Professional Documents
Culture Documents
Lighted
stylet
Fiber-
scope
Surgical
airway
Avoidance of
laryngoscopy
0 ++++ ++++ ++++ +++ ++ ++++
Avoidance of
esophageal
intubation
++ ++++ ++++ + ++ ++ +++
Ease of placement ++ +++ +++ +++ ++ + +
Allows ventilation
without intubation
0 ++++ ++++ +++ NA 0 NA
Patient tolerance + +++ +++ + + ++ +
Cardiovascular/
sympathetic
response
++ +++ ++++ ++ ++ +++ +++
Aspiration risk ++ +++ ++++ ++ ++ ++ +++
PPV requirement ++++ ++ +++ +++ NA NA ++++
Security of airway ++++ +++ + ++ NA NA +++
Use with distorted
facial anatomy
++ ++++ + ++ + + +++
Pediatric use ++++ ++++ +++ 0 0 ++ +
Anesthetic depth +++ +++ + ++++ +++ ++ NA
Learning curve + +++ +++ ++++ ++ + +
Abbreviations: BVM, bag, valve, mask; NA, not applicable; PPV, positive pressure
ventilation.
From Pollack CV Jr. The laryngeal mask airway: a comprehensive review for the emergency
physician. J Emerg Med 2001;20:5366.
270 K.H. Butler, B. Clyne / Emerg Med Clin N Am 21 (2003) 259289
ILMA for the rst time achieved ventilation in less than 15 seconds and
tracheal intubation in less than 1 minute [41]. In a large study involving 245
patients with dicult airways (ie, patients with Cormack-Lehane grade 4
views, immobilized cervical spines, airways distorted by tumors, surgery, or
radiation therapy, or wearing sterotactic frames), insertion of the ILMA was
accomplished in three attempts or fewer. The overall success rates for blind
and beroptically-guided intubation through the ILMA were 96.5% and
100%, respectively, suggesting the device is useful in the emergent treatment
of patients for whom intubation with standard rigid laryngoscopic failed
[41,42]. The ILMA also has been compared with beroptic intubation for
management of the dicult airway and proved to have a high success rate and
a comparable time to achieve tracheal intubation [43]. The ILMAalso may be
used in children who weigh more than 30 kg (Table 2). Most investigators
agree that prociency in use of the ILMA requires practice in a controlled
setting before it can be used successfully under emergent circumstances.
Fiberoptic intubation
Flexible beroptic intubating scopes have become more advanced and
geared to use in the emergency setting. Scopes have become smaller in
diameter, compared with those used by pulmonologists, and completely
Fig. 6. Insertion technique for intubating laryngeal mask airway (LMA-Fastrach). If no
resistance is felt, continue to advance the ETT while holding the LMA-Fastrach steady until
intubation has been accomplished. From Gensia Automedics, Inc., San Diego, CA; with
permission.
271 K.H. Butler, B. Clyne / Emerg Med Clin N Am 21 (2003) 259289
portable. Their built-in battery light source eliminates the time-consuming
setup and connection to a bulky power source.
Fiberoptic intubation, like all alternatives to RSI, has a place in airway
management for selected patients. Awake intubation benets patients with
marked laryngeal or cervical pathology, for whom paralysis and suppression
of the respiratory drive or insertion of a laryngoscope blade may be detri-
mental. A study of more than 13,000 intubations demonstrated that a simple
algorithm for endotracheal intubation conned to only two methods (con-
ventional or beroptic intubation) is reliable, successful (failure rate,
0.045%), and easy to learn [44].
Insertion technique
The nasotracheal approach to the airway with a exible beroptic scope
is often simpler than the oral approach because the instrument is aimed
directly at the glottis as it emerges from the nasopharynx into the hypo-
pharynx. Intubation over a beroptic scope can be performed successfully
through an LMA and around the ETC.
Indications and advantages
There are many advantages to the use of this technique, including
application to all age groups, excellent airway visualization, ability to in-
suate oxygen during the procedure, high success rate, and immediate con-
rmation of ETT placement [45].
