The failed intubation. It’s your worst nightmare and it can look like this. The trauma patient with the cervical fracture, that crashes and you need to tube NOW. You can’t move their neck and you look down with the laryngoscope (your trusted mac blade) and nothing! Wait a minute, I’m sure there’s supposed to be an epiglottis somewhere down there! Where the heck are the vocal cords? You try a little BURP (backward, upward to the right pressure)… nothing. You have a go blind – No waveform on the end-tidal CO2- Take it out. “OK, I’ve done the airway workshop and I know I should have put in an introducer”, you say. You try it with an introducer, but nothing. You call for help. “HELP!” Anaesthetics are in theatre using a fibre-optic on a difficult tube, everyone else in the department has decided this was the perfect time to go to the bathroom. There is no-one more experienced around. You use a bougie, because you practiced with that..but nothing. This is now a failed intubation – the definition being 3 failed attempts by an experienced operator or unable to keep sats up above 90% with bag valve mask. “OK “you say, “I’ll just bag valve mask and ventilate until the sux wears off and we can get someone else to have a go”. I’m sorry, it’s not going to be that easy. You now can’t ventilate and thus can’t oxygenate. You decide, you need to go down the surgical airway. Wait! “The difficult intubation box!” you yell. “Get me the difficult intubation box!” The nurse opens it for you and you look in…. What the $%#*!? What the hey is that?
There’s a corkscrew from the last Christmas party, or even worse, a pack of bits of equipment you’ve never used before. A Melker, a Cook, a leardel, some pointy thing and …you don’t even know what the rest of the stuff is. All about the same use at that time to you, given the last time you trained with any of them was a couple of years ago. The corkscrew is looking attractive! One of the things I am fighting hard for is uniformity in our difficult intubation kits. I want them to be the same wherever you go. I want the training to be uniform. The argument against it, is that we need equipment that works, that is easy to use and that is dependable, user friendly and intuitive. But here’s a new device. It’s something that looks like a laryngoscope and has a light source and a video camera right in front of you, so you can see what you’re doing.
The McGrath Video Laryngoscope. I like this device, because it is familiar to us, it’s like a laryngoscope. The blade is adjustable and is covered by a disposable acrylic cover, that just needs to be disposed of after use. You click on the camera introduce the blade into the oral cavity and look in, position and with an introducer into the tube, bent in the angle of a hockey stick, you tube under direct vision. DONE! The screen is right in front of you. Some of the other video devices will have a screen to the side. This means that you are looking down at what you are doing and looking at the screen This is what I like most about this. There is no coordination mismatch and spacial re-education needed. This may be the ideal device. We’ll have this at the AIRWAY WORKSHOP at RESUS 2010 for you to see( PLus many other gadgets and gizmos). Judge for yourselves. I think the improvements in technology will soon change the way we approach the airway. Think about this. Every airway, is simple, every set of cords is visualised. Every intubation is successful, first time, or at most second. I like that! Let me know what you think. Peter Kas MBBS MArch BArch FACEM AFCHSE
Hi Peter
I am a fan of Airtraq for similar reasons- basically the same technique to laryngoscopy, but converts your grade 3 & 4 to grade 1 effectively. It is disposable and only costs NZ$ 99 a pop. At our training sessions the doc’s that are virginal in it’s use are consistently blown away by how easy it is to use. And if you absolutely want to spend more money you can add the screen.
What is your experience with Airtraq?
Cheers
Willem
DEMT NSH, Auckland
Hi Willem
I agree.
Pound for pound, the best device on the market.
In an airway workshop recently, I altered the anatomy of one of our airway manikins to make it a Grade 4 tube. It was incredibly difficult to intubate, yet everyone could do it with the ‘airtraq’ ( I should say, that I have no financial interest in these).
It’s simple and really effective. I now show it as the only ‘gadget’ I put up at the workshop.
HI Peter,
I am a nurse working in a small rural hospital ED and am interested in what you have in your difficult airways box. Would you be kind enough to share a list with me so I can compare/update our box.
Thanks
Janina
Hi Janina
I actually don’t really believe in a difficult airway box (gasp!).
The only equipment I use are an introducer and a bougie, to assist with the intubation.
If I had one piece of equipment that I would want to have on-board, to assist in a difficult intubation, it’s probably the ‘airtraq’. I discussed this in an earlier blog.
That’s really it, in terms of assisting you to secure an airway.
In terms of airway in general, remember that intubation is not the be-all and end-all, but a desired outcome. If you have good bag valve mask techniques and cannot intubate that’s fine. The only other device that is of help is the laryngeal mask. It doesn’t secure the airway, but allows you to ventilate and oxygenate, without using both hands. You can attach it to a ventilator.
Hope that helps.