To Open The Airway, Optimally Position The Head and Neck

The most basic of airway skill is knowing how to open the airway. Sick patients may be breathing spontaneously, but be unable to maintain an open airway, leading to hypoxia. Hypoxia can easily lead to bradycardia and cardiac arrest, especially in children. Mastering basic airway management skills is essential to avoid serious complications.

Opening The Airway Technique

We’re all familiar with the 3 main ways to open the airway.

Head Tilt

Tilting the head back  tends to allow the larynx to rise away from the posterior pharyngeal structures, opening the airway.

illustration of unconscious patient receiving the chin lift maneuver

Tilting the head back, one of the easiest methods of opening an airway, often works without any additional maneuvers.

Jaw Thrust

To use the jaw thrust maneuver , grip the angles of the mandible with both hands to pull the jaw forward. This motion frequently pulls the head into extension. If you’re using cervical precautions because of potential cervical spine injury, pull upward only on the jaw, keep the head and neck stable. Pressing on the bone 1-2 cm above the angle of the jaw and below the ear is painful and may help rouse a sedated patient enough to breathe on their own.

Photo showing jaw lift in a simulated patient

Lifting the jaw by pulling it forward, even with a neutral neck position, will open the airway.

Triple Airway Maneuver

The triple airway maneuver combines the previous techniques. Tilt the head into extension and lift the angles of the jaw. Use your thumbs to pull the mouth open.

Illustration showing the triple airway maneuver

The triple airway maneuver, both tilting the head back and sliding the lower jaw forward is most effective.

While it’s easy to pull the mandible upward by placing your thumb in the patient’s mouth to grip the chin, I don’t recommend it because it’s potentially dangerous — the patient may bite you.

Why Does Tilting The Neck Open The Airway?

The larynx and surrounding structures will move when you move the head and neck and manipalute the surrounding structures. Look at the following Xrays to see why knowledge of the laryngeal anatomy makes it easier for you to open an airway.

Head and Neck Neutral

Look at the lateral Xray with the head in neutral position. The outline of the epiglottis, hyoid bone, thyroid cartilage, and cricoid cartilage are easily identified. The relationship of the larynx immediately in front of the esophagus explains why aspiration can easily occur and is always a risk

Lateral Xray of a the neutral neck showing the larynx

Xray of neck in neutral position. Note how close the trachea and esophagus are. This image shows how the epiglottis works like a trap door to open and close the larynx.

Head and Neck Fully Flexed

Now lets look at a lateral Xray of the neck flexed fully forward. When the head is flexed forward, the structures in the posterior pharynx and the tongue tend to obstruct the airway and close the larynx. You can test this by flexing your head forward as far onto your chest as you can. It becomes much harder to take a breath.

lateral Xray showing that With the head flexed fully forward onto the chest, the airway is almost fully obstructed. Visualization of the larynx wold be impossible.

With the head flexed fully forward onto the chest, the airway is almost fully obstructed. Visualization of the larynx would be impossible.

Head and Neck Fully Extended

Tilt your head back as far as you can. Your airway is now wide open. When we run up a flight of stairs and get out of breath, we tend to tilt our heads back and slightly forward to maximize airway patency and decrease airway resistence. This position is known as the sniffing position.

Now look at at the Xray to see what happens to the airway when the head is tilted backwards.

lateral Xray of the neck in full extension showing how the relationship of the larynx changes with respect to the rest of the neck structures. Extension without placing the patient in the sniffing position will hide the larynx behind the tongue, or a so-called anterior larynx.

Lateral Xray of the neck in full extension showing how the relationship of the larynx changes with respect to the rest of the neck structures.

Don’t Forget Cervical Spine Precautions

Caution: If you are using cervical spine precautions you should NOT tilt the head back. Tilting the head back with possible cervical spine injury could potentially injure the spinal cord. Maintain a neutral position in this situation and rely on jaw thrust.

It helps to know the anatomy and how your manipulations manipulate that anatomy in order to optimize your ability to manage the airway. Think of that anatomy the next time you open the airway.

For more information on opening an airway and on mask ventilation check out:

Airway Emergency: Start With The Basics of Airway Management

May The Force Be With You

Christine E. Whitten MD
author: Anyone Can Intubate: A Step by Step Guide
and
Pediatric Airway Management: A Step By Step Guide

Click on the images to preview my books at amazon.com

Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon  Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten

Preventing Airway Emergencies

I’m in Egypt at the 35th International Conference Egyptian Anesthesia 2019. I was given the great honor of presenting my article on the 10 Rules For Approaching Difficult Intubation: Always Prepare For Failure. That article was the most read review article on the Anesthesia News site in 2018, another honor. Thank you readers. A link to that article can be found here. Please feel free to share it with your students.

I have attended many lectures at the Egyptian Conference, and the overarching emphasis on patient safety and continuously improving care is impressive.

It’s been estimated that there are at least 25 million intubations in the United States per year and 50 million worldwide. Even though the percent risk of failed airway is very small, when multiplied by large numbers of intubations the estimates of potential number of critical airway events is impressive.

