Airway Gadgets Fiberoptic Intubation D John Doyle MD

Airway Gadgets / Fiberoptic Intubation D. John Doyle MD Ph. D Professor of Anesthesia Cleveland Clinic

Objectives At the end of this presentation learners should be familiar with the following: • Recognizing situations where intubation will be very difficult • The art and science of awake intubation • Routine and specialized equipment for laryngoscopy / intubation

Devices to Relieve Airway Obstruction

Techniques for Difficult Intubation • • • Alternative laryngoscope blades Glide. Scope Awake intubation Blind intubation (oral, digital, nasal) Fiberoptic intubation (awake, asleep) Intubating stylet / tube changer Light wand Retrograde intubation Surgical airway (Modified from ASA Guidelines for Management of the Difficult Airway)

ETT Position Confirmation Devices

Stethoscope

Portable Capnograph

TIDAL WAVE Sp™ Handheld Capnograph/ Pulse Oximeter

Easy Cap Disposable End-tidal CO 2 Detector Changes color from purple to yellow with expired CO 2

Ambu Tubecheck - Bulb Model

Ambu Tubecheck - Syringe Model

Video Laryngscopes

Mc. Grath MAC

The Venner™ A. P. Advance™ Video Laryngoscope

Koyama J, Aoyama T, Kusano Y, et al. Description and first clinical application of Air. Way Scope for tracheal intubation. J Neurosurg Anesthesiol 2006; 18: 247– 50

Photograph of the Airway Scope® with a tracheal tube in place in the side channel. A) Front view. B) Lateral view. The device is held in the left hand passed into the mouth over the tongue, and the tip is placed under the epiglottis. C) View of the glottis of a 33 -yr-old female, which was obtained during tracheal intubation using the Air way Scope®. The target signal shown on the monitor is aligned with the glottic opening. D) A cuffed tube is passed from its position in the channel through the vocal cords. E) The position of the tracheal tube is confirmed at the level of the cords. Canadian Journal of Anesthesia 54: 160 -161 (2007)

Difference of endotracheal tube (ETT) direction comparing curved and straight tubes. A) curved reinforced ETT. B) straight reinforced ETT which often passes posterior to the glottis, potentially resulting in failed intubation. Canadian Journal of Anesthesia 54: 773 -774 (2007)

Glide. Scope Video Laryngoscope

Case 110

Glide. Scope Ranger

Photo Courtesy Dr. Richard Cooper, Toronto General Hospital

INTUBATION DETAILS “We found that the principal limitation in using the Glidescope® was not in getting a good view of the glottis, but rather in manipulating the endotracheal tube (ETT) through the vocal cords. We also found that successful ETT placement was usually best achieved using a stylette formed in the shape of a "hockey stick" (with a 90° bend) to help ensure that the ETT could be directed sufficiently anteriorly to enter the glottis. ” D. John Doyle, MD Ph. D, Andrew Zura, MD and Mangalakaraipudur Ramachandran, MD. Videolaryngoscopy in the Management of the Difficult Airway. Canadian Journal of Anesthesia 51: 95 (2004)

Sample Video

SARS and Intubation The Glide. Scope may offer an advantage in SARS cases and in other cases of respiratory infections because the intubator does not have to get close to the patient to intubate.

USING THE GLIDESCOPE IN A PATIENT WITH AN UNSTABLE CERVICAL SPINE E. M Noguera, MD, John Tetzlaff, MD, D. John Doyle, MD Ph. D CASE DESCRIPTION [Case 422 Feb 13, 2004] A 25 year-old female with a 9 year history of Juvenile Rheumatoid Arthritis (JRA) was scheduled for debridement of sacral and ischial decubitus ulcers. Cervical spine xrays suggested that her spine was unstable at C 1 -C 2.

USING THE GLIDESCOPE WITH CERVICAL SPINE INSTABILITY CASE DESCRIPTION She was 164 cm tall, weighed 31 kg and had no allergies. Swan neck and Boutonnières deformity Maximum flexion of elbows 90 degrees

LIMITED FLEXION LIMITED EXTENSION

Assessment of the airway • 3 cm mouth opening • Thyromental distance of 5 cm • Mallampati I oropharyngeal view • Limited neck flexion / extension

• Intubation asleep (terrified of awake intubation) • Immobilization of the neck with semi-rigid neck immobilizer • Orotracheal intubation: Glide. Scope with fiberoptic bronchoscope ready. • Induction: Lidocaine 2 mg/kg and Propofol 2 mg/kg. NO RELAXANTS. • Extubated in the OR with neck immobilizer in place.

The Glide. Scope was particularly suitable in this case because patients are generally easy to intubate in the neutral position with this system. The alternative of asleep fiberoptic intubation might also have been successful.

Awake Intubation

Awake intubation is not necessarily fiberoptic intubation.

