RSI with Oxylator Preoxygenation and Airtraq Avant wireless laryngoscopy

Dr Jim DuCanto, our resident master airway practitioner and supreme anaesthesiologist, shared this consented video recording of a RSI by his senior resident and himself.

Its a good demonstration of a few things related to RSI and intubation in general.

1. Notice the use of the Oxylator device for preoxygenation. For those not familiar with this, its a device that Jim is passionate about and he uses it daily in his clinical practice of anaesthesia, for both preoxygenation but also ventilation. Its a pressurised gas driven device requiring 30L/Min gas flow to work. It has no electronic parts.

This is a schematic diagram of an Oxylator EMX(used in the video above) from its instructional manual. This model you can dial up the maximal inspiratory pressure limit. The device will provide inspiratory flow up to that pressure limit then cycle into a passive expiratory phase until the flow reduces to a baseline PEEP of 2-4cmH2O then it cycles back to inspiratory phase again.

Note during the video how it produces an audible clicking sound, when there is airway obstruction. This is a great inbuilt alert to the clinician that airway obstruction is occurring and oxygen flow is being limited.

I have been conducting my own testing of the Oxylator for prehospital and retrieval use and its a nifty device being small and lightweight and only gas driven. It will not replace a modern transport ventilator for the bulk of critical care transport work but it has a very handy role in primary missions and prehospital cases where you cant carry everything from the aircraft and must make do with limited gear. One strategy I have conceived is of keeping the main transport ventilator on the aircraft, then going out to stabilise the patient using the Oxylator device, retrieving them back to the aircraft to be hooked then onto the main ventilator. It avoids having to move and secure a larger ventilator with the patient during loading and unloading and going to and from the hospital. Jim has done this to a limited fashion already, using the Oxylator to ventilate intubated patients in MRI suite or Endoscopy suite.

2. Note Jim does not push Succinylcholine until End Tidal Oxygen is > 88%, ensuring adequate preoxygenation and denitrogenation.

3. Note the lack of use of cricoid pressure or Sellick maneuver, although the video is described as a RSI. This is my practice too but its controversial still whether to use cricoid pressure or not. I recent had a twitter debate on this with colleagues. Check out our twitter feeds , @MDaware and @rfdsdoc last 24 hrs!

4. Note use of initial direct laryngoscopy with Macintosh blade then use of Airtraq Avant wireless optical laryngoscope. For those familiar with Airtraq, this is an updated wireless adaptor to plug on over the eye piece of the Airtraq and send the images to a wireless display.  here is a great demonstration video of this system in an awake intubation

Prehospital points to note then:

– disposable wireless video or optical laryngoscope systems are entering the market and will play a role in prehospital intubation strategy. You cannot stop the technology getting better and more relevant. if you carry an iPhone or Ipad, the future of prehospital intubation is half already in your pocket!

-portable gas driven ventilator like devices may provide better options than manual BVM and simple oxygen systems for providing improved oxygenation and ventilation in prehospital care.

stay safe and enjoy

Minh

6 thoughts on “RSI with Oxylator Preoxygenation and Airtraq Avant wireless laryngoscopy

  1. Fantastic post Minh
    Can you give me additional information about the way you use this device prehospital .

  2. I don’t have a twitter account. Briefly can yo explain to me why cricoid preasure is omitted in this procedure? I was under the, obviously, incorrect understanding that it was essential in the sedated/paralysed patient.

  3. Hi Michael
    Cricoid pressure and its issues are well addressed by Dr Levitan in his latest lecture slides, kindly made available here

    Click to access levitan-handout.pdf

    Its greatest problem is that its poorly taught and practiced. Think about it..how hard do you need to press and where? If you had to teach it to a novice what would you tell them? Do you know if it actually works to prevent regurgitation?

    Many emergency docs and anaesthetists have totally abandoned its use. But many still advocate for its use, stating its long traditional history in clinical anaesthesia and its easy application.

    Many Australian anaesthetists have adopted the middle road approach of applying cricoid pressure but removing it if there is any difficulty with BVM or intubation during RSI.

    Many Australian and American Emergency docs have simply abandoned its use.

    If you want to get a sense of the controversy , read this Scottish coroners report on a tragic anaesthetic death and the debate over the use of cricoid pressure by the expert witnesses.

    http://www.scotcourts.gov.uk/opinions/2010FAI15.html

  4. This Scottish airway saga is too painful to read in its entirety. It’s unfair of me to criticize them, so I won’t. Let me just say that simplicity is more important than theory–many of the procedures (added on top of procedures) were done to prevent a potential complication (like aspiration) rather than an actual one. Cricoid pressure use in this case? Maybe it made the DL harder, but maybe not. I’ve largely given up on cricoid pressure in my practice, even in full stomachs. Just my opinion.

    1. thanks Jim. I agree. I do not use CP as a routine anymore. I will choose to use it in selected high risk aspiration cases i.e heavily pregnant women, bowel obstruction, UGIT bleeding and even then I carefully select my assistant and instruct on CP application and removal . With VL, things have changed as my assistant can see the effect of CP and adjust in real time.
      I dont condemn anyone who still uses it routinely. I mean it has been used for decades, in the main safely and I am sure would have prevented airway soiling in the majority of applications. And quite simply, you can remove it whenever you want if its causing trouble.

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