During my presentation, I referred to 3 recurring themes.

  • Preparation is key
    • You can’t prevent every difficult airway situation – but you can prevent most of them
  • Your decisions, and how you make them are important
    • You can always make a bad situation worse
  • Teamwork and Communication are key
    • You cannot and should not do this alone

Let’s look at these more closely.

Preparation is Key To Avoiding Difficult Airway Situations

Patients can be difficult to intubate because of anatomy or the circumstances surrounding the intubation. For example, failed intubations are more common in emergency room settings, prehospital settings, and delivery rooms. Emergency procedures tend to have more severe outcomes than elective ones.

According to the American Society of Anesthesiologists Closed Claims review, airway complications are twice as likely to occur out of the OR. Inadequate oxygenation is 6 times as likely. This makes sense because those situations frequently are emergencies, in locations with minimal specialized airway equipment, personnel unfamiliar with your techniques, distractions, poor patient positioning, and often, poor lighting. But no matter the status of the patient and circumstances surrounding care, there are always things that can be done to optimize the situation.

Assess Your Patient

In an emergency you may not be able to perform a detailed exam, but you should perform as complete an airway exam as possible. Don’t just look at the physical characteristics without considering why those particular traits might make the intubation or the ventilation more difficult. Instead, use the criteria of why you expect difficulty to guide your planning and your actions.

Recognizing a patient with a potentially difficult airway is an opportunity that allows you to prepare ahead to have equipment, personnel, and a backup plan. It can help you decide between awake and asleep intubation, or to choose to use or not use muscle relaxants. It also can alert you to the fact that a patient may need to receive care in a different setting or with more experienced providers, if possible. It can help you prepare your team to assist you.

Take Stock of Your Resources

Intubation is a team effort. You need to have all of the right people and equipment. Sometimes that means moving a patient to a different and more optimal location, or asking for more expert help. Ask yourself the following questions:

  • What type of help do you need for this particular patient?
  • Should this patient be intubated here, or transferred to the OR or other setting?
  • Who should intubate this patient? The first attempt is often the best chance at success. For a particular patient, that may mean allowing someone with more experience to intubate.
  • What equipment do you need?
  • Do you have all the attachments?
  • Is there functioning suction?

Make sure your staff in the OR and on the ward is well trained ahead of time. If you ask for a rescue laryngeal mask airway in a can’t intubate/can’t ventilate event, you don’t want your nurse asking you what it looks like.

Use A Critical Event Check List

No one can remember everything in today’s complex medical world. Things get even worse in a crisis. It often feels as though epinephrine doubles your strength and halves your intelligence. Stress, distractions, and sometimes chaos associated with a critical event often cause highly skilled providers to forget crucial, potentially lifesaving steps and drug dosages.

Access to a critical event checklist can be lifesaving. The aviation industry has used checklists for decades. Use of such a resource in an emergency is a wise decision, not a sign of weakness.

My hospital uses the Crisis Event Checklist from Harvard, and Brigham and Woman’s Hospital.

Position Your Patient

We have all been guilt of not optimally positioning a patient for intubation only to then have difficulty visualizing the larynx. Things are worse outside of the OR where we don’t have all of the normal positioning devices.

Take any patient with an easy airway, place him on the floor in cardiac arrest, surround him with providers whom you don’t know offering help but not knowing what you need, and that intubation will be difficult.

A more detailed discussion on positioning can be found here.

Consider Awake Intubation If You Expect Difficulty

When I was training, we didn’t have video-laryngoscopy or LMAs. Awake intubation for anticipated difficult airway was routine. If any patient looked remotely difficult we would do an awake intubation.  This made us very comfortable with the technique for emergency situations.  Blind nasal intubation and fiberoptic intubation were common procedures.

Today we don’t intubate awaken nearly as often. A main reason is that video-laryngoscopy and LMAs have revolutionized our ability to manage the majority of the challenging intubations another way. It’s fair to say that awake intubation requires more advanced skills and takes more time.

However some patients need to be intubated awake, especially if there is concern about the ability to ventilate the patient. Begin the preparation early when awake intubation is a possibility. Nasal vasoconstriction and oral drying agents take at least 20 minutes to work well. Numbing the airway must be effective. Explain to the patient what to expect and what they must do to help.

How much sedation should you give? It depends on how scary your patient is. If the first 4 steps are done well, you won’t need a lot of sedation. Use sedation cautiously. Over sedation can quickly produce apnea or make your patient uncooperative.

And remember that awake intubation doesn’t just mean fiberoptic. You can perform awake intubation with:

  • Blind nasal intubation
  • Standard laryngoscopy
  • Video-laryngoscopy
  • Via intubating or standard LMA
  • Combined techniques (e.g. Fiberoptic/LMA)

Your Decisions, And How You Make Them, Are Important

Things happen quickly during an intubation, especially in an emergency setting. It’s important to avoid unforced errors.

