Bougie Molding During Laryngoscopy

There is lotsofevidence / that / using / a / bougie will increase your intubation success rate, compared to a styletted endotracheal tube. This is because the bougie is much smaller and easier to maneuver than an ETT, and does not block your view of the target at the last moment, as is often the case with a styletted tube. The Coudé tip allows operators to successfully intubate  grade 3, epiglottis-only views, which means if you are practiced with the bougie and can get a view of the epiglottis, you will be able to intubate.

A less discussed but powerful feature of the bougie is its capacity to be molded; this can be done prior to laryngoscopy (e.g. to conform to the shape of a curved laryngoscope) or during laryngoscopy to allow the bougie to act as a poor man’s flexible endoscope by allowing real-time adjustments to the tip’s trajectory.

This 4-minute video discusses the conventional floppy vs. newer malleable bougies and presents a case where molding a malleable bougie during laryngoscopy turned what could have been a very difficult airway with limited mouth opening into straightforward procedure, even for a junior operator.

There are many manufacturers of floppy and malleable bougies, I have no relationships with any of them.

Airborne Isolation / COVID19 Intubation Checklist

AIIC [pdf]

AIIC [image]

more pearls: make sure cuff is inflated prior to manual ventilation. attach viral filter directly to ETT, if circuit disconnection needed, disconnect circuit on vent side of filter.

References: Zuo 2020, Wax 2020, Weingart 2020, ecuus 1 and 2, Farkas & Thomas 2020

CDC 5 min video on proper donning/doffing, pdf, pulmcrit cheat sheet

 

CDC CV19 Discharge Instructions

LAC DOH CV19 Discharge Instructions

 

Scott’s BVM-on-NIV mask oxygenation setup (6 min vid)

 

Ketamine-Only Breathing Intubation

This 9 minute video demonstrates the strengths and weaknesses of an intubation strategy that relies on dissociation with ketamine.

The essential strength, compared to RSI, is that a breathing technique keeps the patient breathing during laryngoscopy, which transforms the procedure from high-adrenaline to highly controlled. You see in this video that my (fabulous) resident was able to take his time, try different blades, slowly advance and adjust while using view optimization techniques as the patient continued to breathe. This is an extremely powerful way to add safety to the riskiest procedure commonly performed in acute care. We would have been able to carry on with his attempts for longer, had we not been inconvenienced by the arrival of a trauma patient.

Keeping the patient breathing during intubation has a long history in emergency medicine, starting with the brutal and often unsuccessful blind nasal intubation, which, fortunately, is now seldom performed. Many of us learned to do operating room style awake intubation, which relies on thorough local anesthesia using atomized/nebulized/topicalized/regionalized lidocaine, so the patient can remain truly awake and breathing during the procedure. Lidocaine-focused awake intubation is a fabulous technique that requires expertise and equipment not available to all acute care providers, but also–depending on your level of skill–time and patient cooperation. Time and cooperation is something we may not have downstairs or on the side of the road,* but what we lack in time and cooperation, we can make up for in ketamine.

When we use dissociative-dose ketamine to do the heavy lifting in allowing the patient to tolerate laryngoscopy, we obviate much of the needed topicalization expertise/supplies, abbreviate the needed time, and add cooperation with ketamine, cooperation in a vial.  The patient becomes dissociated, breathing but unconscious, which is why I use the term breathing intubation rather than the much more accepted term awake intubation to describe it.

Many patients who receive dissociative-dose ketamine without a paralytic will have some muscle rigidity, and some will develop laryngospasm (which is glottic muscle rigidity).  The patient in this video had some rigidity, which resolved and was not a problem, and this is usually the case. But patients who get ketamine to facilitate laryngoscopy are at much higher risk than procedural sedation patients (who are not having their airway instrumented) to develop laryngospasm and occasionally jaw rigidity, which, together, can cause an immediately dangerous cannot intubate cannot ventilate scenario. Anytime KOBI is being undertaken, a paralytic must be immediately available, ideally drawn up in a syringe, so that the procedure can be converted to a paralyzed technique at any point.

How KOBI fits into our expanding airway toolkit is expertly described by Andrew Merelman and Michael Perlmutter in this WJEM paper.

 

 

 

*some airway experts disagree

 

Postoperative Neck Hematoma

Postoperative neck hematoma is not often discussed in emergency medicine but behaves a lot like neck trauma, because it is neck trauma. These patients should be managed with a high-resource approach and discharged reluctantly, after careful deliberation.

Adapted from Bittner, MD.

The Paper Throat: A Lo-fi, DIY Laryngoscopy Simulator

 

Laryngoscopy involves a series of unnatural movements and hand-eye skills that are not easily learned while simultaneously caring for a dying patient. The Paper Throat is a low fidelity but high yield direct laryngoscopy training tool that is easily assembled and practiced. The hope is that routine use will generate laryngoscopy muscle memory so that training providers can focus on other aspects of airway management when called upon to intubate IRL.

Conceived and produced by Jonas Pologe.

Pulse Ox Lag

Folks put a lot of stock in the pulse oximeter, as they should, because the pulse ox is an awesome feat of engineering and patient safety. But the pulse ox lags.

Here, the inestimable Dr. Jonas Pologe (rhymes with apology) demonstrates pulse ox lag with a breath hold.

Breath hold starts at 0:11, sat is 100%
Saturation starts to drop at 0:48
Breathing commences at 1:25, sat is 82% at this point
Saturation continues to drop until 1:46, then recovers from its nadir of 77%
At 1:58, saturation reaches 100% again

 

Lessons:

1. When the sat is on its way down, the patient is more hypoxic than the pulse ox shows. This is another reason why, when laryngoscopy is not producing an acceptable view of the glottis, you should come out and reestablish ventilation/oxygenation earlier than you think. A more important reason to come out and bag early is described here.

2. When you are reestablishing oxygenation (using a bag mask, laryngeal mask, or endotracheal tube), do not use the pulse ox to judge the adequacy of ventilation, use capnography. That means the capnogram should be attached to the bag mask/LMA/ETT before the first breath is given. If the capnogram is good, ventilation is good, and the pulse ox will catch up, so relax and stop bagging so quickly.