12 thoughts on “Avoiding the airway clean kill on a full moon”
Great technique I’ll try ASAP on critical scenario (HEMS or ambulance) and hopefully get some documentation on that. Till now I used the bougie aided intubation via LMA with the VL as Jim demonstrated. But I think that combining the 2 is a best way to avoid desaturation during the apneic period. Keep in touch
Interesting. I have tried this in elective setting using the VL – and an AirQII (on basis that’s the iLMA I use) – struggled a bit with space, but was able to get reasonable tongue control with non-channelled VL, LMA providing supraglottic oxygen, then pass bougie preloaded with ETT
With DL I struggled more – mostly because of the bulb of the LMA obscuring view. I wonder about a paraglossal approach with a Miller blade, that will be on my next elective list…
I like the idea of a staged approach.
But wonder if a better (and safer) option is to use an iLMA and then DL/VL to visualise ETT/bougie-thro-iLMA. I use a bronch adaptor to allow oxygenation whilst passing the ETT/bougie in this latter approach.
Tim, you gave me an interesting idea–I have not tried this with the ILMA and Bougie–it just made the list of things to try in Simulation.
It would be great if….a whole bunch of PHARM/HEMS pros out there would try this/these techniques in simulation, and then tell us what you Love and what you Hate about the technique.
The whole idea of this is to increase everyone’s Resourcefulness!!!
Be resourceful-use the equipment your department/service has to the mutual benefit of yourself, the patient and your staff.
Also Minh (nice video-talk), good point at the end of the lecture that by keeping the Supreme LMA in place, that if the ETT goes to hell in a handbasket, the Supreme (if left in) is there to help pick up the pieces. If the ETT cuff fails, you would use the bougie as a tracheal tube airway exchange catheter (AEC)–you wouldn’t try to DL again without that AEC.
The technicalities of DL over an SGA are interesting–I use the Air-Q almost exclusively. An interesting feature of the Air-Q is that if the plastic tab (colored red) that is attached to the pilot balloon is left attached, the mask will size itself in the patient. Furthermore, if the red tab is left on, the Air-Q will DEFLATE ITSELF as the laryngoscope blade is inserted. I do prefer a straight blade for this technique–it goes handles the tongue and indwelling SGA better.
The real revolution here goes to the use of the Oxylog during the airway management. Minh brought up the idea of placing a shortened ETT into the posterior nasopharynx during DL while connected to the Oxylog on CPAP mode to provide for oxygenation during DL. There is much to consider here, and I would like to emphasize, that everyone’s observations are important, so please tell us what you Love / Hate about the idea after you have exhausted yourself on trying it in simulation.
My gut instinct is that the use of so many devices adds complexity that doesn’t necessarily enhance care in a resilient way. DL around an lma seems like a suboptimal technique from a time and glottic exposure perspective. If your baseline sats are 60, adding these extra maneuvers only benefit if you are able to get the sats right up with ventilation through the lma. Otherwise you may just be prolonging hypoxia. Just my 2 cents. Blind intubation through an iLMA seems a “cleaner” approach.
thanks Sean. the key is to oxygenate via the SGA and then make a decision. I totally agree intubation via the SGA is better but not all have a SGA suitable for blind ETI/optically aided ETI via SGA. My point is to use gear that almost all of us would have to manage emergency airway. The addition of the vent add some multitasking and oxygenation security.
also some maybe more inclined to attempt a DL ETI with the SGA security in situ, rather than alternative which is surgical airway or pull out SGA and try ETI.
you should practice this on your sim mannikin, then let me know what you think!
FYI I uploaded a video of simulation of this on https://vimeo.com/65283050. We’ve had some good twitter discussion, will have to find some time to upload some other vids and collect the tweets and thoughts about this. Thanks Jim and Minh for sharing and exploring these and other ideas.
Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds 
Great technique I’ll try ASAP on critical scenario (HEMS or ambulance) and hopefully get some documentation on that. Till now I used the bougie aided intubation via LMA with the VL as Jim demonstrated. But I think that combining the 2 is a best way to avoid desaturation during the apneic period. Keep in touch
Interesting. I have tried this in elective setting using the VL – and an AirQII (on basis that’s the iLMA I use) – struggled a bit with space, but was able to get reasonable tongue control with non-channelled VL, LMA providing supraglottic oxygen, then pass bougie preloaded with ETT
With DL I struggled more – mostly because of the bulb of the LMA obscuring view. I wonder about a paraglossal approach with a Miller blade, that will be on my next elective list…
I like the idea of a staged approach.
But wonder if a better (and safer) option is to use an iLMA and then DL/VL to visualise ETT/bougie-thro-iLMA. I use a bronch adaptor to allow oxygenation whilst passing the ETT/bougie in this latter approach.
Will shoot some video next time…
Tim, you gave me an interesting idea–I have not tried this with the ILMA and Bougie–it just made the list of things to try in Simulation.
It would be great if….a whole bunch of PHARM/HEMS pros out there would try this/these techniques in simulation, and then tell us what you Love and what you Hate about the technique.
The whole idea of this is to increase everyone’s Resourcefulness!!!
Be resourceful-use the equipment your department/service has to the mutual benefit of yourself, the patient and your staff.
Also Minh (nice video-talk), good point at the end of the lecture that by keeping the Supreme LMA in place, that if the ETT goes to hell in a handbasket, the Supreme (if left in) is there to help pick up the pieces. If the ETT cuff fails, you would use the bougie as a tracheal tube airway exchange catheter (AEC)–you wouldn’t try to DL again without that AEC.
The technicalities of DL over an SGA are interesting–I use the Air-Q almost exclusively. An interesting feature of the Air-Q is that if the plastic tab (colored red) that is attached to the pilot balloon is left attached, the mask will size itself in the patient. Furthermore, if the red tab is left on, the Air-Q will DEFLATE ITSELF as the laryngoscope blade is inserted. I do prefer a straight blade for this technique–it goes handles the tongue and indwelling SGA better.
The real revolution here goes to the use of the Oxylog during the airway management. Minh brought up the idea of placing a shortened ETT into the posterior nasopharynx during DL while connected to the Oxylog on CPAP mode to provide for oxygenation during DL. There is much to consider here, and I would like to emphasize, that everyone’s observations are important, so please tell us what you Love / Hate about the idea after you have exhausted yourself on trying it in simulation.
AS mentioned, I tried this in sim then on elective list – am sure you have done same. I cheat and use CGO on anaes machine.
My gut instinct is that the use of so many devices adds complexity that doesn’t necessarily enhance care in a resilient way. DL around an lma seems like a suboptimal technique from a time and glottic exposure perspective. If your baseline sats are 60, adding these extra maneuvers only benefit if you are able to get the sats right up with ventilation through the lma. Otherwise you may just be prolonging hypoxia. Just my 2 cents. Blind intubation through an iLMA seems a “cleaner” approach.
thanks Sean. the key is to oxygenate via the SGA and then make a decision. I totally agree intubation via the SGA is better but not all have a SGA suitable for blind ETI/optically aided ETI via SGA. My point is to use gear that almost all of us would have to manage emergency airway. The addition of the vent add some multitasking and oxygenation security.
also some maybe more inclined to attempt a DL ETI with the SGA security in situ, rather than alternative which is surgical airway or pull out SGA and try ETI.
you should practice this on your sim mannikin, then let me know what you think!
FYI I uploaded a video of simulation of this on https://vimeo.com/65283050. We’ve had some good twitter discussion, will have to find some time to upload some other vids and collect the tweets and thoughts about this. Thanks Jim and Minh for sharing and exploring these and other ideas.
Thanks!
Jim is the concept creator/ genius !
FYI #Storify collection of the IOSIS tweets in progress at http://storify.com/TBayEDguy/iosis-intubating-over-sga-in-situ