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How Do You Do That Airway Voodoo That You Do So Well?

“Okay, so how do you bridge from a King LT airway to an endotracheal tube? I’m not familiar with the procedure, and I’m having trouble visualizing it.”

A reader e-mailed me that question a while back, in response to something I wrote in this post. At first, I thought I’d write a simple reply to him detailing how it’s done, but then I said to myself, “Self, a lot of people might like to know that particular nugget as well, and it gives you a chance to talk out of your ass wax philosophic about airway management.”

First, what qualifies me to talk as an expert about airway management?

Answer: not much.

I have no idea of the number of intubations I’ve performed successfully. I quit counting after my paramedic clinical rotations. During my OR rotations, I went 34 for 34 on intubation attempts. A few years later, I had occasion to review three years worth of run data at the Little Ambulance Service That Could, while I was preparing a proposal to add Rapid Sequence Induction to the scope of practice for Louisiana paramedics.

I discovered that, in the three years I’d been a medic, I’d gotten 37 of 38 intubation attempts. The one I missed, I was able to bag successfully for the twenty minute trip to the hospital.

In the fifteen years I’ve been a medic, there  have been four nasotracheal intubations, a few RSIs, and two memorable occasions where I performed digital intubations – both done lying flat on my back, with the patient suspended above me.

Both of those patients died, by the way, but not for lack of an airway or ventilation.

Add another few dozen ET tubes over the next five years at TLASTC, quite a few more during my years working for the Wal Mart of EMS, and the ones I’ve dropped during my current stint at The Borg. Both of those latter two companies track such things, but I never really bothered to track any number other than the ones I’ve missed.

And that number is seven.

Three of those got Combitubes, one got a King LT airway, and two more got an LMA. The first tube I ever missed  was bagged successfully with just a BVM.

Now, I’ve dropped a few more Kings and LMAs, and even a few Cobra airways over the years, but all of those were done as a first attempt. I never attempted intubation on any of those, and most of those were done, well… unofficially. You guys who have worked rural EMS know what it’s like to be the unofficial Code Team for a rural hospital. I’ve been called to a Bandaid station community hospital ER more than a few times to drop a tube that the doctor couldn’t get himself. On a few of those occasions, I didn’t bother to attempt intubation, opting for a supraglottic airway instead.

So there you have it. In fifteen years, seven missed intubation attempts. And I’ve never had a missed esophageal intubation nor, to my way of thinking, had a failed airway. Every time I’ve needed to ventilate someone, or protect against aspiration, I’ve found a way to do it effectively.

How many successful intubation attempts I’ve done, I have no idea, but the number probably approaches a couple of hundred. It’s certainly not many more than that.

It’s worth noting, however, that the American Society of Anesthesiology  considers the minimum competency for an anesthesiologist to be 200 successful intubation attempts. Viewed in that light, I’m less Airway Samurai than I am rookie practitioner still on the wrong side of marginally competent.

So those are my credentials: probably a good bit less than a medic who has worked a busy urban system for 20 years, and nowhere approaching that of an experienced anesthesiologist. Still, I am not without experience and insight.

Because, you see, it’s not how many notches you’ve carved on your laryngoscope handle, but what you’ve learned from each one of them. As I’ve said before, there are a few medics with twenty years of experience, and many, many more with one year of experience, repeated twenty times. The corollary to that is that there are a few airway experts with a couple thousand successful tubes, and likely many more with twenty successful tubes, repeated a hundred times.

I’ve written about the mindset necessary to effective airway management in the post entitled A Treatise On Marksmanship, and in columns and lectures on The Airway Continuum. If you haven’t read those, I encourage you to go check them out. You may find them enlightening, and I’ll be here when you get back.

**********

Okay, everybody back? Good.

Now, I’m not going to presume to alter anyone’s intubation technique. Aside from the fundamentals, like staying off the teeth, holding the scope in your left hand, and things of that sort, intubation technique is as personal and varied a thing as, say, a golf swing. How pretty it looks isn’t as important as practicing it enough that it’s infinitely repeatable.

Then again, maybe I should talk about technique a bit. After all, not all medics received the same level of instruction. I once had a preceptor, a very experienced CRNA, tell my students that it didn’t matter so much if you broke a few teeth now and then, that sometimes it was inevitable. That same preceptor also took it upon himself to correct a few of my female students’ technique, which actually made it harder for them to intubate someone.

