Intubation question.

[Lone Star]

Since I'm the one that brought this question up in chat, I feel compelled to speak up.

I know I'm 'inexperienced' in intubation at best, but here's my thoughts on the topic. Since the trachea is anterior to the esophagus, and not to the right or left; does it REALLY matter if the tongue is displaced to either side, or is the whole 'sweep the tongue to the left' just something that came about because of the dominance of the right handed person?

Secondly, according to the material I've read; the tongue and jaw are displaced upwards and caudually (toward the feet). If I can do this with the laryngoscope in my right hand, then where's the issue?

I can't see that working better than right handed, unless you're doing face-to-face intubation or working with some really messed up airway anatomy.

Since we're discussing visual intubation,...is there another method other than 'face to face intubation'?

*DISCLAIMER*: I'm not trying to be a 'jerk', 'be confrontational' or anything else. I'm only on a fact finding mission so that I can either correct any detrimental actions, or show justification for doing things this way.

[VentMedic]

Since I'm the one that brought this question up in chat, I feel compelled to speak up.

I know I'm 'inexperienced' in intubation at best, but here's my thoughts on the topic. Since the trachea is anterior to the esophagus, and not to the right or left; does it REALLY matter if the tongue is displaced to either side, or is the whole 'sweep the tongue to the left' just something that came about because of the dominance of the right handed person?

Secondly, according to the material I've read; the tongue and jaw are displaced upwards and caudually (toward the feet). If I can do this with the laryngoscope in my right hand, then where's the issue?

You can pull up many intubation videos on YouTube and see why it is important for you, the light, and slide groove on the blade to line up appropriately. Also, it is a little more than just moving the tongue and jaw as each blade type has a specific anatomy landmark destination for correct visualization of the cords.

Here is a good site. It also has some of the intubation methods and devices I have mentioned in previous posts.

http://www.theairwaysite.com/video/videos.aspx?videoID=8

Here is a good animation.

http://www.medicalvideos.us/videos-2121-Endotracheal-Intubation-Sample-Animation

Since we're discussing visual intubation,...is there another method other than 'face to face intubation'?

*DISCLAIMER*: I'm not trying to be a 'jerk', 'be confrontational' or anything else. I'm only on a fact finding mission so that I can either correct any detrimental actions, or show justification for doing things this way.

I believe the face to face method Anthony is referring to is also known as "the pick axe" or "tomahawk" method.

This technique is performed with the intubator facing the patient and holding the laryngoscope like a pick axe or tomahawk. Unlike conventional laryngoscopy, the laryngoscope is held in the right hand with the blade facing downwards and the endotracheal tube is held in the left hand. The blade is inserted in the mouth from the patient's right side and the tongue is displaced to the patient's left while the intubator pulls the laryngoscope downwards and towards him/her.

This technique is useful in the patient presenting in a seated position and is useful in motor vehicle collision scenarios. A variation of the technique can also be used in the limited access patient who is supine by having the intubator straddle the patient and bend forwards to be face-to-face with the patient. Such a scenario might occur when intubating an unresponsive patient who is wedged in a bathroom between the toilet and the tub or similar setting.

Edited November 5, 2009 by VentMedic

[Lone Star]

I believe the face to face method Anthony is referring to is also known as "the pick axe" or "tomahawk" method.

This technique is performed with the intubator facing the patient and holding the laryngoscope like a pick axe or tomahawk. Unlike conventional laryngoscopy, the laryngoscope is held in the right hand with the blade facing downwards and the endotracheal tube is held in the left hand. The blade is inserted in the mouth from the patient's right side and the tongue is displaced to the patient's left while the intubator pulls the laryngoscope downwards and towards him/her.

This technique is useful in the patient presenting in a seated position and is useful in motor vehicle collision scenarios. A variation of the technique can also be used in the limited access patient who is supine by having the intubator straddle the patient and bend forwards to be face-to-face with the patient. Such a scenario might occur when intubating an unresponsive patient who is wedged in a bathroom between the toilet and the tub or similar setting.

If this is the method that Anthony was referring to, wouldn't it be almost impossible to visualize the vocal cords....due to their inferior positioning?

In the scenario presented (the MVA), wouldn't digital or 'blind intubation' actually be better until you could get them extricated, due to C-spine precautions hindering your ability to visualize the vocal cords?

One would think that even the most basic of adjuncts would be beneficial for a short period of time, then move to the 'traditional intubating position' when space and conditions allow.

[VentMedic]

If this is the method that Anthony was referring to, wouldn't it be almost impossible to visualize the vocal cords....due to their inferior positioning?

In the scenario presented (the MVA), wouldn't digital or 'blind intubation' actually be better until you could get them extricated, due to C-spine precautions hindering your ability to visualize the vocal cords?

One would think that even the most basic of adjuncts would be beneficial for a short period of time, then move to the 'traditional intubating position' when space and conditions allow.