Call For Help Early

Oxygen desaturation once it begins will cause rapid deterioration. Don’t wait until it begins to call for help, it takes time for help to arrive and equipment to be brought.

Change Plans If Something’s Not Working.

We’re all human. Once we begin a task it is a common failing to just keep repeating the same steps over and over again, expecting that eventually it will work. This is the definition of insanity. If something doesn’t work the first time, change something.

Be Aware: Time Stands Still In A Crisis.

What seems like 1 to 2 minutes can really be 10 to 15. Force yourself to keep track of the clock. Especially pay attention to the duration of apneic periods. Lack of ventilation harms patients, not the lack of an endotracheal tube.

Know When To Stop

There are many times when we can stop and wake the patient up to do an awake intubation, or to cancel surgery and bring the patient back another day when more optimal preparations can be made — and any edema or airway trauma can have a chance to resolve.

Teamwork And Communication Are Key

You cannot and should not do this alone. I teach my students that intubation is a team effort, which means it’s a coordinated effort by a small group of people with a common goal. To succeed, everyone needs to know the problem and the plan, especially when you are expecting difficulty. If your helpers don’t know the plan, then they either could fail to do what you need them to do or could even accidentally sabotage your efforts.

Function As A Team.

Anesthesiologists really good at talking to each other and not so good at keeping the team informed. Your team can’t read your mind.

Your team also needs to be empowered to give suggestions. Everyone needs to know that if they see something, they should say something.

We need the leaders in a critical event to be open to feedback and suggestions. We need to foster a clinical environment in which all of our staff feels empowered enough to speak up when they see something.

TeamSTEPPS is an educational program whose goal is to create highly functioning crisis management teams. In TeamSTEPPS, there is something called the Two-Challenge Rule for when you feel there has been a potential breach of safety. The Two-Challenge Rule states that if your first verbal observation of a problem is not acknowledged or acted upon, then you should challenge again. If the safety issue persists, then becoming more assertive is recommended. Don’t curse, but use “CUS” words, that is:

  • I am Concerned about …
  • I am Uncomfortable because …
  • This is a Safety issue …

It’s very difficult to challenge anyone in authority. The airline industry recognized this prior to initiating industry-wide retraining in teamwork and communication. There were accident reports of airplanes crashing, flying into mountains and running out of fuel, because copilots and other flight personnel did not feel empowered to point out mistakes they had recognized. The airlines realized they had a culture that showed:

  • excessive deference to a leader;
  • hesitation of subordinates to speak up; and
  • reluctance to immediately question a clearly unusual or suspect event.

If a copilot facing personal death in an airplane crash can’t question the pilot, how easy is it for a nurse, for example, to challenge a doctor?

We Have The Power To Decrease The Incidence Of Bad Outcomes

In closed claims analyses, human error has been implicated in 80% of critical events. Human error is unavoidable and therefore we need to work hard to avoid it.

We need to carefully assess, develop a strategy for Plans A, B and C and gather our resources before we start.

We need to think carefully and reassess how our plan is going as our care proceeds. You can always make a bad situation worse.

We need to improve our skills in teamwork, leadership, and communication.

Pay attention to those three principals. If we do, then we can help make errors much less likely to occur, and much less damaging when they do.

 

May The Force Be With You

Christine Whitten MD, author

Anyone Can Intubate: A Step By Step Guide
And
Pediatric Airway Management: A Step by Step Guide

 

Click images to review my books at amazon.com

Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon    Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten

Pediatric Airway Risks: Inefficient Mechanics of Breathing

Inefficient mechanics of breathing is one major risk factor for infants and young children because it increases work of breathing. In many ways pediatric anatomy and physiology predisposes a child to respiratory distress and respiratory failure.

(Illustrations copyright Whitten, Pediatric Airway Management: A Step By Step Guide)

Mechanics of Normal Breathing

Normal quiet breathing is effortless. The rate is neither too fast nor too slow, however, rate varies greatly depending on age and metabolic rate. The chest rises and falls easily and symmetrically. Air flows into and out of the lungs through the open airway based on changes in air pressure.

Adult Chest Cavity Anatomy Makes Breathing Efficient

Let’s start by reviewing the adult mechanics of breathing. The angulation and rigidity of the ribs during the breathing cycle maximizes efficiency in the adult. The lungs are housed in a skeletal cage formed by the ribs. In order to initiate airflow into the lungs, pressure in the lungs must drop below atmospheric pressure. The body accomplishes this by expanding the airtight chest cavity, thereby decreasing the pressure inside. Two motions are involved:

  • expansion of the rib cage by contraction of intercostal muscles
  • contraction and descent of the diaphragm

The ribs form three functional groupings. The first rib attaches rigidly to the sternum to anchor the rib cage. It hardly moves during respiration.

The 8th through 12th ribs expand mostly laterally during inhalation. This effectively increases intra-abdominal space for organs pushed downward by the diaphragm. The motion is like a bucket handle, swinging up and down toward the side away from the centerline and expanding the width of the chest cavity.

