation channel several times to coat the lumen.
In the above three pictures, I demonstrate insertion of the King Vision video laryngoscope next to the LMA Supreme. To get a good view of the larynx, deflation of the LMA mask is required. The King Vision blade tip can be passed directly in the midline between the tongue and LMA mask as is shown in the middle picture, or it can be passed laterally then angled toward the midline , as shown in last picture on the right. The advantage is that if using the suction swivel connector to pass the bougie, one can keep ventilating and oxygenating the patient during the laryngoscopy and it allows you to convert an initial RSA approach with a LMA Supreme, into a cuffed ETT protected airway, without having to pull out the Supreme right at the start of your tracheal intubation attempt.
These last two pictures above address one of the issues encountered with the bougie via LMA technique. As the bougie exits the LMA mask, its angle of approach is such that it is on a trajectory to abut against the anterior tracheal wall as it passed through the vocal cords. DuCanto addressed this with his novel improvised CrankShaft maneuver with a haemostat clamped to the bougie and twisting the tip to face posteriorly. I discovered an alternative technique to address this issue. Once the bougie tip has been seen to negotiate the level of the cords into the trachea, the King Vision or whatever video laryngoscope you are using, the force applied with it can be relaxed(shown on picture on left) to allow the larynx to resume a more natural position and this is shown in the picture on the right, with a down folded epiglottis. This enables the bougie to be passed at a less acute angle into the tracheal lumen.
Once bougie is placed into the trachea satisfactorily, the Supreme can be removed over the bougie, the King Vision can be left in place to observe passage of a ETT railroaded over the bougie.
Advantages of the hybrid technique:
-prehospital providers can place a LMA quickly using a RSA approach. If the LMA or SGA has a gastric drain channel ( e.g Supreme, iGel, AirQ II, Proseal), then gastric decompression can occur. Preoxygenation and reoxygenation can optimally occur with PEEP, aiming for an eventual staged strategy of tracheal intubation
-On arrival into the ED or ICU, the hybrid technique requires only a standard bougie, ETT , suction swivel connector and video laryngoscope to convert to a cuffed ETT protected airway. At $1000 AU, The King Vision device demonstrated makes for an affordable solution to the challenge of intubating via an established LMA.
Disadvantages of the hybrid technique:
-with poor mouth opening or obstructed upper airway, this technique will likely fail.
-it does not provide a nasal route of intubation, and so does not completely supercede a flexible intubating endoscope.
Summary:
IN conclusion DuCanto and I have demonstrated in live patients and during mannikin testing that it is feasible to successfully intubate the trachea with a bougie passed via a LMA Unique and Supreme, using video assisted guidance from either a King Vision video Laryngoscope, McGrath Video Laryngoscope or Levitan FPS optical stylet.
Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds 
Have you or Dr. DuCanto tried using the swivel connector to pass a bougie through a regular KingLT? We don’t have access to LMA style SGA’s in the field here.
Jim showed this on an earlier video I posted. it should work fine with the swivel connector. challenge will be getting the bougie to go through the cords as might take some manipulation as the angle it exits the King LT is different to a LMA or AirQ. I will ask Jim to do some specific testing with King LT,
Thanks! I’ve been playing with bougies and our KingLTS-D’s on our mannequin at the station, but it is an easy intubation regardless. I’d rather we not go down the road of pushing that technique if it isn’t reliable!
Thanks Minh, have also been playing with this
I am always leery of removing an LMA even with bougie in…but it’s not so easy to railroad the ETT via a SLMA
Have also been playing with KingVision, swivel connectors and LMAs – the Air Q II seemed to work quite well, and of course can pass the ETT via this as a guided visual technique with the Kingvision rather than blind
This technique is based on using the RSA method, and the management of the airway following that approach. This technique also relates to the aftermath of the failed DL attempt, i.e., what you do NEXT when DL fails.
I will investigate this further in the next few weeks, both in simulation and clinical practice, combining the King LT, bougie, bronchoscopic connector.
Let me clarify WHY this is useful. Braude’s RSA technique is the major basis of this technique. Here is a clinical case to clarify.
78 yo male with a “positive” past medical history (i.e., disease in almost every major organ system–CAD, DM, ESRD……..) presents with hip fracture for ORIF. Anesthetic induction and airway control plan includes a medication regimen (Etomidate, rocuronium) while maximizing patient comfort and safety. As he has a hp fracture, it is painful to move patient from his bed to OR table, so the induction of anesthesia takes place with patient in his bed. Following induction, the patient is moved to the OR table, but…..the staff is not immediately prepared to do this, as I had hoped. I immediately intervene with the placement of an Air-Q 4.5 SGA and place the patient on the ventilator. 4 minutes later, we move the patient over to the OR table, and position him supine for definitive airway management. In lieu of removing the Air-Q and proceeding with direct laryngoscopy, I elected to perform DL over the heel of the Air-Q with a Miller 3 blade–grade 1 visual–and the styletted tracheal tube was placed into the larynx over the heel of the airway. In retrospect, I could have guided the tube into the larynx THROUGH the Air-Q, but I’ll save that for next time.
So what did I achieve here? Immediate, rapid and controlled induction of anesthesia, control of ventilation and the ability to position a patient who is otherwise compromised significantly by the pain of his hip fracture. An analogous situation in Emergency Medicine is the management of an agitated, combative patient, or one in severe distress due to pain.
This RSA style induction is not my first, however, I was much more conscious of my choices and actions in this instance in choosing the RSA approach. Most anesthesia providers would not see the rationale of “doubling up” on airway tubes like this (i.e., it may appear wasteful) unless it could be explained that by proceeding with RSA, ventilation and oxygenation could be maximized in these clinical situations. Timing of medication delivery and ventilation support is vital. If they are not well coordinated, significant complications can occur, including cardiac arrest.
I can appreciate the utility of visualization alongside a functional airway for conversion to a “more definitive” airway; unable to visualize, abort ETT exchange and use SGA. I guess for EMS providers my only concern is the risk-benefit of trading a functional SGA for an ETT if not absolutely required.
Thank you for the additional insight!
You bet. Thinking about this technique gives you the vision to see what needs to happen next should the occasion require it. We had to intubate a 300 pound patient this morning at the start of surgery due to inadequate ventilation with the SGA. We intubated through it (an Air-Q) guided by a Glidescope placed over the top of it (sorry, no video).