I lost a great deal of respect for that preceptor that day, but I learned a very important lesson: Just because someone has far more experience and training than you, doesn’t mean they’ve learned anything from it.

As I said before, twenty successful intubations, repeated a hundred times.

So, on second thought, I will offer just one critique of what many people consider proper technique. If, when intubating, your left elbow is akimbo, pull it in towards the midline of your body. You should be able to draw a straight line through your shoulder and left forearm, a line that tracks across the left side of your patient’s face,  extending to an imaginary point high on the wall beyond the patient’s feet.

Have you ever seen someone trying to intubate, grunting and straining to displace the jaw forward, with their elbow all cocked to one side, hand and arm shaking with the exertion? Or perhaps you’ve done it yourself. One of the most common refrains I hear from airway novices – petite female nurses, usually –  is, “My arm just isn’t strong enough to do this!”

Wrong.

If you’re relying more on arm strength than finesse, you’re doing it wrong. I can take the biggest snowman out there, with no neck to speak of, and displace his lower jaw enough to pass an endotracheal tube, using nothing more than the index finger and thumb of my left hand. For the infrequent patient where that isn’t sufficient, I have other tricks up my sleeve, which we’ll get to in a minute.

So whether you’re one of those “sweep the tongue to the left” types or the medic who walks the blade down the tongue incrementally, if you find yourself straining to displace  the jaw, pull your left elbow back in line with your body. It makes for much better body mechanics, allowing you to use the strength of your shoulder, and your upper body weight, if need be. Heck, if necessary, brace your left forearm on the patient’s face and forehead. Unless they’ve got massive facial fractures, you’re not going to hurt them by doing it.

Now, for the infrequent patient where manual displacement of the jaw isn’t sufficient, comes the first of my little airway tricks: try external laryngeal manipulation (ELM).

Any medic who has wielded a laryngoscope a few times has either asked for, or provided, cricoid pressure. Sellick’s Maneuver, as it is often called, is an excellent technique for limiting air entry into the esophagus, or just as importantly, for keeping vomit from coming up. When you need to occlude the esophagus, it works well.

But if you’re trying to visualize the glottic opening during laryngoscopy, there’s a better way to do it, and that way is called the BURP technique.

Rather than manipulating the cricoid cartilage, BURP involves directed manipulation of the thyroid cartilage. It stands for Backwards, Upwards, Rightward Pressure.

Facing the patient, place your thumb and index finger on either side of the thyroid cartilage – the Adam’s Apple – and press back towards the spine, up towards the top of the head, and rightward pressure in the direction of the patient’s right ear.

Try this on a manikin, and you’ll see the difference it makes. In clinical practice, it can improve a laryngoscopic view by at least one Cormack and LeHane grade, and sometimes even two. It can make the moderately difficult tubes easy, and the very difficult tubes manageable.

And if you don’t know what Cormack and LeHane grading is, or Mallampati scoring, or LEMON, get thee hence and fill that gaping hole in your airway management knowledge. If you carry paralytics and aren’t intimately familiar with those things, you are, well… dangerous.

If you couple the BURP technique with gentle lip retraction at the right corner of the mouth, you can improve your laryngoscopic view, and the room to manipulate a tube, significantly.

Last, but certainly not least, there is the $5 piece of equipment no airway kit should be without, and that is the Eschmann Intubation Stylet, commonly referred to as a bougie:

bougie

Typically, you use a bougie to intubate the trachea when you are faced with one of those folks with a very anterior glottis – typically less than three finger breadth’s across the middle knuckle (roughly 7 cm) of thyromental distance.

[On a side note, next time a colleague blames his difficulty intubating a patient on that “anterior larynx,” check the patient’s thyromental distance to see if it truly is. The anterior larynx is one of the biggest “run home to Momma” excuses in paramedicine, right on up there with “looks like atrial fib” and “I was up against a valve.”]

One usually inserts the Coude tip of the bougie in that anterior glottic opening, feeding it gently forward and feeling it “tick” on the tracheal rings as you do so, until the stylet holds up at the level of the carina. Then, you simply slide a lubricated ET tube of the appropriate size down the bougie, and – voila! – the patient is intubated.

