Course

Participant
Notes




NATCAT
2
Preface

These notes have been written to try and approximate the NATCAT course as close as
possible and are not intended to be another airway text book. It is hoped that these
notes, combined with the course, will provide a useful source of practical airway
management information that trainees and critical care practitioners will use throughout
their careers.

We would like to thank Drs Andrew Heard and Keith Greenland for allowing us to
incorporate their publications and ideas into the notes. Large sections of these notes have
been taken from unpublished material prepared for Anaesthetic Trainees at the Austin
Hospital by Dr Jon Graham. We thank him for permission to use his work.

We would welcome any feedback regarding these notes and the NATCAT course in
general. Please send through your comments/ideas to:
reny.segal@mh.org.au
adriano.cocciante@wh.org.au

NATCAT November 2013















This work is copyright. Apart from any use permitted under the Copyright Act 1968, no part
may be reproduced by any process, nor may any other exclusive right be exercised,
without the permission of A. Cocciante & co-authors, Melbourne 2010




NATCAT
3
Contents

Introduction ....................................................................................... 5

MODULE 1
Airway Equipment & Usage .............................................................. 6
Supraglottic Approach ................................................................................................ 7
Equipment for bag-mask airway management ............................................................. 7
Bag and Mask Ventilation Techniques ......................................................................... 8
Supraglottic airway devices ........................................................................................ 10
LMA insertion .............................................................................................................. 13
Infraglottic Approach ................................................................................................. 15
Equipment for intubation ............................................................................................. 15
Laryngoscope Blades ............................................................................................. 15
Endotracheal tubes (ETT) ....................................................................................... 19
Aides in tracheal intubation ..................................................................................... 23
Endotracheal Intubation Techniques .......................................................................... 25
Intubating using a laryngoscope ............................................................................. 25
Intubating through a LMA ........................................................................................ 31
Fibrescope assisted intubation through a LMA ....................................................... 32
Surgical Airway Devices ............................................................................................. 35
Cricothyroidotomy devices ...................................................................................... 35
Emergency Cricothyroidotomy ................................................................................ 35
Cannula Cricothyroidotomy ..................................................................................... 37
Oxygenation via a transtracheal cannula ................................................................ 39
Inserting a surgical airway via the Seldinger technique .......................................... 42
Scalpel Bougie Technique ...................................................................................... 43
Scalpel Finger Cannula Technique ......................................................................... 44
Tracheostomy devices ........................................................................................... 45
Equipment Reference Sheet ................................................................................... 50

MODULE 2
Fibreoptic Intubation ....................................................................... 52
Introduction to the fibreoptic endoscope .............................................................. 53
The basic movements of the fibreoptic endoscope .................................................... 55
Performing an awake fibreoptic intubation .......................................................... 57
Practical hints for successful awake fibreoptic intubation ........................................... 71

MODULE 3
Airway Assessment & Practical Airway Management .................... 72
The Focused Airway Examination ......................................................................... 73
Predictors of difficult bag-mask ventilation .............................................................. 75
Predictors of a difficult intubation ............................................................................ 76
Predictors of difficult LMA ventilation ...................................................................... 80
Predictors of difficult cricothyroidotomy .................................................................. 81
The Predicted Difficult Airway ................................................................................ 82




NATCAT
4
Troubleshooting Common Technical Airway Issues ................................................... 83
An Example of a Systematic Airway Exam ................................................................. 86
Practical Airway Management ................................................................................ 89
The Unanticipated Difficult Intubation ......................................................................... 89
The Anticipated Difficult Airway .................................................................................. 96
An approach to the problem of difficult or impossible ventilation through an ETT or
tracheostomy tube .................................................................................................... 104






NATCAT
5
Introduction

Airway management can be divided into 2 broad approaches:

A. Supraglottic approach consisting of:

i. Bag mask ventilation: either supporting the patients own
spontaneous breathing or using intermittent positive pressure
ventilation (IPPV)
ii. Supraglottic device insertion e.g. LMA insertion

B. Infraglottic approach consisting of:

i. Endotracheal intubation
ii. Surgical airway insertion e.g. cricothyroidotomy or tracheostomy


Although there is often more then one way to manage a patients airway for a particular
situation or procedure, the chosen method of airway management will be influenced by:

1. The presence of patient factors including the predictors of a difficult airway.
2. Surgical factors.
3. The experience of the person managing the airway.
4. The equipment available.

Successful airway management thus hinges on being able to integrate the above 4 factors
to develop an airway management strategy which should include an initial airway
plan as well as a back up plan(s) in the event of the first plan failing.

As far as possible, we have tried to keep the format of these notes simple by keeping to
the supraglottic and infraglottic approaches to airway management. All equipment and
issues pertaining to each approach will be discussed together in Module 1. Module 2 will
focus on the technical issues related to performing an awake fibreoptic intubation and in
module 3, we will review where each technique fits into the overall airway strategy.











