How Do You Intubate While Ventilating?

[chbare]

Sorry, off topic.

Spock, this case was discussed at a work shop I attended. The term "Rapid Sequence Airway" was discussed. What are your thoughts on this concept?

Take care,

chbare.

[tniuqs]

Interesting points all:

I believe in the PHTLS they are refering to non visualized airways, I have observed a few "Gas Passers" do this.

But a moving target is going to reduce first attempt sucess, I suspect ?

I like the SLOPE acronym and first time I have heard of it.....must be an eastern coast thing?

LOL.

[Spock]

I think the RSA has some merit. If you think the intubation will be difficult why not just punt to an alternate airway? Our new Pennsylvania state protocols always list ETI or alternative airway device (combitube or King LT) on the same line. It is worth considering.

I'm not sure what a "non-visualized airway" is unless you mean putting the tube in the trachea without ever seeing the vocal cords. And yes, this gas passer has done it many times. Sometimes out of necessity and other times just to make it a challenge. Warning! I have gas and I know how to use it!

Live long and prosper.

Spock

[sladey67]

By passing it throught the LMA (and into the trachea), remove the LMA, then just slide the tube (while visualizing or not) over the boogie into the trachea, remove boogie and bag.

Overactive

Hmm ... Now how do you know the boogie is in the trachea??

Passing a boogie down an LMA does not guarantee it will pass through the cords ... just means it's in the laryngopharynx ... somewhere. Could just as easily be sitting in the esophagus.

[fiznat]

Hmm ... Now how do you know the boogie is in the trachea??

.

You are supposed to pass the bougie down as far as you can. In theory they say you should hit the carina and meet resistance. You also might be able to feel the bumpy tracheal rings. If it is in the esophagus you would be able to pass the entire bougie (depending on the size of the pt of course) without feeling resistance.

Intubating LMAs kind of maximize your chances for blind insertion into the trachea through positioning near the area, and partial covering of the esophagus by the inflated cuff. Youre right, it's not perfect, but I've done it on a dummy a few times and works pretty well.

(I wonder if a stiff, hollow tube might be more useful here. ...Something through wich a small amount of ventilation could be passed and then ETCO2 measured afterwards to approximate placement.)

[sladey67]

You are supposed to pass the bougie down as far as you can. In theory they say you should hit the carina and meet resistance. You also might be able to feel the bumpy tracheal rings.

So just jam that bougie down there huh? How much trauma we doing to this guys larynx.

And what percentage will actually hit the spot ... ie. take an upward turn and through the cords? Not too many I bet. In my experience the hard plastic airway of a dummy is far different to the real thing. Have you or anyone ever tried this on a real person? with success?

The LMA cuff does not occlude the osephagus ... it just provides a seal.

[fiznat]

So just jam that bougie down there huh? How much trauma we doing to this guys larynx.

And what percentage will actually hit the spot ... ie. take an upward turn and through the cords? Not too many I bet. In my experience the hard plastic airway of a dummy is far different to the real thing. Have you or anyone ever tried this on a real person? with success?

The LMA cuff does not occlude the osephagus ... it just provides a seal.

Chill out, sladey.

I didnt say "jam" the bougie down there at all. I imagine the extent of the trauma depends directly on the technique of the provider. The bougie is a soft, pliable gummy tube. I dont think it would cause that much trauma if handled properly.

I have no idea what percentage will hit the cords, although I do know that "intubating LMAs" are specifically marketed to healthcare providers. I'm sure they did research, and while I dont very much care to hunt it down because my service does not use this tool, I'm sure it is available if you wish to find out more about the science behind this procedure. I do have some faith, though, that specifically marketed intubating LMAs are able to do what they claim at least a significant porportion of the time. They are widely used.

No I have never tried this on a real person. My service does not supply LMAs at all, nevermind the intubating ones. Besides, even if I had, what value would my individual ancedotal information on this subject carry? Other people have used this and found success with it. If this is the kind of evidence you want, feel free to search them out.

I know that the cuff does not occlude the esophagus, I didnt say that it did. ...Only that it does do it's part to help direct a bougie towards the correct general direction.

I googled the subject and the very first link lead me towards some research:

1. Brain AIJ, Verghese C, Addy EV, Kapila A. "The Intubating Laryngeal Mask-I. Development of a New Device for Intubating the Trachea." Brit J Anaesth 79:699, 1997.

2. Baskett PJF, Parr MJA, Nolan JP.. "The Intubating Laryngeal Mask. Results of a Multicentre Trial with Experience of 500 Cases." Anaesthesia 53:1174, 1998.

3. Dhar P, Osborn I, Brimacombe J, et al. "Blind Orotracheal Intubation with the Intubating Laryngeal Mask vs. Fiberoptic Guided Orotracheal Intubation with the Ovassapian Airway. A Pilot Study of Awake Patients." Anesth Intensive Care 29:252, 2001.

I dont know the results of the studies, but this should help you find some scientific basis for your obvious skeptcism of this procedure.

[spenac]

Here is a good site that sells the bougie under the name of Tube Introducer 15 F Coude Tip.

https://securesite.nittanylink.com/AirwayCa...t/Products.aspx

EMP also sells the bougie.

I am aware of numerous medics that carry one with them and they get the airway when others including the Doctors don't. I have only recently began practicing with them and have them at one of the services I work for and will order for the other service soon.

From what I have seen they do a lot less damage than the medics that just keep unsuccessfully trying to intubate.

[chbare]

I think there may have been a misunderstanding regarding the bougie. You can pass it down LMA's and Kings and attempt to pass through the glottis. These airways actually set you up for a good chance of passing the bougie through the glottis when the airways are in proper position. This is not an absolute however. In addition, we are not cramming the bougie down. The bougie is gently inserted and we assess for two findings: 1. Tracheal clicking, the unique shape of the end of the bougie will allow it to run across the tracheal rings during insertion. The clicking is a very accurate indicator of proper glottic insertion. 2. Stop sign, you should meet resistance as the tip stops on the carina. True, you could go dow a mainstem; however, when inserted into the esophagus, you will meet no resistance. When used in conjunction, these two findings are very accurate. If you fail to place the bogie in the trachea you can simply pull it out and continue using the rescue airway. I am not sure why some people have an issue with this technique. When performed properly and carefully, the possibility of trauma is quite small. We should talk about all of the problems with laryngoscopy if we insist on discussing the pitfalls of the bougie. It is like any other technique, you need proper education, training, and validation.

Take care,

chbare.

[AZCEP]

It can be done with an NG tube, but they tend to be too flexible to be very useful for this purpose.

There are also oxygen supplying versions of the flexible endotracheal tube introducer on the market. They allow for the connection of oxygen supply tubing to a standard bougie, and it is delivered through the distal end. A bit pricey for the times you will actually need it, but they are out there.