Contraindications and disadvantages
There may be diculty in the use of a beroptic scope in the emergency
setting. The presence of uncontrolled secretions, mucus, or active bleeding
markedly impairs visualization. Suction through these instruments is
Table 2
Larynegeal mask airway (LMA) and intubating LMA sizes and maximum cu ination
volumes
Mask
size
Patient
description
Available in
LMA-Classic
RM
Available in
LMA-Unique
(disposable)
Available in
LMA-Fastrach
(intubating LMA)
Max. cu
volume (cc)
1 Infants up to 5 kg X 4
1.5 Infants 510 kg X 7
2 Infants and
children 1020 kg
X 10
2.5 Children 2030 kg X 14
3 Children 3050 kg X X X 20
4 Adults 5070 kg X X X 30
5 Adults 70100 kg X X X 40
6 Large adults >100 kg X 50
From Pollack CV Jr. The laryngeal mask airway: a comprehensive review for the emergency
physician. J Emerg Med 2001;20:5366.
272 K.H. Butler, B. Clyne / Emerg Med Clin N Am 21 (2003) 259289
ineective. Attaching an oxygen source to the suction channel may increase
the eld of view by blowing away oending secretions or debris. Advance-
ment of the ETT over the beroptic scope may be dicult, as the bevel of
the tube may catch on the arytenoids, cartilages, or aryepiglottic folds.
Withdrawing and rotating the ETT 90
, Kendall-
Sheridan Catheter Corp, Argyle, NY) is a blindly inserted, double-lumen
tube designed to facilitate ventilation during cardiopulmonary resuscitation
(CPR) [12]. Its predecessor, the esophageal obturator airway (EOA), led
to complications such as esophageal rupture and tracheal obstruction,
prompting an improved design [48]. The ETC combines the concept of the
EOA with that of the ETT. The device consists of two lumens:
a pharyngeal lumen and a tracheal lumen separated by a partition
wall. One lumen has an open distal end, similar to an ETT, and the other is
closed at the distal end, with multiple ventilating eyes proximal to its
inatable cu. A second larger oropharyngeal balloon inates to secure the
ETC in position. Because ventilation is possible through either lumen, the
Combitube can be used after esophageal or tracheal insertion (Figs. 7, 8).
The device comes in two sizes: a 41 Fr for adult males and a 37 Fr
(Combitube
and Combitube
and Combitube
illustration
courtesy of Laerdal Medical Corporation.
278 K.H. Butler, B. Clyne / Emerg Med Clin N Am 21 (2003) 259289
quick and reliable and has minimal complications. In the ED, it is best used
as a backup technique for the patient who cannot be intubated by
traditional laryngoscopy but who can be ventilated. For patients with
unstable cervical spine injuries or patients who cannot be intubated orally, it
may be a faster, more accessible rst choice over beroptic intubation. As
with any airway device, preparation and frequent practice are essential to
maintain skills.
Gum elastic bougie
The gum elastic bougie or Eschmann stylet is an endotracheal tube
introducer originally described by Macintosh in 1949 as an aid to intubation
[74]. The standard bougie is a semirigid malleable device, 60 cm long, made
of woven polyester with a resin coating. It has a diameter of 15 Fr (5 mm),
allowing easier passage through the vocal cords, and has a 40
angle 3.5 cm
from its distal tip to facilitate tracheal placement [75]. A plastic, less
expensive version of the bougie is available in the United States as the Flex-
Guide endotracheal tube introducer (ETTI) (GreenField Medical Sourcing,
Inc., Northborough, MA) [76]. The bougie is commonly used in Europe for
dicult intubations and has reduced the incidence of failed intubation and
cricothyrotomy [7678].
Insertion technique
When visualization of the vocal cords is poor or impossible, the
lubricated bougie is passed posterior to the epiglottis with the distal tip
angled anteriorly. If it enters the trachea, palpable clicks are felt as the tip of
the stylet passes over the tracheal cartilage rings. This washboard eect
and the fact the stylet cannot be passed beyond 40 cm (as the tip reaches the
small bronchi) are reliable signs of tracheal placement [79]. With esophageal
placement, clicks are not felt and the device can be advanced unobstructed
beyond 45 cm. With the bougie stabilized in place by an assistant and the
laryngoscope maintaining anterior displacement of the oropharyngeal
structures, an ETT is passed over the bougie into the trachea (Fig. 10).
Passage of the ETT is made easier by rotating the tube 90
counterclock-
wise, keeping the bevel of the tube posterior [80].
Indications and advantages
The bougie is indicated whenever anatomic, traumatic, or pathologic
factors prevent a good view of the vocal cords by direct laryngoscopy. It has
proven particularly useful in patients with airway edema, neck trauma, and
cervical spine immobilization [8183]. It is reasonable to attempt one
bougie-assisted intubation before performing a cricothyrotomy in certain
failed airway situations. It should be stressed that the bougie is no substitute
for proper technique and should be used only after other attempts to
optimize the laryngoscopic view have failed.