Seriously, it is a very effective tool, and too damned inexpensive not to have one.

Besides being an effective aid to conventional intubation, the bougie is also an effective means of transitioning from a supraglottic airway to an endotracheal tube.

To answer my reader’s original question, one simply feeds the bougie down the King airway -or LMA, or Cobra, for that matter – feeling it “tick” against the tracheal rings for confirmation of endotracheal placement. Then, stabilize the bougie with one hand while deflating the cuff and removing your supraglottic airway with the other. Then, simply slide an endotracheal tube down the bougie and you’ve got the patient intubated. It will work on any supraglottic airway except the PTL and the Combitube.

Practice it on a manikin first, until you feel proficient with the technique. Neck extension and judicious application of cricoid pressure may facilitate lowering of the glottic opening and allowing easier passage of the bougie.

That’s all there is to it!

Comments - Add Yours

  • wvmedicgirl

    AD, Have you ever seen and or used the S.A.L.T.? (Supraglottic Airway Laryngopharyngeal Tube) Its a pretty amazing development in rescue airways.

  • wvmedicgirl

    AD, Have you ever seen and or used the S.A.L.T.? (Supraglottic Airway Laryngopharyngeal Tube) Its a pretty amazing development in rescue airways.

  • Ambulance_Driver

    Used one of their prototypes on an airway manikin. I liked it.

    I've heard they had some problems intubating through them on real patients, but that they tweaked the design a bit to address those problems. Saw the current versions at a trade show the other day. I certainly like the idea, though!

  • Ambulance_Driver

    Used one of their prototypes on an airway manikin. I liked it.

    I've heard they had some problems intubating through them on real patients, but that they tweaked the design a bit to address those problems. Saw the current versions at a trade show the other day. I certainly like the idea, though!

  • http://thehappymedic.com the Happy Medic

    Great stuff AD. We learned to point the end of the handle up towards where the ceiling meets the wall over the patient's feet, similar to what you described, to get the lifting motion over the wrist twisting I'm seeing in the folks coming out of school lately.

    Tried using the bougie with the KingLT and it wouldn't pass through the spot they made for it, kept getting caught at the end. Then again, if my King is working, I'm leaving it.

    Thanks again.

  • Ambulance_Driver

    Huh. Worked fine with the bougie I used. Looking closer at the ones I have in my teaching box o' stuff, the Portex Introducer brand of bougie is a little slimmer and the ball on the end of the coude tip is a bit smaller. It passes pretty easily, even though the slightly larger blue bougies I have on hand will also pass.

    May depend upon the size of the King LT and the brand of bougie you use.

    Good to know, though!

  • http://thehappymedic.com the Happy Medic

    Great stuff AD. We learned to point the end of the handle up towards where the ceiling meets the wall over the patient's feet, similar to what you described, to get the lifting motion over the wrist twisting I'm seeing in the folks coming out of school lately.

    Tried using the bougie with the KingLT and it wouldn't pass through the spot they made for it, kept getting caught at the end. Then again, if my King is working, I'm leaving it.

    Thanks again.

  • Ambulance_Driver

    Huh. Worked fine with the bougie I used. Looking closer at the ones I have in my teaching box o' stuff, the Portex Introducer brand of bougie is a little slimmer and the ball on the end of the coude tip is a bit smaller. It passes pretty easily, even though the slightly larger blue bougies I have on hand will also pass.

    May depend upon the size of the King LT and the brand of bougie you use.

    Good to know, though!

  • Lexi

    That was really good reading. Thanks very much for the tips.

  • Lexi

    That was really good reading. Thanks very much for the tips.

  • CBEMT

    I watched a resident use a Bougie and gut-tube my patient during RSI. I couldn't believe it.

    • nelly

      it’s the attending Doc’s patient. not yours. You do a good job of getting the patient to the door in one piece but that doesn’t mean you could manage him medically.

  • Ambulance_Driver

    #1 reason people tube the goose: they didn't recognize their landmarks.

    Apparently having extra tools and vastly more training doesn't improve your airway navigation if you can't read the anatomical map.

  • CBEMT

    Scary, isn't it?

  • Ambulance_Driver

    Musta been in July. Never get sick at a teaching hospital in July…

  • totwtytr

    Very good tips here, AD. A couple of points if I might.