The 2nd to 7th ribs flexibly expand mostly anterior-posterior with a little lateral motion. This motion is like a pump handle — mostly up and down in the front of the chest, expanding the depth of the chest cavity.

Illustration comparing the motions of ribs 8-12 to the motion of ribs 2-7. Each set has unique movements for expanding the rib cage.

a. Ribs 8-12 expand mostly laterally, like a bucket handle. b. Ribs 2-7 expand mostly anteriorly, like a pump handle.

Diaphragmatic Contaction Is The Bellows

The diaphragms are two large dome-shaped sheets of muscle separating the thoracic cavities from the abdominal cavity. As the diaphragms contract with each inhalation, they act like a bellows. During inhalation the bellows descends and flattens, increasing intrathoracic volume and decreasing intrathoracic pressure. This pulls air into the lungs as they inflate.

During exhalation, the diaphragm and intercostals relax. As a result, the diaphragms rise and become dome shaped again, decreasing intrathoracic volume and raising intrathoracic pressure. Lungs deflate. The patient exhales. Unless there is obstruction, exhalation is passive, requiring little energy.

Full contraction of the intercostals and the diaphragm allows for much greater expansion of the chest cavity and produces a larger breath, assuming that air is free to flow into the lungs..

Illustration showing how relaxation and contraction of the diaphragm produces air flow into and out o the lungs by changing air pressure inside the thoracic cavity.

The diaphragm contracts and relaxes during breathing, expanding and contracting the volume of the thoracic cage. The associated air pressure changes inside the thoracic cavity cause the lungs to expand (a) and to deflate (b).

What Factors Affect Ease of Air Flow?

A variety of factors affect how easily that air flows:

  • breathing rate
    • too rapid or too slow a rate impairs air movement
  • inspired tidal volume
    • ventilating close to dead space volume causes CO2 levels to rise
  • airway resistance
    • smaller airways have higher resistance than larger airways
    • increased resistance impairs airflow
  • tissue resistance
    • increased frictional resistance of lung tissues and chest wall increases work of breathing and limits tidal volume
  • elastic recoil
    • with weaker elastic recoil, airways tend to remain partially collapsed on exhalation rather than passively reinflate to baseline
  • compliance
    • poor compliance makes it harder to distend the lungs, limiting air movement and increasing the work of breathing

Changes in any of these parameters can significantly affect adequacy of respiration and how hard it is to take a breath.

Anatomical Features That Increase Pediatric Work of Breathing

When the patient works hard to take a breath, for example against an obstruction, he generates a more negative pressure inside the chest cavity.  The intercostal muscles more fully contract. Retractions, noisy breathing, and a rocking chest wall motion are common. As respiratory failure progresses, the pattern of respiration becomes more and more inefficient and ineffective. Work of breathing increases.

In the patient exhausted to the point of respiratory collapse, or in the patient with respiratory depression due to altered mental status, there may be little effort to breathe. Hypoventilation worsens hypoxia, hypercarbia, and respiratory acidosis. Level of sedation increases, further depressing respiratory drive.

Normal infants and small children have significant anatomic predispositions to serious disruption of their mechanics of breathing if they become sick or injured.

Factors Increasing Infant Work of Breathing

The differences in the mechanics of breathing of small children compared to adults places them at much higher risk of respiratory failure.

Evaluating the degree of respiratory compromise is a judgment call. Mild or potential obstruction may have no signs or symptoms at all. In certain patients such as facial burn victims or patients having a severe allergic reaction, mild airway obstruction can convert to total obstruction quickly as edema forms. Constant reassessment is important so that you may intervene early if necessary — before the airway is lost.

The Infant’s Chest Wall Increases The Work Of Breathing

In the infant or small child, the chest wall is more box-like in shape compared to the adult’s. The ribs are more at right angles to the vertebral column and won’t be angulated like an adult until age 10 years. This makes the pediatric chest wall mechanically less efficient and limits potential lung expansion.

comparison infant vs adult rib angulation

The shape and flexibility of the infant chest, and the shape and immaturity of the diaphragmatic muscle both increase the risk of respiratory failure when the child is ill.

Babies “belly breathe”. To take a deep breath, the infant’s chest therefore expands a little and the abdomen rises a lot as the diaphragm descends, pushing abdominal contents down and out of the way.  Anything that interferes with descent of the diaphragm, such as a stomach or intestines distended with air or liquid, can seriously impair an infant’s breathing.

The infant’s chest wall is also more compliant than an adult’s, with an elastic recoil close to zero because of the lack of rib cage ossification. When the infant takes a breath against resistance, such as with airway obstruction or poor pulmonary compliance from pneumonia, the chest wall actually moves inward as the belly moves outward. The inward movement of the chest wall decreases the amount of air that enters. A rocking chest wall motion is very common in children with even partial airway obstruction.

Illustration showing the components of infant anatomy that make the mechanics of breathing inefficient, increasing risk of respiratory failure.

The inefficient mechanics of infant/toddler breathing increases the risk of respiratory failure.

