The rare “can’t intubate-can’t ventilate” scenario is frightening. It’s important to master as many techniques as possible to prepare for this possibility. Video laryngoscopes have helped a lot with unexpected difficult intubations, but you can’t ventilate a patient with a Glidescope. One intubation device exists that is designed specifically designed to ventilate a patient intermittently during a prolonged intubation attempt: the LMA Fastrach.
Knowing how to use this tool could potentially save a patient’s life. Using the Fastrach is not difficult.Intubation and safe device removal involve several steps that can appear daunting. Below, you’ll find tips, tricks, and a video clip of intubating a patient using the Fastrach.
What is the Fastrach?
The Fastrach is a rigid, anatomically curved, latex free, airway tube. It’s wide enough to accept an 8.0 mm cuffed ETT and short enough to ensure passage of the ETT cuff beyond the vocal cords. This tube has a 15 mm standard connector that allows attachment to a breathing apparatus for ventilation. It has a rigid handle to facilitate one-handed insertion, removal, and adjustment of the device’s position to enhance oxygenation and alignment with the glottis. Like the LMA, the Fastrach has an inflatable cuff that fits over the glottis and seals the supraglottic space allowing ventilation.
The cuff’s bowl has a bar at its opening to lift the epiglottis as the ETT passes through. A ramp inside the intubating tube channel guides the tube centrally and anteriorly. This helps prevent arytenoid injury or accidental entry into the esophagus. The Fastrach comes in 3 sizes: one for children, two sizes for adults. The reusable Fastrach ETT is a wire-reinforced, straight, cuffed tube with a Murphy eye and a standard 15 mm connector. It has a unique molded tip for atraumatic passage through the vocal cords. The distal tip extends approximately 2 cm beyond the wire-reinforced tube. Although it can be used with a standard ETT, extra caution is needed to prevent laryngeal trauma due to the stiffer tip. Both a reusable and a disposable Fastrach are available.
Preparing the Fastrach
Prior to insertion, completely deflate the cuff using a syringe. The leading edge of the cuff must be smooth and wrinkle free. Otherwise the tip of the deflated cushion will curl. Curling can potentially fold the epiglottis down over the glottis during insertion, or prevent a good seal. Lubricate the posterior surface of the LMA Fastrach™. Never lubricate the anterior surface, where the bar is, because lubricant can obstruct the opening or enter the trachea.
Prior to applying lubricant to the ETT cuff, gently fit the connector into the end of the LMA Fastrach™ ETT. In order to remove the Fastrach after the intubation, you will have to remove the ETT connector. Make sure the connector is secure enough to allow adequate ventilation —but not so tight that you can’t remove it easily.
Insert the ETT into the Fastrach™ metal tube. Rotate it up and down to evenly distribute lubricant until it moves smoothly through the tube. Slide the ETT in and out of the intubating channel until it passes easily.
Make sure to lubricate all the way to the epiglottis elevating bar. You will initially feel resistance as you pass the the endotracheal tube through the channel past the bar. However, as the channel gets lubricated, passage becomes easier and easier. Skipping this step may make it hard to introduce the tube into the trachea.
Fastrach Insertion Technique
Hold the Fastrach™ by its handle as shown, with the handle approximately parallel to the patient’s chest. Position the mask tip so it’s flat, not folded against the hard palate. It should press against the palate just inside the mouth immediately posterior to the upper teeth. Placing the Fastrach is like placing an LMA: press against and follow the palate.
You might have to pull the lower jaw upward to allow the widest part of the mask to enter the mouth. Be careful not to pinch the gums.
Don’t use the handle as a lever to force the mouth open. Insert the curved part of the handle downward into the mouth. Push against the palate until the straight part of the rigid tube contacts the patient’s chin . Only at this point in the intubation should you begin to rotate the handle. Allow the mask to slide around the tongue into the posterior pharynx.
Like the LMA Supreme, slide the cushion backwards, following the curve of the rigid airway tube. Keep the cushion firmly applied to the soft palate and posterior pharyngeal wall as you rotate the handle downward. Otherwise the cuff tip will accidental fold.
After insertion, the tube should exit the mouth roughly parallel with the upper teeth, aimed somewhat caudad. Inflate the cuff with just enough air to obtain a seal.
Verify Optimal Placement By Ventilating Through the Fastrach
Now attach your breathing apparatus to the Fastrach metal connector and ventilate the patient. In this particular photo, the anesthesia machine circuit is being used to ventilate rather than a ventilation bag. If you can’t ventilate through the Fastrach, then the ETT will probably NOT pass into the trachea. Stop and improve positioning. Insert the Fastrach deeper. If ventilation is still difficult the epiglottis may be folded over the glottis.