    1) I think some people get too hung up on Mallampati classifications and the like. If the patient needs airway control, the score means nothing, we still have to do something. The score might, maybe, change our approach, but it's just us out there, so we better get something done and done correctly.

    2) People forget, although if they spent any time in an OR, they learned, the trick pictured at this link. http://www.anest.ufl.edu/at/case1/positioning.html

    3) I think some people and some systems have too many devices, if that makes sense. Medics should become very proficient using the techniques and equipment they have rather than concentrate on getting every airway toy out there.

    4) There is nothing wrong with bringing a well ventilated patient into the hospital using an OPA or some other “BLS” device. It's far better than bringing in a well hypoventilated patient because you thought that getting an advanced airway in was the goal. It's not, ventilation is.

  • Ambulance_Driver

    1. Agreed. If I worry about Mallampati, it's in those instances where I perform RSI. In other words, potentially converting a compromised airway into none at all. In those circumstances, Mallampati scoring might be a factor in choosing na supraglottic airway over ETI.

    I included it not because I think it's relevant in crash intubations, but to demonstrate just how shockingly limited EMS airway education really is. Most medics have no idea what Mallampati scoring or Cormack and Lehane grading even is.

  • totwtytr

    Very good tips here, AD. A couple of points if I might.

    1) I think some people get too hung up on Mallampati classifications and the like. If the patient needs airway control, the score means nothing, we still have to do something. The score might, maybe, change our approach, but it's just us out there, so we better get something done and done correctly.

    2) People forget, although if they spent any time in an OR, they learned, the trick pictured at this link. http://www.anest.ufl.edu/at/case1/positioning.html

    3) I think some people and some systems have too many devices, if that makes sense. Medics should become very proficient using the techniques and equipment they have rather than concentrate on getting every airway toy out there.

    4) There is nothing wrong with bringing a well ventilated patient into the hospital using an OPA or some other “BLS” device. It's far better than bringing in a well hypoventilated patient because you thought that getting an advanced airway in was the goal. It's not, ventilation is.

  • Ambulance_Driver

    1. Agreed. If I worry about Mallampati, it's in those instances where I perform RSI. In other words, potentially converting a compromised airway into none at all. In those circumstances, Mallampati scoring might be a factor in choosing na supraglottic airway over ETI.

    I included it not because I think it's relevant in crash intubations, but to demonstrate just how shockingly limited EMS airway education really is. Most medics have no idea what Mallampati scoring or Cormack and Lehane grading even is.

  • ted

    Great post, AD. Have you ever heard of The Airway Course? They teach a very similar approach.

    One thing I'd add: The intubating bougie (AKA Eschmann) is a great tool when in its original shape. However, if you coil it up and leave it in the bottom of a jump bag for a couple of months it tends to hold that coil and become a lot less effective. Store 'em straight.

  • Ambulance_Driver

    Not that one, but something similar.

    I've taken SLAM, and had the privilege of being an adjunct instructor for several of their courses at the Texas EMS Conference over the years. It's a great airway course, one every medic should take.

  • ted

    Great post, AD. Have you ever heard of The Airway Course? They teach a very similar approach.

    One thing I'd add: The intubating bougie (AKA Eschmann) is a great tool when in its original shape. However, if you coil it up and leave it in the bottom of a jump bag for a couple of months it tends to hold that coil and become a lot less effective. Store 'em straight.

  • Ambulance_Driver

    Not that one, but something similar.

    I've taken SLAM, and had the privilege of being an adjunct instructor for several of their courses at the Texas EMS Conference over the years. It's a great airway course, one every medic should take.

  • http://paramedicherbie.blogspot.com/ Herbie

    Excellent post, AD.

    After reading your Airway Continuum, I follow it to a T. I've actually NOT intubated patients because of it, since I was ventilating well with a BVM and OPA.

  • http://paramedicherbie.blogspot.com/ Herbie

    Excellent post, AD.

    After reading your Airway Continuum, I follow it to a T. I've actually NOT intubated patients because of it, since I was ventilating well with a BVM and OPA.

  • http://paramedicherbie.blogspot.com/ Herbie

    Excellent post, AD.

    After reading your Airway Continuum, I follow it to a T. I've actually NOT intubated patients because of it, since I was ventilating well with a BVM and OPA.