Because chest wall structure and “belly breathing” limit the ability to increase tidal volume, the baby must rely on respiratory rate increases to compensate for stress. The harder a child tries to breathe, the less efficient and more labored breathing becomes.

You can see video of a toddler with croup and the signs of airway obstruction described above here.

Monitor Your Pediatric Patient Carefully

Watch for signs of airway obstruction.

chart listing the signs of airway obstruction

Infants and toddlers tire easily when they have airway or respiratory compromise. Respiratory distress can easily progress to respiratory failure. Assess your patients carefully and monitor for change. Always ask yourself: “How well is my patient breathing?” Follow the link below for discussions and video of recognizing and treating airway obstruction.

Recognizing Airway Obstruction May Save Your Patient’s Life

Click here see a video clip comparing the signs of airway obstruction in a pediatric patient with a more normal breathing pattern once the obstruction is relieved.

May The Force Be With You

Christine E Whitten MD, author:
Anyone Can Intubate: A Step By Step Guide
and
Pediatric Airway Management: A Step By Step Guide

Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten    Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon

Click on the covers to preview books at amazon.com

PostObstructive Pulmonary Edema

Patients with postobstructive pulmonary edema (or P.O.P.E.) develop sudden, unexpected and potentially life-threatening pulmonary edema after relief of airway obstruction.  It can be mild or severe. My first experience with it was in 1983.

The Case

In 1983, we didn’t have pulse oximetry, end-tidal carbon dioxide monitoring or even automated blood pressure cuffs. The patient was a healthy 6’3” tall and 250 lbs , 20 year old man. All muscle and clearly in great shape. He had just had knee surgery under general anesthesia and was on the verge of waking up.

He was coughing vigorously on the endotracheal tube. Four people held him down. My resident, fearful he night hurt himself or the team, extubated him while he was still coughing and before he was following commands. Unfortunately the patient was still in stage 2, when the airway reflexes are hyperdynamic.

Within seconds the patient went into laryngospasm, intense spasmodic closure of the vocal cords and other laryngeal muscles. There followed several minutes of struggling to re-establish an open airway. Finally the spasm broke with the use of positive pressure and the patient awoke.

However the mood in the room quickly turned from relief to concern. Our patient started to panic, claiming that he couldn’t breathe. His color was poor. He was wheezing badly, with pink frothy sputum bubbling out of his mouth. He was awake enough to communicate with us but so panicked that he started to fight the team of caregivers. Continue reading

Anatomic Dead Space Affects Hypoventilation

Understanding anatomic dead space is important to recognizing subtle hypoventilation. Hypoventilation from sedation, pain medications, anesthesia in the immediate postoperative period is common. The most obvious sign is slowing of the rate of breathing. A more subtle sign is that tidal volume becomes shallower. Having a tidal volume close to, or smaller than the patient’s dead space can lead to significant hypercarbia, hypoxia, and respiratory failure. This article discusses the concept of dead space and it’s clinical use in recognizing hypoventilation and preventing hypoxia and hypercarbia. Continue reading

Difficult Intubation In A Newborn

Difficult neonatal intubation can occur unexpectedly. We’re ready to perform neonatal resuscitation in the delivery room. We may be less ready to have to deal with a difficult neonatal airway at the same time. Recently I, and my colleagues, had to manage an unanticipated difficult neonatal intubation in labor and delivery.

The Case

The baby was born extremely edematous, and in respiratory distress. Although it was easy to ventilate the baby using the NeoPuff, airway swelling prevented the neonatologist  from identifying the epiglottis and vocal cords. The anatomy was too distorted. Following protocol when faced with a difficult intubation, the neonatologist called a “Code White”, an overhead page that in my hospital summons help from anesthesia, nursing, respiratory care and pharmacy to assist with either a emergency pediatric cardiac arrest or emergency intubation.

As a responding anesthesiologist, I too was unable to see landmarks during laryngoscopy. Continue reading

Announcing My New Book: Pediatric Airway Management: A Step-by-Step Guide

At long last, after two years of writing (and rewriting),  illustrating, and  filming  on-line videos, I’m excited to announce the publication of my new book Pediatric Airway Management: A Step-by-Step Guide, by Christine E. Whitten MD.

Anyone who rarely cares for children tends to be anxious when faced with a small child’s airway. This is true even if they are comfortable with adult airway management.

My goal for this book is to demystify basic pediatric airway management. I want to give you the skills you need to recognize when a child is in trouble and act quickly to safeguard that child, including helping them breathe if necessary. Continue reading

Intubation During Cardiac Resuscitation

Intubation during cardiac resuscitation is often challenging because of the circumstances surrounding the intubation. Excitement and apprehension accompany this life saving effort. If you don’t intubate often, you’re likely to be nervous. Even experienced intubators get excited in emergency situations, but we control our excitement and let the adrenaline work for us, rather than against us.

Step one, therefore, is to remain in control of your own sense of alarm. The leaders, which includes the person in control of the airway, must stay calm. If you appear panicked, the rest of your team will follow your lead.

