The MAC Blade, The Vallecula, and the Hyoepiglottic Ligament

Intubation with the MAC blade requires precise placement of the tip of the blade in the vallecula in order to manipulate the hyoepiglottic ligament and lift the epiglottis. This discussion uses illustration, Xray, and video to demonstrate proper intubation technique. Read More …

Learning Intubation: Head Position Effects Laryngeal View

When first learning intubation,  a beginner often concentrates on memorizing the key laryngeal anatomy. This is important of course. If you can’t recognize the vocal cords, you will not be able to successfully intubate. However, even more important to learning intubation is understanding how the larynx relates to the other structures in the head and neck. In order to intubate you must manipulate those other structures to bring the larynx into view. This post uses lateral X-rays and CT scan images to help novice intubators master the anatomical relationships they must know to intubate. Read More …

Announcing My Latest Article Has Been Published: “10 Rules for Approaching Difficult Intubation”

I’m excited. My latest article, titled, “10 Rules for Approaching Difficult Intubation, Always Prepare for Failure” has just been released in the journal supplement Airway Management, published by Anesthesiology News. Managing the difficult airway is one of the most challenging, risk ridden, and downright scary clinical problems in anesthesia. The article makes the Read More …

GlideScope Technique For Intubation In Small Mouths

The GlideScope can be difficult to use in a patient with a small, narrow mouth. This article discusses a technique for improving successful intubation in that type of patient. Read More …

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. 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. My sincere wish is that this new book helps in the care of our littlest patients, no matter where they are. Read More …

NITROUS OXIDE: SHOULD WE USE IT?

When I was training, we used nitrous oxide on just about every anesthetic. It was easy to use. It was inexpensive. It didn’t tend to effect hemodynamics so it was useful in less stable patients when combined with an opioid. It helped speed induction through the second gas effect. It was not metabolized so renal and liver insufficiency were of less concern.

However, a lot more is now known about the pharmacologic disadvantages, and potential harm, of nitrous oxide in certain patients. N2O interferes with the B12/folate pathway and methylates DNA. This discussion reviews some of those patients at risk of harm from nitrous oxide exposure during anesthesia. Read More …

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 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. This article discusses 4 chief technical barrier to learning to intubate. Read More …

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

When I’m teaching airway management to my Perioperative/OR nurses, I often recount the story of management of a young child’s postoperative respiratory depression. In addition to illustrating the importance of evaluating ventilation in addition to oxygenation, this case shows how good communication makes management of a critical event more effective. Read More …

Airway Emergency: Start With The Basics of Airway Management

A case of “can’t intubate- can’t ventilate is discussed which illustrates the importance of always using good techniques of basic airway management. Read More …

Finding PEEP In a Bottle (of Water): Thinking Outside The Box

As you read this I am flying to Honduras with International Relief Team on a head and neck surgery medical mission. I will attempt to post mission updates from the hospital compound, pending internet connections. Participating in a medical mission to the developing world is never easy.

Medical personnel trained in a high tech environment take for granted the complex monitoring devices, multiple choices of drugs, and plentiful support peronnel which simplify our job. When medical volunteers travel to the developing world they are often unprepared for the potential hazards produced by outdated technology, unfamiliar and sometimes poorly maintained equipment, poor sanitation, limited supplies, and a malnourished, often poorly educated population.

Let me give you an example of one rather exciting case from early in my volunteer experience in which I had to reinvent PEEP using some suction tubing and an irrigation bottle filled with water.
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MacGyvering In Anesthesia

I used to love the old TV show MacGyver, which featured an inventive hero who frequently had to improvise some clever device from ordinary objects in order to beat insurmountable odds and save the day. The concept was so popular that the word MacGyver became a verb. Oxford Dictionaries state that to “MacGyver” is to make or repair something “in an improvised or inventive way, making use of whatever items are at hand”.

As I have traveled the developing world on medical missions I have often had to reinvent ways to do the things I take for granted in my sophisticated operating room, such as producing PEEP from some suction tubing and a bottle of water. (see story here)

But being able to improvise is just as important in the settings of the more modern hospital. This article describes two examples of having to improvise for an anesthetic. Read More …

Avoiding Pediatric Drug Errors

Pediatric medication errors are distressingly common. This article discusses various ways to reduce the risk of administering an incorrect medication dose to a child. Read More …

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

Ventilating 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 discusses the difference in the use of a self-filling ventilation bag and a free-flow ventilation bag. Read More …

Ventilation Perfusion Mismatch

There are 2 types of mismatch: dead space and shunt. Alveolar gas exchange depends not only on ventilation of the alveoli but also on circulation of blood through the alveolar capillaries. This makes sense. You need both oxygen in the alveoli, and adequate blood flow past alveoli to pick up oxygen, other wise oxygen cannot be delivered.

When the proper balance is lost between ventilated alveoli and good blood flow through the lungs, ventilation/perfusion mismatch is said to exist. The ventilation/perfusion ratio is often abbreviated V/Q. V/Q mismatch is common and often effects our patient’s ventilation and oxygenation. Read More …

Intubation With A Curved Blade

Direct laryngoscopy depends on being able to bring the 3 axes of the airway into alignment to see the larynx. Straight and curved blades use different techniques for bringing the larynx into view. Curved blades are commonly used, especially by beginners because they are more forgiving of less than optimal placement and provide more room to pass the tube. However, it’s important to use them correctly. This article will discuss intubation technique using a curved blade. Read More …

Help! My Anesthesia Machine’s Not Working!

There is nothing quite as scary as being in the middle of administering an anesthetic and having your anesthesia machine fail. In my 36 years of anesthesia practice I’ve had this happen to me a few times. Knowing how to quickly troubleshoot your machine, and knowing how to protect your patient are important, potentially life-saving skills. It helps to have thought through the steps to rescue the situation before it happens to you. This article discussed the steps you should take if your machine fails. Read More …

Codeine Risk In Children, Especially Those With Sleep Apnea

Although the initial FDA warnings about potentially fatal codeine overdose in children were released in 2012, I’m recently discovered that a few of my surgeon and nursing colleagues were still unaware of the potential risks. This article reviews some of the risks of using codeine in the pediatric population as well as the patient’s at highest risk for potentially fatal respiratory depression. Read More …

Intubation: Step By Step

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 to steps that flow naturally from one to the next. The trick to a smooth intubation is to allow each step to blend seamlessly together. The description and illustrations below are excerpted from my book Anyone Can Intubate, where you can find more detail about this and many other topics. Read More …

Tips To Teaching Intubation

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. Teaching intubation skills on living patients, even those that have practiced on a manikin, can be challenging. It’s important to anticipate the common errors so we can safeguard our patients. Read More …