279 K.H. Butler, B. Clyne / Emerg Med Clin N Am 21 (2003) 259289
The bougie is an inexpensive, nonsurgical device that can be readily
available for urgent use in the ED. Unlike other airway adjuncts, it requires
little training time and no technical expertise beyond the skill of lar-
yngoscopy. Its exibility allows the airway manager to customize the
bougieto suit the patients anatomy and increase the likelihood of success.
When inserted properly, the bougie is reliable in avoiding esophageal
intubations.
Contraindications and disadvantages
The bougie is contraindicated when the epiglottis cannot be visualized
under any circumstances. Unlike some airway adjuncts, it is not a blindly
inserted device and should be guided under the epiglottis or through the
vocal cords under direct vision. It is not indicated for patients who require
nasotracheal intubation. The smallest ETT the standard bougie can
accommodate is a 6.0 mm ETT, limiting use to adults. Minor complications
associated with the bougie are uncommon and include local trauma to the
Fig. 10. Gum elastic bougie directed into the trachea. The endotracheal tube is inserted over the
bougie. From McCarroll SM, Lamont BJ, Buckland MR, Yates APB. The gum elastic bougie:
old but still useful [letter]. Anesthesiology 1988;68:6434; with permission.
280 K.H. Butler, B. Clyne / Emerg Med Clin N Am 21 (2003) 259289
airway, sore throat, and hoarseness [84]. Major complications such as
pharyngeal perforation, pneumothorax, hemopneumothorax, and medias-
tinal emphysema have been reported only rarely [85,86].
The bougie is an inexpensive, easily used device and should be the rst
backup device considered for the anticipated or known dicult airway.
Routine or dicult, a bougie should be kept within arms reach during every
intubation.
Digital intubation
Blind digital intubation or tactile intubation is an uncommon technique
in which the intubator guides the ETT into the trachea with his or her
ngers. The emergency physician has other devices and skills for manage-
ment of the dicult airway, but digital intubation deserves mention as a
valuable technique for some rarely encountered situations.
Technique
Using a stylet, the clinician forms an ETT into a U-shape. The intubator
approaches with the nondominant hand closest to the patient and an
assistant retracts the tongue. This pulls the epiglottis upward and facilitates
palpation of the epiglottis and glottic opening. The index and middle ngers
of the nondominant hand are inserted palm down toward the base of the
tongue. The middle nger is used to identify the epiglottis and direct it
anteriorly. The ETT with stylet is then passed between the index and middle
ngers and advanced into the glottic opening, guided by the middle nger.
The stylet is then withdrawn and placement is conrmed.
Indications and advantages
Digital intubation is indicated when poor lighting, patient positioning,
copious airway secretions, or equipment failure render direct laryngoscopy
dicult or impossible [87]. These situations are more likely to occur in the
prehospital setting than in the emergency department. Other indications
include cervical spine immobilization and disrupted airway anatomy. It
should be considered a last resort before cricothyrotomy for the failed
airway [88]. It can be performed as an adjunct to blind nasotracheal
intubation [89]. Other than an ETT and a stylet (and gloves), digital
intubation requires no technical equipment and can be performed rapidly in
poorly lit environments with the patient in any position, making it
particularly suitable to the prehospital setting. It has been used successfully
in pediatric patients and is preferred by some for neonatal resuscitation [90].
Contraindications and disadvantages
In the awake or semiconscious patient with intact oropharyngeal reexes,
digital intubation is relatively contraindicated. Attempting this technique on
responsive patients can lead to oropharyngeal trauma and biting injuries.
281 K.H. Butler, B. Clyne / Emerg Med Clin N Am 21 (2003) 259289
Placing a bite block to prevent the patient from biting down reexively and
double gloving may help minimize the risk for infectious disease trans-
mission. Other relative contraindications include caustic ingestion, thermal
burns, and upper airway foreign bodies.
The length of the intubators ngers relative to the dimensions of the
patients oropharynx is an important predictor of success. Factors such as
limited mouth opening, large teeth, and distorted anatomy can further place
the intubator at a disadvantage. Iatrogenic trauma to the upper airway is
possible but can be avoided with gentle technique. Esophageal intubation is
a concern with digital intubation; therefore, diligent conrmation of
tracheal placement is required.
