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. 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. Straight and curved blades use different techniques for bringing the larynx into view. For a discussion of how to use a straight blade click here. 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

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

Avoiding Difficult Intubation Of The Easy Airway

It’s extremely easy to make any otherwise routine intubation difficult just by failing to properly position the patient or to use optimal technique. We’ve all done it. Let’s see how to avoid this pitfall. (All illustrations by Christine Whitten MD, Anyone Can Intubate). 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

Positioning The Head For Intubation

Positioning the head and neck for intubation in the sniffing position can make intubation easy, or extremely hard. Many years ago our operating room administration decided that the bath towels we were using to position the head for intubation were a potential danger for shedding lint. So one night, in their infinite wisdom, the towels were all summarily confiscated and when we arrived the next morning there wasn’t a single towel to be found, ever again. It may be an exaggeration to say that chaos ensued, but it felt like that.

The reason this event is so memorable is 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. Continue reading

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

Assessing extubation criteria, and then deciding when to extubate a patient safely can sometimes be a difficult decision.

Extubation Criteria

We all know the common extubation criteria:

  • recovery of airway reflexes and response to command;
  • inspiratory capacity of at least 15 ml/kg;
  • no hypoxia, hypercarbia, or major acid/base imbalance;
  • no cardiopulmonary instability;
  • signs of intact muscle power;
  • absence of retraction during spontaneous respiration;
  • absence of a distended stomach.

In other words, you want your patient to be stable, able to breathe without help, and able to protect the airway.

However, sometimes the decision is not so easy. Here I describe a case of a patient who met some but not all of the criteria for extubation. The reason turned out to be due to a rare complication: plugging of the endotracheal tube. However, getting to that solution required working through the extubation algorithm.  Continue reading

Glidescope: Tricks For Successful Intubation

Glidescopes, one of the several videolaryngoscopes in use, are very easy to use. However, 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. Let’s explore those mistakes and discuss how to correct them.illustration of a glidescope intubation in cords section, with the view of the larynx behind in a monitor Continue reading

The Bougie: Use Wisely To Avoid Rare But Serious Complications

Inserting a bougie to assist with difficult intubation

Inserting a bougie to assist with difficult intubation

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. However bougies must be used with care to avoid patient injury.

The bougie is an endotracheal introducer that is made of a braided polyester base with a resin coating, giving it both flexibility and stiffness at body temperature. The standard size for intubation is 15 Fr, which is 60 cm long. There is a 10 Fr pediatric version which can be used for endotracheal tubes as small as 4 to 6mm. A bougie will retain the curvature given to it, making it very useful for anterior airways. I highly recommend that you have a bougie in the room whenever you intubate because it is a quick and easy aide when the unexpected difficult intubation occurs. However, like so many of our tools you you have to use it wisely or you can seriously hurt your patient. Continue reading

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? Are there advantages and disadvantages to each?  The answers comes from understanding some of the anatomical differences between children and adults. Continue reading

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. 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.

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Beware: Your Patient Can Bite That Pilot Tube

I was called to the ICU to replace an endotracheal tube because air was leaking around the cuff and the respiratory therapist could not maintain a good tracheal seal, even after re-inflating the pilot balloon. Knowing the differential diagnosis of an endotracheal tube that no longer maintains a seal can avoid unnecessary tube exchanges. Even more important is taking precautions to avoid having to change the tube to begin with. Continue reading