Step two is to quickly assess the situation. Is the patient being ventilated? Ventilation takes priority over intubation. Is there suction available? Without suction you many not be able to see the glottis, and you won’t be able to manage emesis. What help do you have? The intubator almost always needs some assistance in having someone hand equipment, or assist with cricoid pressure, among other tasks. As I tell my students, intubation is a team sport.

Finally you need to assess what position the patient is in, and how can you optimize that position. The patient is often in a less than optimal position while chest compressions are in progress. You usually find the patient in one of two awkward positions: on the ground or in a bed. This article discusses techniques to better manage intubation during cardiac resuscitation, especially with the patient in an awkward position. Illustrations are copyright from Anyone Can Intubate, 5th Edition.  Continue reading

When Learning Intubation Is Hard

Learning to intubate is easier for some people than for others. Sometimes, no matter how knowledgeable you are about the theory of the intubation technique, the novice can still struggle to bring it all together to pass the endotracheal tube. The anatomy can be confusing. Understanding how to place the laryngoscope blade and manipulate that anatomy can be challenging. And all the while you must be ever vigilant to protect those precious front teeth, avoid hypertension and tachycardia, and breathe for the patient at regular intervals.

I believe there are 4 chief barriers that inhibit learning how to intubate:

  1. Failure to visualize how the outside anatomy links with the inside anatomy makes it hard to predict how deeply to insert the blade.
  2. A mistaken belief that placing the laryngoscope blade itself is all that is needed to align the axes of the airway and reveal the larynx.
  3. Failure to grasp the dynamic nature of the larynx, and the need to actively manipulate it during intubation.
  4. A lack of understanding that intubation is not a sequence of isolated steps, but is instead a complex dance of interacting steps, each setting the stage for the next.

This discussion is going to assume some knowledge of the basic intubation technique. If you’d like to review those basics you can find links for multiple prior in depth discussions at the end of this article. (Illustrations and animation from Anyone Can Intubate, 5th edition, C Whitten MD.) Continue reading

Not All Airway Emergencies Need Intubation

An emergency department physician I met the other day shared with me an experience from her hospital  that offers a good example of the fact that there are many different ways of managing an airway emergency in a child that don’t involve intubation. Medical management can sometimes avoid some of the risks of losing the airway that intubation might impose.

The Case

The child was an 18 month old girl whose older brother had been playing with laundry detergent pods. He had offered a pod to his little sister, who promptly put it in her mouth and chewed it, releasing the liquid. Her mother had brought her to the emergency room with respiratory distress. The child had severe stridor and was breathing at 40 times a minute. Oxygen saturation was 92%. She was awake and alert but anxious.

The ED doctor recognized significant airway obstruction and was concerned that the obstruction could worsen if the edema got worse. She immediately called for an anesthesiologist and a Head and Neck surgeon to come to the Emergency Department to evaluate the child. While waiting, she gave 10 mg of IM decadron and treated the child with nebulized racemic epinephrine. She attached a pulse oximeter and left the child sitting on her mother’s lap and otherwise did not disturb the child, trying to avoid making her cry. By the time the anesthesiologist and surgeon arrived the stridor, although still present, sounded better.

The question was what to do now? Continue reading

Remember That Respiratory Failure Is Not Always Due to Lung Failure

There are many causes of respiratory failure. Some causes of respiratory failure result from disease or damage to the respiratory system. However disease or injury to other organ systems such as the central nervous system, the musculoskeletal system, or the presence of cardiac or septic shock can also cause respiratory dysfunction.

While final diagnosis will certainly affect treatment, assessing and managing the patient’s ability to breathe will not change with diagnosis.  However, once the airway is secure, you then have to diagnose and treat the real problem in order to resolve the respiratory failure.

The Case

In this case, I was an anesthesia resident doing my pediatric rotation at a children’s hospital. It was my turn to be on call for the weekend. At this particular hospital back in 1982, the anesthesia department managed the airway emergencies in the Emergency Department so when I got the page to go to the ED, I ran.

Inside the triage cubicle a 6 year-old girl was clearly unresponsive. She had been sick with fever, nausea, vomiting and diarrhea for several days according to her mother, who was crying in the corner. She hadn’t been able to hold down any food or fluids for over 24 hours. Her temperature was 102F. She was breathing rapidly but very shallowly. We did not as yet have pulse oximetry, but her color was dusky blue. Her blood pressure was 60/40 and her pulse was 150. She looked septic.

I placed an oral airway and assisted her breathing. She didn’t react at all to the oral airway — no gag reflex. We decided to intubate.

My colleagues quickly placed an IV and I decided to intubate without induction agent or muscle relaxant. If she didn’t need those agents then I didn’t want to potentially compromise her status by giving them. Had she reacted at all when I started to perform direct laryngoscopy I would have aborted and changed the plan.

She didn’t respond at all as I slid the endotracheal tube into the trachea.