Up-Down Maneuver
Try the “up-down” maneuver. Without deflating the cuff, grasp the handle, swing it outward about 6 cm, and then reinsert it. This maneuver can also be used if you are having difficulty passing the endotracheal tube. If you still can’t ventilate remove the device and start again.
The Fastrach enables intermittent ventilation during extended intubation, making it an excellent rescue device.
Insert the Endotracheal Tube
After confirming ventilation, insert the ETT with the black line facing the handle up to 15 cm, stopping at the transverse marker (just before the tip enters the cushion). Firmly lift the larynx forward a few centimeters without levering against the teeth.
This lifting action is called the “Chandy maneuver”. It increases the seal pressure and optimally aligns of the axes of the trachea and the ETT. It will also correct any tendency for the cuff to be flexed, which may happen if not positioned correctly. If the cuff is flexed, the ETT will not emerge at the correct angle, making the ETT more likely to slide into the esophagus.
Gently push the ETT into the Fastrach past the 15 cm line. If properly aligned, the ETT raises the bar and epiglottis, enabling the endotracheal tube to enter the trachea. Keep inserting until you think you have reached an appropriate depth.
Verify Successful Endotracheal Intubation
Don’t assume that you have successfully intubated through the device: always verify tracheal placement! You do not have to remove the Fastrach to verify endotracheal placement.
Inflate the ETT cuff in the usual manner. Attach your bag or breathing circuit to the endotracheal tube, and verify tracheal placement by listening for breath sounds. For a video clip showing Fastrach insertion and removal, as well as Glidescope use, click here.
Failure to Intubate With the Fastrach
Failure to intubate may be caused by one of the following problems:
- Down folded epiglottis or tube impaction on vestibular wall,
- LMA Fastrach™ is too small (doesn’t overly glottis)
- LMA Fastrach™ is too large (cushion is obstructing glottis)
- Inadequate anesthesia and/or muscle relaxant. (Patient is guarding his airway)
- Large lingual tonsils (blocks elevation of the epiglottic bar and exit of the tube)
If the ETT doesn’t pass, align the Fastrach opening with the glottic opening by finding the position that allows easiest ventilation. Once air exchange is optimal, keep the Fastrach steady and try passing the tube again. Use the up-down or Chandy maneuver if needed. If it still won’t pass then remove and reinsert. Make sure to ventilate the patient.
Removing The Fastrach Device After intubation
Since prolonged presence of the Fastrach can cause swelling, remove it after intubation. Managing several pieces of equipment at once can be challenging, especially when you’re attempting these steps for the first time. After pre-oxygenating the patient, remove the ETT adapter. Deflate the Fastrach cuff but leave the ETT cuff inflated. Hold the end of the ETT firmly as you slowly back the Fastrach out of the mouth. You may have to slightly tap or rock the device as you rotate it around the chin. When the end of the ETT reaches the top of the metal tube, use the stabilizer rod to continue to apply counter pressure to the ETT.
At some point you will be able to reach into the Fastrach cuff and grab the endotracheal tube inside the mouth. Hold the endotracheal tube firmly. Put down the push rod and back the Fastrach out of the mouth overf the tube. You may need to help feed the endotracheal tube pilot balloon through the Fastrach channel. It’s would be easy to extubate during this maneuver so move slowly and deliberately.
Pay attention to anything that’s pulling or caught. Once the Fastrach is out, reattach the ETT adapter and immediately verify that you are still intubated.
For a video clip showing Fastrach insertion and removal click here.
If you need to keep the Fastrach in place after intubation, deflate the cuff and avoid moving it to reduce the risk of pressure, ischemia, accidental extubation, or trauma.
LMA CTrachTM
The CTrach is placed like the Fastrach. However once in place, the intubator attaches a small video monitor which provides a full color view of the larynx. You can then pass the ETT into the larynx under direct vision. The same maneuvers described above are used to obtain good alignment. The in-out and Chandy maneuvers for ventilation and intubation are identical to those used with the Fastrach.
Main Difference Fastrach and CTrach
The main difference is that you can see how effective those maneuvers are in a particular situation. Lingual tonsillar hypertrophy can prevent epiglottis elevation, leading to reported failures of both CTrach and Fastrach devices.
Once intubation is confirmed, remove the video monitor,. Inflate the ETT cuff, and remove the CTrach device using a procedure identical to the Fastrach. Always verify breath sounds and tracheal placement once the device is removed before securing the tube.
Conclusion
The Fastrach is the only intubation device at present that allows ventilation. As such, it can be invaluable for difficult intubations, especially those of the can’t intubate, can’t ventilate variety. If you have practiced the technique, then you usually can intubation quickly. If you’re inexperienced, it can take quite a few minutes. Always ensure proper ventilation and monitor your patients’ vital signs throughout the procedure.