NATCAT
6







MODULE 1

Airway Equipment & Usage











NATCAT
7
Supraglottic Approach
Equipment for bag-mask airway management

Mask
A correct fitting mask-covers the nose and mouth and should form an airtight seal on the
face. Care must be taken not to make contact with the eyes.
It is important to correctly size the mask on patients face before commencing airway
management.

Breathing circuit:
This can be an air viva bag e.g. ambubag (ideally with reservoir bag attached) or
anaesthetic circuit e.g. Mapleson, circle
It must be checked to ensure the ability to generate positive pressure and ideally should
be connected to an oxygen source.

Aids in successful bag-mask airway management




Oropharyngeal airways (Guedel airways):
These are curved plastic devices with a central lumen which, when inserted properly over
the tongue, will create an air passage between the tongue and posterior pharyngeal wall.

They come in a variety of sizes: size 3 (8cm long, green rim)
(Only adult sizes shown) size 4 (9 cm long, yellow rim)
size 5 (10 cm long, red rim)
size 6 (11cm long, orange rim)

Ensure the correct size: Distance from the corner of the patients mouth to angle of jaw
should correlate to length of airway. The flange should lie flush with lips when correctly
inserted and should not interfere with bag-mask ventilation.

Nasopharyngeal airways
These are long, cylindrical shaped devices made of flexible material which need to be
lubricated before insertion.




NATCAT
8
In the awake/semiconscious patient, they are better tolerated then oropharyngeal airways.
Their size is measured by their internal diameter in mm (as for endotracheal tubes).
The correct size can be determined by the size of the patients nostril but generally a size
6 for a female and a 7 for a male.
The end should lie flush with the nostril and should not cause gagging. If so, pull the
airway back slightly.
They are contraindicated in a suspected base of skull fracture.

Bag and Mask Ventilation Techniques
5


The ability to bag-mask a patient is the most important airway skill to possess.
Airway patency during bag-mask ventilation is maintained by:

1. A correct fitting mask.
2. Optimal head position.
3. Manipulation of the head and neck.
4. The use of oral or nasopharyngeal airways.

If any difficulty is experienced during bag-mask ventilation, it is important to ensure that the
above 4 factors are optimised. Two hands and even two people may be required to
optimise the airway for bag-mask ventilation.

1. Mask

A correct fitting mask covers the nose and mouth and should form an airtight seal on
the face. It should sit in the palm of the left hand with the hypothenar eminence extending
below the left side of mask. The IPJ of the thumb should hold the collar of the mask,
closest to you in the midline with the index finger reaching around the other side of the
collar with the PIPJ in the midline. The middle finger should rest on the mask or under the
chin. The ring and little finger should be applying jaw thrust (upward pressure) at the angle
of the jaw.
Before applying the mask, the mouth should be opened slightly and the mask first applied
to the area below the bottom lip and then down onto the face.

Achieving a seal

It is important to be able to achieve a good seal to enable adequate bag mask ventilation.
There are 3 areas where leaks commonly occur:

I. Nose: To achieve a seal at the nose, apply downward pressure with the thumb.
II. Chin: To seal at the chin, the index and middle finger should apply downward
pressure to the mask whilst the ring and little fingers should simultaneously apply
jaw thrust (upward pressure) at the angle of the jaw.
III. Sides: To seal the left side, the skin of the cheek is gathered against the side of the
mask by the hypothenar eminence. At the right side of the mask, the ends of the
thumb and index /middle finger apply downward pressure to the right side of the
mask or an assistant can lift the right check up to form a seal.




NATCAT
9

Generally one should imagine trying to pull the face up to meet the mask, not pushing
the mask down to meet the face.




2. Positioning
6


There is limited research as to whether the sniffing position (neck flexion with head
extension) is better than simple neck extension for bag and mask ventilation but it probably
is and is also convenient if intubation is to follow.

3. Manipulation of head and neck

This can be achieved in the following 3 ways:

Head tilt and chin lift: lengthens the anterior neck which elevates the
tongue and epiglottis away from the posterior pharyngeal wall.
Jaw thrust: achieved by elevating the angle of the mandible. Because the
tongue is attached to the mandible, it elevates the tongue from the posterior
pharyngeal wall.
Opening the mouth: an oral airway may assist with this.

4. The use of oral or nasopharyngeal airways

An oral airway (Guedel airway) should be inserted with the curvature facing upwards and
then rotated 180 as it is advanced (this insert and rotate maneuver is applicable in adult
patients but potentially hazardous in infants). It is important to ensure that the correct size
of airway is used. The length of the oral airway should be equal to the distance from the
corner of the patients mouth to the patients ear lobe/ angle of the jaw and the flange
should lie flush with the lips once fully inserted.

Nasopharyngeal airways are better tolerated than oral airways, however they do have the
disadvantage of potentially causing epistaxis and a potential bloody airway. They are
contraindicated in facial fractures and base of skull fractures. The correct sized
nasopharyngeal airway should reach from the nostril to the ear lobe/ angle of jaw. If they
induce a cough, withdraw slightly.




NATCAT
10
Two-person bag-mask ventilation

Sometimes despite optimising all of the above, 2 people are required to enable successful
bag-mask ventilation. This is commonly achieved by one person using both hands to apply
jaw thrust with the fingers whilst holding the mask with the thumbs and the second person
applying positive pressure ventilation.





