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. However, there are enough steps during intubation, as well as during safe removal of the device without accidental extubation, that can make it seem intimidating. In addition to some tips and tricks that make it work, you’ll find a link below to a video clip of intubating a patient with the Fastrach.
What is the Fastrach?
The Fastrach is a rigid, anatomically curved, latex free, airway tube 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.
Instead of a grill, the bowl of the cuff contains a bar in the cuff opening which is used to elevate the epiglottis as the ETT is passed through the aperture. A ramp in the intubating tube channel directs the tube centrally and anteriorly to reduce the risk of arytenoid trauma or esophageal placement. 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 conventional ETT if necessary care must be taken to avoid trauma to the larynx because of 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. It’s crucial that the leading edge of the cuff be smooth and wrinkle free to prevent the tip of the deflated cushion from curling. 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 take it out easily.
Insert the ETT into the Fastrach™ metal tube, rotating and moving the ETT up and down within the shaft to distribute the lubricant until it travels freely through the entire extent of 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, but 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 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 pass into 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, pushing 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, allowing 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, in order to avoid accidental folding of the cuff tip.
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 and you should improve positioning. Insert the Fastrach deeper. If ventilation is still difficult the epiglottis may be folded over the glottis. 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.
Note that the ability to ventilate through the Fastrach allows you to ventilate off and on during a prolonged intubation process. This makes this an ideal rescue device.
Insert the Endotracheal Tube
Once you have verified ability to ventilate, insert the ETT with the longitudinal black line on the tube facing the handle up to the 15 cm mark until you reach the transverse marker line. This line corresponds to the point at which the ETT beveled tip is about to enter the opening in the cushion. Grip the handle firmly and lift the larynx forwards a few centimeters. Don’t “lever” against the teeth. This lifting action is called the “Chandy maneuver” and 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 everything is aligned optimally, the ETT will now lift the bar that in turn lifts the epiglottis out of the way, allowing the endotracheal tube to slide into 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)
In the event the ETT won’t pass make sure that the Fastrach opening is in optimal alignment with the glottic opening by locating the Fastrach position where ventilation is easiest. Once air exchange is optimized, hold the Fastrach steady in that position and try to pass the tube again. Try the up-down maneuver or the Chandy maneuver. 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, you should remove it after intubation. This can be a bit tricky the first time you try this since multiple steps require you to manage several pieces of equipment in a coordinated fashion. 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 metal tube reaches the end of the ETT 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 clinical conditions dictate that you must leave the Fastrach in place after intubation, then deflate the cuff and avoid moving the device inside the mouth to minimize the risk of excessive pressure, ischemia injury, inadvertent extubation or trauma..
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. Techniques such as the in-out maneuver and the Chandy maneuver for improving ventilation and view/intubating conditions are the same as for the Fastrach. The main difference is that you can see how effective those maneuvers are in a particular situation. Failure of the CTrach, as well as the Fastrach, have been reported with the presence of lingual tonsillar hypertrophy since the tonsillar tissue prevents elevation of the epiglottis. 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.
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. May the force be with you