Although rarely used, dicult to perform, and risky, digital intubation
can be a life-saving skill and can prevent the need for creation of a surgical
airway. It should be considered for select patients with dicult airways
when alternative techniques are unavailable or inoperative. As with any
airway technique, digital intubation requires preparation and practice.
Retrograde intubation
Retrograde intubation (RI) is an invasive technique that involves
puncture through the cricothyroid membrane and passage of a guide wire
retrograde into the oropharynx to facilitate ETT placement. Originally
described in 1960, RI is simplistic in principle but requires time and practice
to perform [91].
Technique
Commercially available kits for RI contain a syringe, an 18-gauge
introducer needle with catheter, a guide wire with a soft J-tip, and an
introducer catheter. Although RI is used most commonly for patients with
limited neck mobility, ideally the patients neck should be hyperextended.
The cricothyroid membrane is identied and, time permitting, local an-
esthesia is inltrated after skin preparation. While the larynx is stabilized, an
18-gauge needle attached to a syringe partially lled with saline is used to
puncture through the cricothyroid membrane in a cephalad direction.
Aspiration of air conrms placement in the trachea. The guide wire is then
threaded through the needle cephalad into the oropharynx and is retrieved
under direct visualization using Magill forceps. The guide wire then can be
placed directly into the lumen of an ETT or through the Murphy eye of the
ETT. Passing the wire through the Murphy eye permits slightly more
advancement of the ETT below the vocal cords [92]. Alternatively, a guide
catheter can be placed over the guide wire to prevent lateral movement of
the ETT and ease its passage through the vocal cords [93]. With the ETT
advanced through the vocal cords and abutting the cricothyroid membrane,
the guide wire is pulled out through the proximal end of the ETT and the
ETT is advanced into its proper position. A common variation of this
282 K.H. Butler, B. Clyne / Emerg Med Clin N Am 21 (2003) 259289
technique involves threading a beroptic bronchoscope over the guide wire,
allowing direct visualization of the patients anatomy and the ability to
deliver continuous oxygen [94].
Indications and advantages
RI is indicated for the dicult airway resulting from cervical spine
immobilization, anatomic abnormality, or trauma, particularly upper
airway trauma that makes oral or nasal access dicult or impossible. It
should be considered when intubation has failed but adequate oxygenation
and ventilation can be maintained and when cricothyrotomy is impossible
or unavailable. RI has been used successfully in the prehospital setting and
the emergency department [95,96].
Contraindications and disadvantages
Relative contraindications to RI include unfavorable upper airway ana-
tomy such as exion deformity of the neck, pretracheal mass or infection,
obesity, coagulopathy, and laryngeal injury [97]. Bleeding is a common
but generally minor problem with RI. Other potential complications
include subcutaneous emphysema, pneumomediastinum, infection, and
injuries to the trachea and laryngeal structures. Data on RI for the pediat-
ric population are limited, but the procedure seems to be useful and safe in
experienced hands, particularly with the adjunct use of a beroptic bron-
choscope [98].
Emergency physicians and anesthesiologists have used RI with success
for dicult airway management. It should be considered when cervical spine
immobilization, anatomic derangements, copious secretions, or blood
prevents adequate laryngoscopy, and after failed intubation when time
and patient status allow. Drawbacks to RI are that it is invasive, it can be
time consuming, and the equipment may not be readily available.
Jet ventilation
Percutaneous transtracheal jet ventilation (TTJV) involves puncturing
the cricothyroid membrane with a large-bore catheter for temporary
ventilation in failed airway situations. It is a simple, quick, and eective
technique associated with fewer complications than surgical cricothyrot-
omy. Although rarely performed, emergency physicians should be familiar
with this lifesaving skill for desperate, cannot intubate, cannot ventilate
scenarios when surgical cricothyroidotomy is unavailable or unsuccessful. It
is considered the surgical airway of choice in children younger than 12 years
of age as a bridge to securing a denitive airway.
Technique
If permissible, the patients neck should be hyperextended while the
cricothyroid membrane is identied. With the larynx stabilized, a large-bore
283 K.H. Butler, B. Clyne / Emerg Med Clin N Am 21 (2003) 259289
(12- to 16-gauge) catheter-over-needle attached to a 20-mL syringe partially
lled with saline is directed caudally through the cricothyroid membrane.