Awake Intubation Will Rosenblatt, ASA Refresher Course 218

The Secrets of Mastering Fiberoptic Intubation

Andranik (“Andy”) Ovassapian (1936 -2010)

Dr. Ovassapian’s Most Difficult Airway Case

Preliminaries do count! • Know your equipment and set it up correctly • Know your patient and the surgical plan • Establish a plan for FOBI – Discussion with patient – Oxygen (nasal cannula) – Antisialagogue (e. g. , glycopyrrolate) – Sedation (e. g. , midazolam, dex) – Oral vs nasal – Awake vs asleep 1

2 • • Reassurance Explain need for awake FOBI Don’t rush patient Agree to stop / pause when requested Remember to provide extra topical anesthesia if needed

3 Pharmacologic Sedation

4 Use two suctions: one for the Yankauer, and one for the scope

5 Use standing stools (unless you are an NBA star)

Correct vs. Incorrect Position

6 Use the biggest scope available (better image, better suction). Use a video scope where possible.

7 Good topical anesthesia is essential; invasive blocks are usually not needed. MADgic Laryngo-Tracheal Atomizer • “Spray as you go” • Epidural catheter • Wolfe Tory Medical

Transtracheal Block

Retrograde Nasal Intubation In A Case Of Subdural Haematoma With Mandible Fracture: A Case Report. The Internet Journal of Anesthesiology™

8 http: //faculty. washington. edu/pcolley/

9 Use an FOBI airway (Williams, Ovassapian, ROTIG)

10 Try a Parker Flex-Tip ETT

11 Attend FOBI Workshops

12 • • Practice FOBI on Easy Asleep Patients Standard induction Williams airway Jaw thrust Backup intubation method readily available • Try in conjunction with Glide. Scope

Sample Video

Awake Intubation with the Glide. Scope

Awake Intubation Technique Following sedation with midazolam, the airway is anesthetized with gargled and atomized 4% lidocaine; superior laryngeal and transtracheal blocks are not usually employed. Once a good view of the glottis is obtained, additional lidocaine is administered under direct vision, using a MADgic® atomizer (Wolfe Tory Medical, Salt Lake City, USA).

MADgic® atomizer (Wolfe Tory Medical, Salt Lake City, USA).

Advantages There are several advantages of using the GVL for awake intubation. First, the view is excellent. Second, the method is less affected by secretions or blood as compared to fiberoptic intubation. Third, everyone can view the intubation, while this is the case only for video bronchoscopes. Fourth, the intubation can be recorded using a regular camcorder. Fifth, there are no restrictions on the type of ETT that can be placed, while this is not the case for fiberoptic methods. Sixth, the GVL is more rugged than a bronchoscope, and is less susceptible to damage. Seventh, the GVL is easily cleaned. Finally, while advancing the ETT into the trachea over a bronchoscope often fails as a result of the ETT impinging on the arytenoids, this is not a problem with the GVL.

Glide. Scope. Assisted Fiberoptic Intubation

Glide. Scope-Assisted Fiberoptic Intubation Case Description: – 60 yo female with a history of “difficult intubation” and previous fiberoptic intubation presents for reversal of loop ileostomy – Awake fiberoptic intubation is attempted orally, then nasally, without success – Unable to visualize vocal cords

Glide. Scope-Assisted Fiberoptic Intubation • Second physician attempt at fiberoptic intubation unsuccessful • After administration of more sedation, Glide. Scope introduced, revealing a very anterior larynx • Under Glide. Scope guidance, fiberoptic bronchoscope redirected 90 degrees anteriorly and through vocal folds for successful intubation

Intubation Using the Aintree Catheter

Step 1. Introduce a Laryngeal Mask Airway (LMA)™ in the usual manner.

Step 2. Next, a fiberoptic bronchoscope placed through an Aintree Intubation Catheter, is introduced into the LMA™.

Step 3. The fiberoptic bronchoscope is advanced through the LMA™, through the vocal cords, and into the trachea.

Step 4. Once visualization of the tracheal rings is confirmed, the fiberoptic bronchoscope is removed while the Aintree catheter is left behind.

Step 5. The LMA™ is carefully removed, taking care not to displace the catheter.

Step 6. One can now “railroad” an endotracheal tube over the Aintree Intubation Catheter into the patient’s trachea.

Step 7. After the catheter is removed, inflate the endotracheal tube cuff and begin ventilation. Be sure to check for bilateral air entry and an appropriate capnogram.

Negative Pressure Ventilation

Polio Macintosh Blade (1950 s) The blade is mounted at 135 degrees to the handle. This equipment was originally designed to facilitate intubation in patients encased within iron lung ventilators during the polio epidemic. It is also useful in patients with barrel chest, restricted neck mobility or breast hypertrophy. These blades are more popularly used in conjunction with a short ‘stubby’ handle. From http: //www. frca. co. uk/article. aspx? articleid=262

Cuirass

Negative Pressure Ventilation

Negative Pressure Ventilation A light cuirass encircles the thorax of the child from the clavicles to the upper part of the abdomen including the diaphragm and exerts successively a negative pressure corresponding to inspiration and a positive pressure at a frequency between 4 to 1000 cycles per minute. http: //picubook. net/parts/lung/NIPPV/text 9. html