TheAirwayToolbox

JamesDuCanto,M.D.AnesthesiologistandQualityOfficer

DirectorofSimulationLabAuroraSt.Luke’sMedicalCenterMilwaukee,Wisconsin,USA

NoCOI’stoDeclare

• …ButIdoregularlyreceivequiteabitofequipmentforevaluation

• Noproductendorsementsperse—butIdohavemyownpreferences,ofcourse.

TherewasStuff.Butnotalotofstuff.

TheworldofMedicinewaslimitedtowhatcouldbefoundintheForestortheSwamp

“FinestCricothyrotomyToolDevisedbyNature”—M.LeCong

BrownKiwi(Apteryxaustralis),ChicagoFieldMuseum

• …Andtherewasaproliferationofstuff,beginningwithtoolstointubateandventilate

Draeger Pulmotor,1907-1940’s

Batteryoperatedlaryngoscope

So,WhereDoesThatLeaveUsToday?

• Multitudeofdevices,techniquesandchoices• Choiceofsmall-purposebasedkitsinadditionto

thelargerbundles

InthewordsofWilliamGibson,

• “TheFutureHasArrived— It’sJustNotEvenlyDistributedYet”

http://quoteinvestigator.com/2012/01/24/future-has-arrived/

FrenchVideoconferencingconcept

Inotherwords…

• Off-the-shelftechniquesandequipmentexiststotakeairwaymanagementtothenextlevel

Soherearethefirstrelevantquestions…

• #1-WhereAreWewithEmergencyAirwayManagementwithrespecttoequipmentandtechniques?

• 2-Whydoweneednewdevicesandprocedurestoaugmentanalready“crowded”disciplinelikeairwaymanagement

• #3-Howarewegoingtoimplementthesetoolsandmethodsinourpractice?

Question1:WhereareWe?

• WeareatSteps1-2-3!– Step1isDL,VL,Bougie,etc...• Wecallit“PlanA”

– Step3isCricothyrotomy.• Mostofuscallthis“PlanC”

• Step2isaknown butlargely“MissingLink”– Step2isSupraglotticairwaybasedtechniques• Shouldbe“PlanB”,butisstillabitsketchytoEmergencyAirwayManagement

Question2:Whyallthisnewstuff?

• Because…EveryNowandThen,YouStepinIt,andthebackupplantoamissed“Step1”issorelylacking.

OK,Whatjusthappened?CICV.Briefly,untilIwenttoPlanB

• Unsuccessful“Step1”– Marginalpreoxygenation withplanforRSIwithAirtraq

– Attachedheadframepreventsfacemaskventilation

– Larynxvisualizedbutunabletobecannulated• Successful“Step2”– RescueVentilationestablishedwithSGA– VideoStyletintubationthroughSGA

HowshouldweproceedwhenStep1(akaPlanA)doesnotsucceed?

• Weneedtoplanforfailure.There,Isaidit.

XXXXXXXXXXXX

Step3Readiness:TheKitIDon’tLeavetheLockerRoomWithout

Carrying

--IntubatingCatheter(Bougie)--6.0mmETT--Scalpel(#10BladeRetractableor#11)--Syringe--34fr NasalAirway(SplitLongitudinal)

• Thekityouwouldalways carrywhenonclinicalduty

• SupportsreadinessforSurgicalAirway

• Componentsalsosupportwidevarietyoftechniques– (DL/VL,blindnasal,blindoral,Trans-SGA,Maskventilation)

ExperiencewithSurgicalAirwayMarch2015

• “ITHAPPENEDSOFASTTHAT…–NopausetoactivateoverheadlightsintheOperatingRoom!–Scrambletofindthebougie and6.0ETT!

Doesthissoundlogical?

Analysis,Mr.Spock….

Now..for theSecond SmallKit

Kit#2:AincA VideoStyletKit#1:Cric-Kit

VideoDrivenEndoscopeDesignedtofitWithintheTrachealTube

--AincA VideoStyletà$500USDà100Uses

VideoStyletVisualizationSystems…Simplifiedfiberoptic

intubationsystemstosupportStep2(andStep1)

• Similarhandlingskillstorigidstylets usedw/VLandDL– Functionsasastylet,scopeorlightwand– Visualizationthroughtipoftrachealtube

• Easyandquicktosetup,integrallightsource

• WorkinacomplementaryfashionwithDL,VLandSGA

Clarus VideoStylet

-Semi-Malleablevideodrivenstyletendoscope-Currentprice$8000USD

UEMedicalStylet-RigidVideoStylet(UEMedical),-CurvedforSGAIntubation

-CurvesettofunctionthroughtheAir-QSGA;alsow/Glidescope-Currentprice$3000USD

VideoStyletSimplicity--72yo Malew/RecognizedDifficultAirway,electivesurgery--H/oFusionSkullBasetoT12--Intubationperformedwithlightsedation

JenningsMouthGag

-FirstmentionmedicalLiterature1914forCleftLipandPalaterepair

-ModificationoftheWhiteheadMouthGag1877

-CurrentlyusedinENTandOralSurgery

SimpleDevicetoSupportStep2(aswellasStep1)—JenningsMouthGag

JenningsMouthGagSolvesProblemofIntraoralSpace

• Carefullyappliesforcetoopenoralcavitywithsmallmovementsofthelockingratchet

• Intuitivelyeasytouse• MiddleopeningopensmidlineforstylettedETTdelivery

VideoStyletAssistStep1

• Morbidobesitywithseveresleepapnea–Grade3to2Bvisualization

• Navigationofstyletendoscopetooffercompletevisualizationduringintubation–Visualizationbecomesgrade1

OneMoreShiftfromStep1/PlanA

Lasttopic—Devicetoassistventilation

• IntroducingtheOxylator Resuscitator– AlternativetoBag-Valve– Fixedminuteventilation(10-12litersperminute)– Suitableforadultandpediatricuse(patientsgreaterthan10kg)

– Fixedflowrate30litersperminute

TheOxylator SolvesSeveralImportantProblems

• Thoroughpreoxygenation priortoRSI• TheProblemofInconsistenciesofVentilationwithBVM’s– Controlsflowratetopreventhighinspiratoryflowrates• Leadtogastricinsufflationandcentralvenouscollapse

• PermitsTwo-HandedMaskVentilationTechnique

InClosing,OneLastQuestionaboutStep3—

Whatareyougoingtodowhenit’sTimetoCuttheWatermelon?

-Stepinandcut!”–M.Ueshiba