We gave her two boluses of 20ml/kg of normal saline. Her color improved, her pulse came down to 110 and her blood pressure rose to 80/50, appropriate for her age. But she still hadn’t woken up.

Ten minutes later the first blood test results returned. Her blood glucose was 10, extremely low. We gave her 2 ml/kg of D25W. Within two minutes she woke up and started fighting the endotracheal tube. As her other vital signs looked much improved and she was now awake and protecting her airway, we elected to extubate her.

The child was admitted to the pediatric ward, was treated for gastroenterits and she did well.

Learnings: Hypovolemia and Hypoglycemia Can Cause Respiratory Failure

This was the first experience that I remember seeing in my career that demonstrated that hypovolemic shock and hypoglycemia can cause profound respiratory failure without lung pathology.  It’s important to remember that respiratory failure can result from a variety of other systemic problems, not just dysfunction of the respiratory system.

Table showing the difference multi-system causes of respiratory distress and respiratory failure

Respiratory distress or respiratory failure can come from many causes.

While assisting ventilation and protecting the airway are first priorities to stabilize a patient, treating the cause of the respiratory failure may require more than just ventilation and/or intubation. In fact, treating the cause can sometimes help you avoid the progression of respiratory distress to respiratory failure. If you don’t consider a potential problem or cause, you’re not going to be able to diagnosis it.

May The Force Be With You

Christine Whitten MD
Author of Anyone Can Intubate: a Step by Step Guide, 5th Edition
and
Pediatric Airway Management: a Step by Step Guide

Button to see inside or buy the book Pediatric Airway Management: A Step-by-Step Guide by Christine Whitten    Button link to see inside or buy the book Anyone Can Intubate, A Step By Step Guide to Intubation and Airway Management, 5th edition on amazon

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Communication In A Crisis: A Case of Respiratory Depression In A Child:

When I’m teaching communication in a crisis to my Perioperative/OR nurses, I often recount the story of what happened during one particular child’s recovery years ago. This case, involving a 2 year old child who developed respiratory depression in the recovery room, demonstrates how good communication in a crisis, including the ability to challenge an authority figure, can improve patient safety and allow collaborative teamwork in a crisis management situation. Continue reading

Airway Emergency: Start With The Basics of Airway Management

We have just finished another round of Critical Event Training for my hospital’s Anesthesia and OR staff. One of the scenarios we ran was how to manage a failed airway emergency: the dreaded “can’t intubate-can’t ventilate” airway emergency scenario.

As an instructor, it’s important for me to set the stage realistically. The more real the scenario, the more the providers will learn and be able to apply the information should they ever find themselves in a comparable situation. I must observe as the trainees respond to the emergency, and then help the trainees self-analyze what went well — or not so well — during the scenario. Of course, discussion of how things went during a training scenario always leads to sharing of examples from past real life scenarios. And after 37 years of practice I’ve had a lot of sharable experiences.

One past case we discussed is particularly appropriate for those students around the country who are just beginning to learn airway management because the solution rested in basic airway management techniques. This case, involving an intubation in an ICU patient that turned into a “can’t intubate/can’t ventilate” emergency demonstrates how returning to the basics of airway management can sometimes be the way to save your patient from harm. All illustrations from Anyone Can Intubate 5th Edition. Continue reading

Intubation With Airway Bleeding and Massive Emesis

During intubation, any liquid in the mouth that obscures the view of larynx not only hinders visualization, it risks aspiration. We’re used to being able to rapidly suction the mouth clear or secretions, blood, or vomit and then have a clear view of the larynx. But sometimes, either because of continued profuse airway bleeding or massive emesis, fluid continues to accumulate while we’re watching. How can you manage this situation and successfully intubate? Here I describe two cases, one involving blood and the other massive emesis, that required intubation through a large puddle of fluid. I offer tips and tricks to assist you in your future emergency management. Continue reading

Difference in Manual Ventilation: Self-Inflating Ventilation Bag vs. a Free Flow Inflating Bag

Manual ventilation with a bag-valve-mask device requires a good mask seal against the face in order to generate the pressure to inflate the lungs. But it also requires knowledge of how to effectively use the ventilation device to deliver a breath. This article will discuss the differences in ventilation technique for self-inflating vs free-flow ventilation bags. Understanding those differences is important for successful manual ventilation of your patient. Continue reading

Intubation: Step By Step

Learning intubation technique can be challenging. Fall is the time of year when new students commonly begin to learn how to intubate. My first intubation was one of the first times I literally held someone’s life in my hands. I was nervous. The anesthesiologist teaching me tried to not look too anxious as I awkwardly grabbed my laryngoscope blade, fumbled while opening the patient’s mouth, and cautiously maneuvered the endotracheal tube into the trachea. It felt like time stopped until the tube was in place, after which the three of us (me, my teacher and my patient) all took a deep breath. Since then, over the last almost 37 years, I’ve intubated thousands of people in the U.S. and, as an international volunteer, eight countries.

