Monday, May 11, 2015

Airway Pearls from The CRASH Airway Course - Part 1

I was lucky enough to show up at the CRASH Airway Workshop at The Crashing Patient Conference by the Airway Guru "Ken Butler" at The University of Maryland, Baltimore held in October 2014. It was an amazing trip where I got an opportunity to meet some great people. 

Today, I am going to share three big "Airway Pearls" that I learned form the course:
1. Positioning is the key (often ignored in the ED):

For every ED Airway - Make sure that the Ear and Sternal Notch are in the same horizontal plane when you position the patient. To achieve this, you need to support the occiput with some sheets OR in obese you may need to elevate the head end (ramped up position - Reverse Trendelenberg position) and support the occiput as well as the shoulders. Bottom line is take a look from the side to bring EAR and STERNAL NOTCH in the same horizontal plane.

Ear --> Sternal Notch
Ramped up position can be achieved this way in trauma
when you can't mobilise the neck

This position maximizes the upper airway patency and improves the mechanics of ventilation. In morbidly obese this position also lengthens the apneic time period to critical hypoxia + shortens the time needed with BMV to return back to normal oxygen saturation.

2. Apneic Oxygenation OR Nasal Oxygen during efforts securing a tube  (NODESAT)

Apnoeic oxygenation is the application of high flow oxygen via nasal prongs at 10-15L/minute during intubation (during laryngoscopy!). Keep the O2 flow at 4L/min to start with and once you push the induction agent, go upto 15L/min. Continue to provide O2 via nasal prongs  until you pass the tube inside. With this, you will be blowing some oxygen into the lungs, that will diffuse into the bloodstream (it works because even when they are paralysed, blood is still flowing in their body), and buys you some time before the sats start to  drop (extends your safe apnea time). And 30 more seconds of safe apnea time is a lot during the heat of resuscitation. In adddition, again this also shortens the time needed with BMV to return to normal oxygen saturation. 

Apneic Oxygenation

Some high risk groups for desaturation are Obese, Paediatrics, Pregnant and those with a lung pathology. 

One of my anecdotes with apneic oxygenation, Recently I remember bagging a sick hypoxic patient to get the sats up, the maximum I could reach was 97% but then with apneic oxygenation I witnessed the sats going from 97-->100% during laryngoscopy!! 

So make it a part of your Intubation checklist and use it for every ED intubation.

3. Bimanual Laryngoscopy (Using both your hands during the procedure)
This one is my favourite. When we use both our hands during laryngoscopy, that gives a great view without applying too much force. Lets see how it is done:

Bimanual Laryngoscopy (This image in only for demonstration purpose, Always use full PPE)

With scope in your left hand, enter inside the mouth and move in, step by step and the first structure to be visualised is the epiglottis (epiglottoscopy), following which the tip of the blade should be placed in the valeculla (Don't go too far). Now, with your right hand optimise the view using ELM (External Laryngeal Manipulation), once you get an optimal view, take off your hand and ask your assistant to maintain the pressure 


To start with, ask you assistant place his hand over the larynx and give pressure on top of your assistant's hand to get an optimal view (see the image below). This keeps the pressure exactly at the same spot. Bimanual Laryngoscopy dramatically improves the view of the cords.

Bimanual Laryngoscopy with an assistant to start with 
(This image in only for demonstration purpose, always use your full PPE)

Stay tuned.. I will be back next week with Airway Pearls - Part 2


One game changer paper on Airway, that is worth reading is:
Weingart SD, Levitan RM. Preoxygenation and Prevention of Desaturation During Emergency Airway Management Ann Emerg Med. 2012 Mar;59(3):165-75.

Special note of thanks to Dr. Azhar and the authorities of Simulation Lab, Apollo Health City, Hyderabad