Anticipated Difficult Intubation: Should I Intubate The Patient Awake?

When facing any intubation, you must decide whether the intubation is safer to be performed asleep or awake. 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. This article discusses some of the criteria for deciding when to do an awake intubation. Read More …

Avoiding Difficult Intubation Of The Easy Airway

We’ve all done it. It’s extremely easy to make any otherwise routine intubation difficult just by failing to properly position the patient or to use optimal technique. This article discusses the various ways you can adjust patient positioning and use your equipment to make intubation easy. Read More …

Intubating An Infant or Toddler

This article discussion some of the key points to intubating an infant or small child safely. Providers who infrequently care for infants and 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.
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. However, anyone who can intubate an adult can also intubate an infant or toddler safely if they take these differences in anatomy and physiology into account and are gentle and methodical in their approach.
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Positioning The Head For Intubation

This article discusses the different ways of placing the patient in the sniffing position and the advantages and disadvantages of each to improve first pass intubation success. Position of the head and neck for intubation can make intubation easy, or hard.
Many years ago our operating room administration Removed the towels we had been using to position the head for intubation. It may be an exaggeration to say that chaos ensued, but it felt like that.

For the next several days our anesthesia providers had trouble intubating. We likened it to an expert golfer who, when suddenly faced with a new set of golf clubs of slightly different weight and length, suddenly has to relearn the game. It made us realize that how we position the head in the sniffing position often sets us up for either an easy or for a more difficult intubation if you don’t realize what’s happening during the positioning. Read More …

Apneic Oxygenation: Increase Your Patient’s Margin Of Safety During Intubation

Breathing room air, oxygen saturation drops precipitously to below 90% within about a minute of the start of apnea in the average healthy adult. While preoxygenation is one of the most important safety measures we can use prior to induction of anesthesia and in preparation for intubation, apneic oxygenation can allow even more time for intubation to occur. Apneic oxygenation using nasal cannula can significantly delay the onset of critical hypoxia.

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To Extubate, Or Not to Extubate, That Is The Question

Deciding when to extubate a patient safely can sometimes be a difficult decision. Removal of an endotracheal tube when you are not sure of the diagnosis is a risk not to be taken lightly. This case discusses assessing extubation criteria in the face of ambiguous respiratory symptoms. Read More …

Awake Intubation With The GlideScope

One of the most challenging scenarios to face is a tumor in the airway. Working closely with your surgeon is important. In these days of advanced technology, we often avoid awake intubate because of concern of causing the patient pain or distress. However, sometimes awake intubation is the safest way to proceed and if you are gentle and prepare the patient well, it can be comfortable as well. The Glidescope is another tool you can use for awake intubation. Read More …

Use Of A Nasal Airway To Assist Ventilation During Fiberoptic Intubation

Attaching a nasal airway to a breathing circuit as a tool to assist or control ventilation is a very helpful trick to have in challenging airway management situations. This technique is particularly helpful during blind nasal intubation or fiberoptic intubation in young children after induction of general anesthesia for surgery, although it can be used in adults. Here we discuss use of this technique for a case of accidental extubation of a patient with Ludwig’s Angina.
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Tongue Necrosis From Endotracheal Tube Compression

Tongue necrosis from compression by an endotracheal tube or oral airway is a rare, but devastating complications when it occurs. It can occur with poor endotracheal tube positioning, flexed head and neck positioning, impaired blood flow, and shock. It is important to familiarize ourselves with this entity so that we as anesthesia providers can minimize the risks.
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A Case of Endotracheal Tube Obstruction

Normally we view patients who are intubated as being protected in terms of ventilatory support. However, being intubated makes the patient vulnerable to a variety of potential problems. Rapid deterioration of an intubated patient can be a challenging and frightening scenario because the providers must rapidly troubleshoot the causes as well as treat. Here a case of endotracheal tube obstruction and its management is described. Read More …

Glidescope: Tricks For Successful Intubation

Glidescopes are very easy to use, but intubation with the Glidescope is very different than direct laryngoscopy. I have seen many novice Glidescope users struggle to intubate, despite having great views of the larynx. Failure to recognize the differences of using the Glidescope can make intubation not only frustrating but also hazardous to your patient. Beginners almost always make the same few easy to correct mistakes. This article discusses those mistakes and how to correct them. Read More …

The Bougie: Use Wisely To Avoid Rare But Serious Complications

One of the simplest and most valuable devices to help with a difficult intubation is the bougie. The primary use is a difficult intubation, when you cannot see the larynx well but are able to predict where the glottic opening should be based on anatomy. This article discusses techniques as well as potential complications. Bougies must be used with care to avoid patient injury. Read More …

Risks of Placing Your Endotracheal Cuff Too High

When intubating, we all know to check the depth of the endotracheal tube. Most people believe this is just to ensure that the tube is not too deep and therefore causing a mainstem intubaton: intubating just one bronchus and therefore only one lung. However, there are significant risks with having the tube too shallow as well, risks such as accidental extubation and potentially causing permanent damage to the recurrent laryngeal nerves. Here we discuss some of the warning signs that the cuff is too high and what to do about it. Read More …

Should I Use A Cuffed or Uncuffed Endotracheal Tube In a Child?

When intubating children, the question always arises whether to use a cuffed or an uncuffed endotracheal tube (ETT). Historically uncuffed endotracheal tubes have been used when the child is less than about 8 years old. Why is it that we can get away with using an uncuffed tube in a young child, but not an adult? The answer comes from the difference in airway anatomy between child and adult. Understanding the advantages and disadvantages of using uncuffed and cuffed tubes in children is important to safe patient care. Read More …

Tips for Mastering the LMA Fastrach

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. The LMA Fastrach is designed specifically designed to ventilate a patient intermittently during a prolonged intubation attempt. 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. Read More …

Embrace the Catastrophist Within: Protecting Ourselves From Respiratory Infection

A good anesthesiologist, or any health care provider, has to embrace the catastrophist within because our goal is to protect our patients from the unexpected. We have to constantly imagine the worst-case scenario so that if, or when, it happens we not only recognize it early, we’re ready for it. What we’re often not good at is protecting ourselves at work. We tend to be so patient focused that we often don’t even think about personal hazards. This article discusses some of the risks we face during airway management of the infectious patient. Read More …

Airway Obstruction Can Occur After Thyroglossal Duct Excision

Airway obstruction can occur following uneventful thyroglossal duct excision because of removal of the hyoid bone. This article describes reasons why the anatomical change can cause obstruction and discusses a case where such airway obstruction needed treatment in the immediate postoperative period. Read More …

Beware: Your Patient Can Bite That Pilot Tube

Persistent endotracheal tube leaks may require the need to exchange the endotracheal tube in a critical patient or situation. The differential diagnosis of such leaks is discussed. In addition, a case regarding a patient biting a pinhole in the pilot tube of their endotracheal tube is presented. Read More …

Using Straight Laryngoscopy Blades

Intubation by direct laryngoscopy depends on using the laryngoscope blade to give you a clear field of view of the larynx by shifting the tongue and other pharyngeal structures out of the way. As you might imagine, the patient’s anatomy, pathology, or position can sometimes make this visualization difficult. Laryngoscopy blades come in different shapes to help manage these various situations. Read More …