So I thought it would be helpful at this time of year to discuss a step-by-step approach to intubation with the commonly used curved blade. Intubation, like a dance, is composed of steps that flow naturally from one to the next. The trick to a smooth intubation is to allow each step to blend seamlessly into the next. The text and illustrations below are excerpted from my book Anyone Can Intubate, as well as from my upcoming book on pediatric intubation, which I’m busy writing. Continue reading

Tips To Teaching Intubation

To teach intubation skills on living patients, even those that have practiced on a manikin, can be challenging. With fall comes the new crop of trainees eager to learn how to intubate. There will also be a new group of instructors teaching their first students to intubate. It’s important to anticipate the common errors so we can safeguard our patients. Here I describe the all of the barriers, physical as well as psychological, that interfere with your student’s learning of the intubation technique. I offer tips on how to help your student conquer those barriers, while keeping your patient safe. Continue reading

Anticipated Difficult Intubation: Should I Intubate The Patient Awake?

When I was training, awake intubation for anticipated difficult airway was routine. Blind nasal intubation and fiberoptic intubation were common events. The advent of video laryngospcopy  has made the need for awake intubation much less common. Instruments like the Glidescope and the McGrath video laryngoscope have revolutionized intubation, and made the difficult intubation scenario fortunately much more uncommon.

However, awake intubation with the patient breathing spontaneously is still sometimes optimal for patient safety.  Awake intubation can be performed using standard laryngoscopy techniques, but it is more commonly done using specialty intubation techniques such as blind nasal or fiberoptic intubation.

Many providers are uncomfortable with performing awake intubations and leave it as a last resort. There are a variety of reasons for this discomfort, including lack of experience and/or the fear that the patient will remember the intubation and think poorly of their care. However, awake intubation can be a safe and comfortable strategy in many clinical situations and all providers should develop expertise with one or more techniques of choice — before an emergency forces them to use one.

This article will discuss how to decide when to do an awake intubation. Future articles will discuss how to do them. Continue reading

Alert: We May All Be Over-Inflating Our LMA Cuffs!

 

Since its invention, the Laryngeal Mask Airway, or LMA, has become quite valuable as a surgical airway alternative to intubation. When I first started in anesthesia, the only way to avoid intubation during surgery was to manually assist ventilation with a bag-valve-mask attachment. Cases that went on for hours often resulted in cramped fingers, and sometimes progressively poorer ventilation over time as the hand holding the mask became overly tired. A poor mask seal could potentially cause the stomach to distend with air, pushing up the diaphragms, limiting tidal volume, and increasing the risk of aspiration. The LMA has changed anesthesia so much that residents now find it challenging to find cases to practice their masking skills.

However, the LMA is so commonly used, and so apparently safe, that it’s easy to become complacent. Research is showing that it’s apparently very common for us to over-inflate our LMA cuffs — to the potential harm of our patients. Continue reading

Intubating An Infant or Toddler

This article discussion some of the key anatomy, physiology, and technical points to intubating an infant or small child safely. I’ve been hard at work on writing and illustrating my upcoming book on pediatric airway management so I thought I would spend some time talking about care of our littlest patients.

Providers who infrequently care for children less than two years of age are often rightfully anxious when faced with a sick child, especially if airway management is required. This is especially true if the child is less than one. Healthy respect is certainly indicated because airway complications are one of the leading causes of pediatric cardiac arrest.

Children are not small adults. From infants to toddlers to teenagers, the anatomy and physiology of the child is continuously morphing until finally reaching the adult form and function. We all know this instinctively. When we look at a child we can often tell how old he or she is simply by looking at head size, characteristics of the face, length of neck, shape of the body, and how long the arms and legs are related to the trunk. It should not be surprising that the inside of the child is changing as well.

Photo placing oral airway in preparation to mask ventilating an infant

Even placing an oral airway and using a mask in an infant can seem more challenging because of the size and fragility of the patient.

Infants and young children are small. The head of a newborn infant can fit on the palm of my hand. The palm of a premature infant’s hand may be the same size as my thumbnail. It’s challenging to open the airway of such a small infant when adult fingers dwarf the size of the baby’s mouth and all of the instruments are smaller. And babies are fragile, with little reserve.

Like adults, children can be small or tall, lean or overweight. But unlike adults, their airway anatomy is changing shape and structural relationships as they grow. A particular 2 year old may be as tall as a particular 6 year old, or as heavy as a particular 8 year old, but all have very different airways.

Intubating an infant or small child is more of a challenge than an older child or adult both because of their anatomical differences as well as their physiologic predisposition for hypoxia. One can certainly argue that faced with elective care, that only experienced providers should manage the airways of infants and children less than two. However, medical care is not always elective.

Faced with a sick child, especially in more urgent settings, anyone who can ventilate and intubate an adult can also ventilate or intubate an infant or toddler safely —if they take the differences in anatomy and physiology into account, and are gentle and methodical in their approach. Illustrations and photos from Anyone Can Intubate: a Step by Step Guide, and Pediatric Airway Management: a Step by Step Guide. Continue reading