That depends on how long extrication will take and the injuries of the patient. C-spine shouldn't be a problem if you have someone holding the head. There are some facial injuries that may be unsuitable for supraglottic devices especially the Combitube. It is always good to have many intubation alternatives with indepth knowledge of various methods in your tool kit. I have used many different intubation methods t/o my career for whatever reasons including location/position of the patient and equipment failure. Also, when I first started in EMS, the EOA was about the only alternative airway device available. Thus, I became very knowledgable and proficient at ETI by whatever method. Of course knowing how to use a BVM and when not to do ETI or cause harm by repeated attempts are equally important.

I will say Digital Intubation would not be my preferred alternative method for adults but for neonates it is an option.

Edited November 5, 2009 by VentMedic

[tniuqs]

Practice L and R handed technique(s) because in if in an aircraft, like Bell 205, 407, A-Star or Lear Jet sometimes one cannot use a conventional approach.

The first time I have ever heard of the tomahawk, but it sounds from the description one would need to practice YOGA for a year

The nasotracheal blind approach and even in the suspected C spine and entrapped, just saying Airway is priority before Fractures in my book.

Inserting fingers and a digital insertion did lead to one of my partners being treated for HEP.

Interesting comments all.

cheers

[Lone Star]

The entire reason this thread came about is because I've been told:

1). There is absolutely no way you can visualize the vocal cords when you hold the laryngoscope in the right hand.

2). If you do that on (use the laryngoscope in the right hand) on your NR practicals, you'll be automatically failed.

3). We've always done it this way.

Granted, the only 'experience' I have with the ETT is on a mannequin (yes, I'm clever enough to know that intubating a mannequin is vastly different from intubating a 'real, live person'). I was able to visualize the ETT slide through the 'vocal cords', and when ventilations were administered; the 'lungs' inflated.

So far, no one's addressed the biggest questions out there:

Since the trachea is anterior to the esophagus, and not to the right or left; does it REALLY matter if the tongue is displaced to either side, or is the whole 'sweep the tongue to the left' just something that came about because of the dominance of the right handed person?

Secondly, according to the material I've read; the tongue and jaw are displaced upwards and caudually (toward the feet). If I can do this with the laryngoscope in my right hand, then where's the issue?

*DISCLAIMER*: I'm not trying to be a 'jerk', 'be confrontational' or anything else. I'm only on a fact finding mission so that I can either correct any detrimental actions, or show justification for doing things this way.

[Kaisu]

The first time I have ever heard of the tomahawk, but it sounds from the description one would need to practice YOGA for a year

I've practiced the "tomahawk" in airway labs. It is not a blind technique and is not as difficult as it sounds. (of course, I've practiced yoga for 30 years )

[VentMedic]

This is not that difficult. There are over 50 different styles of blades out there that are off the curved and the straight. I don't know which one you are using and frankly I don't need to know. The important thing is that you UNDERSTAND how and why your equipment is designed the way it is and the anatomy and/or condition of the patient.

If you want to use your other hand, choose the appropriate equipment for the patient. Don't do something because someone says this or that or dares you. Use equipment correctly and the way it was designed and/or the way you have been trained. In the field is not the time to be screwing around trying to do something just to prove something. Also, wasting classroom time mucking around instead of perfecting good technique is not the best use of the lab either. Class time is too short already and too few intubations "the regular way" are required as it is now.

I mentioned the "tomahawk" method. If you have not been trained for that method, don't do it. But, you should have an alternative method that you are comfortable with.

Supraglottic devices are not always appropriate for facial trauma because of bleeding, foreign bodies and aspiration. Thus, have a plan A, B, or C handy.

And yes I did answer your questions by this comment and the links I posted. Observe how the blade is to be positioned and how the light and groove assist the passage of the tube.

Also, it is a little more than just moving the tongue and jaw as each blade type has a specific anatomy landmark destination for correct visualization of the cords.

[tniuqs]

'VentMedic'

I mentioned the "tomahawk" method. If you have not been trained for that method, don't do it. But, you should have an alternative method that you are comfortable with

I have well after Kaisu's post entered in a Yoga Class, not to actually learn the method but due to >25 years of lifting and a proud member of the L5S1 Club ... my comment well besides I could just not visualize it was a poor attempt at Ha Ha.

Supraglottic devices are not always appropriate for facial trauma because of bleeding, foreign bodies and aspiration. Thus, have a plan A, B, or C handy.

Absolutely agreed but what I have not seen or posted here is a retrograde intubation with the use of a Boogie introduced cricothyroid approach I was fortunate to work with an CAF PA but the link uses a wire.

This is my plan just my plan "B" but a rarely disused topic in my hood.

http://www.medicalvideos.us/videos-284-Retrograde-Intubation

[VentMedic]

I have well after Kaisu's post entered in a Yoga Class, not to actually learn the method but due to >25 years of lifting and a proud member of the L5S1 Club ... my comment well besides I could just not visualize it was a poor attempt at Ha Ha.

Please tell me you are not getting as old and feeble as spenac.

Here are a couple photos of "face to face" or "tomahawk intubation.

http://www.anestezjologiairatownictwo.pl/archiwum/2009_02_face_to_face_intubation.pdf

http://highered.mcgraw-hill.com/sites/dl/free/0073520713/462736/SS16_ET_Intubation_Face_to_Face.pdf