Large-bore wire-coiled transtracheal catheters that are less likely to kink are
preferable to intravenous catheters. Tracheal puncture is marked by
aspiration of air bubbles. The needle is then withdrawn slightly and the
catheter is advanced over the needle and into the airway with the aid of a small
skin incision. The catheter should be advanced to the hub, and placement in
the trachea reconrmed by aspiration of air. Once in place, great care should
be takentostabilize the catheter andprevent subsequent air leakat the incision
site. The hub of the catheter is then connected to the jet ventilation system.
A variety of TTJV systems are available. The most commonly used is
composed of high-pressure tubing in line with a regulator, a pressure gauge,
and a jet ventilation toggle switch. The jet ventilation system is connected to
a wall oxygen source of 50 pounds per square inch (psi). In children older
than 5 years of age, the oxygen pressure should be down-regulated to 2030
psi to prevent barotrauma, and in children younger than 5 years of age, a bag
should be used for ventilation. Ordinarily, less than 1 second of inspiration
is required to provide an adequate tidal volume to the lung, whereas
exhalation occurs passively because of the elastic recoil of the lung in 23
seconds. An inspiration to expiration ratio (I:E) of 1:3 therefore is
recommended to allow adequate time for exhalation and avoid barotrauma.
Maintaining upper airway patency by using a jaw thrust maneuver with
oropharyngeal and nasopharyngeal airways helps maximize exhalation,
preventing air trapping and high expiratory pressures.
Indications and advantages
In the emergency department, TTJV is rarely used. It is indicated for
cannot intubate, cannot ventilate situations when a surgical airway is not
possible and when the equipment or personnel for conventional airway
management are unavailable. It is generally considered to be quicker and
less prone to complications than surgical cricothyrotomy; however, fa-
miliarity with the jet ventilator assembly is critical for rapid execution of this
technique [99]. It can be performed in all age groups and is the preferred
surgical airway in children.
Contraindications and disadvantages
Airway obstruction below the vocal cords and complete upper airway
obstruction render exhalation dicult or impossible and constitute relative
contraindications to TTJV. In these situations, surgical cricothyrotomy is
the best choice. Complications with TTJV are uncommon but include
subcutaneous emphysema, esophageal puncture, bleeding, exhalation dif-
culty, and barotrauma [100103]. The catheter used in TTJV can become
kinked or obstructed and does not confer airway protection.
TTJV should be viewed as a temporary rescue technique, primarily for
children under 12 years of age, until a denitive airway can be established.
284 K.H. Butler, B. Clyne / Emerg Med Clin N Am 21 (2003) 259289
Despite the infrequent need for TTJV in the ED, emergency physicians
should be well versed in this technique for crisis situations.
Summary
Rapid-sequence intubation using conventional laryngoscopic technique
remains the standard of airway management in emergency medicine and
continues to have a success rate of approximately 98%. Preparation and
proper intubation technique must be optimized at the initial attempt using
direct laryngoscopy. Failure causes multiple repeated attempts, leading to
a failed airway. Each repeated attempt increases the likelihood of bleeding,
oral, pharyngeal, and laryngeal edema, and malposition, causing decreased
visualization of the glottic opening, equipment failure, and hypoxia.
Preparation must be an ongoing process. Faulty suction, no oxygen source,
choice of the wrong laryngoscopic blade or ETT, poor light source, or
misplaced equipment can domino into mechanical failure. Intubation equip-
ment stations must be inventoried constantly, organized, and kept simple
in their layout to decrease confusion during selection. Medication for seda-
tion and paralysis should be readily available and not kept distant from the
intubation station in a medication-dispensing unit that would require time
for acquisition.
Proper positioning of the patient remains paramount for alignment of the
oral, pharyngeal, and laryngeal axis to provide optimal visualization of the
vocal cords. Proper technique during insertion of the laryngoscope blade in
the oral cavity for displacement of the tongue must be ensured. Without
proper technique, even with proper positioning, the glottic opening cannot
be visualized. Laryngeal pressure to maneuver the larynx into position
should be exerted initially by the laryngoscopists right hand and, when in
view, maintained by an assistant to free the laryngoscopists hand for ETT
insertion. With preparation and proper technique, the rst attempt is the
best attempt, and the vicious cycle of multiple attempts and complications
will be averted.
Acknowledgment
The authors thank Linda J. Kesselring, MS, ELS, Division of Emergency
Medicine, University of Maryland School of Medicine, for help with
manuscript preparation.
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