Muscle relaxants
7


Administration of muscle relaxants generally improves the conditions for bag and mask
ventilation and intubation. However, the concern is that one is burning bridges by
delaying the possibility of a return of spontaneous ventilation for a more prolonged
period. As a general rule, in the setting of difficult bag-mask ventilation, muscle relaxants
should not be used.

Supraglottic airway devices

Supraglottic devices establish a direct conduit for air to flow when placed in the
supraglottic area. They come in a variety of sizes and shapes and most have balloons or
cuffs that once inflated, provide a reasonably tight seal in the upper airway.

A large variety of such airways exist, however we will limit our review to the variety of
laryngeal masks commonly available.

Classic laryngeal mask (cLMA)

This device has wide bore tubing connected to an oval inflatable cuff that seals around the
larynx.
It is currently available in eight different sizes for use in patients ranging in size from
neonates to adults.
Typical adult sizes are:
Size 3 patient 30-50kg
Size 4 patient 50-70kg
Size 5 patient 70-100kg





NATCAT
11
cLMAs were initially designed to help provide an airway in a spontaneously breathing
patient. However, current evidence suggests that the cLMA appears to be effective and
probably safe for positive pressure ventilation in patients with normal airway resistance,
compliance and normal tidal volumes.
14

The cLMA does not protect the airway from aspiration and does not easily allow for the
removal of pulmonary secretions and therefore should not be used in an elective setting
for patients at a high risk of aspiration.

The cLMA, as with all the various types of LMAs, plays a major role as a rescue device in
an unexpected difficult airway.





Flexible LMA (fLMA)

The fLMA is similar in design to the cLMA but incorporates a non-kinkable, wire-reinforced
tube.
It was designed specifically for use in ENT, head and neck and dental surgery.
The long flexible, narrow bore tube provides better surgical access to the oropharyngeal
cavity compared with the cLMA.


Proseal LMA (pLMA)

The pLMA is a variant of the cLMA with the following design modifications:
The airway tube is reinforced, similar to the fLMA, to improve flexibility and avoid
kinking.
The airway tube is shorter than in the cLMA.
The drainage tube runs parallel to the airway tube exiting at the mask tip. This is
designed to vent gas and gastric contents from the stomach and allow the passage
of an orogastric tube. The drainage tube can accommodate any standard gastric
tube (<18Fr).
The presence of a bite block
An anterior pocket for seating a finger or introducer to assist with insertion.






NATCAT
12
It is designed to improve performance and safety during controlled ventilation by:
Improved airway seal compared with the cLMA.
Theoretically providing improved protection against aspiration compared with the
cLMA. When the pLMA is correctly placed, the drainage tube lies in continuity with
the oesophagus and the airway tube in continuity with the trachea, providing
effective separation of the respiratory and GI tract.

It is available in the same sizes as the cLMA.



Supreme LMA (sLMA)

The sLMA is marketed as a disposable pLMA but has its own particular design features
It is precurved
It has moulded fins within the bowl to protect the airway from epiglottic obstruction,
performing a similar role to the epiglottic elevating bar in the ILMA.
It has bite block and oesophageal tube.
Ventilation is via the airway tube, which incorporates a drain tube within its
lumen to shorten and straighten its path.


Intubating LMA (ILMA)-Also known as the Fastrach LMA

Although it is possible to intubate blindly through any LMA, the success is variable and it is
generally unreliable. The ILMA was therefore specifically designed to facilitate intubation of
the trachea through the LMA with greater success and ease.

The device consists of:
A rigid metal curved airway tube with a manipulating handle.
An epiglottic elevating bar
A deeper bowel
A ramp that directs an ETT up and into the larynx enhancing the success rate of
blind intubation.

The ILMA comes with its own dedicated wire-reinforced, silicone bullet tipped ETT, which
has been shown to have the highest intubation success rate.




NATCAT
13
The ILMA is available in sizes 3, 4 and 5 and the dedicated ILMA endotracheal tubes are
available in sizes 7, 7.5 and 8. All 3 sizes of ILMA are able to accommodate all 3 sizes
of tube.

The ILMA endotracheal tube contains a low volume-high pressure cuff, which is not
suitable for prolonged intubation.

The ILMA endotracheal tube has been found to be easier to use for awake nasal
intubations
19
and this will be discussed further in module 2.




LMA insertion

Inserting a cLMA

Many different techniques have been described to insert a cLMA. The method described
here is the one developed by the designer of the LMA, Dr Brain. It also applies to the
flexible LMA and supreme LMA.

Preparation:
Ensure that the LMA has a properly functioning cuff and valve.
Ensure that cuff of the LMA is properly lubricated, taking care to avoid getting
lubricant into the bowel of the cuff as this may potentially obstruct the airway.
Ensure that the cuff is fully deflated

Insertion
Position the patients head and neck as you would for a normal intubation.
Open the patients mouth and insert the LMA.
Press the tip of the LMA up against the hard palate and slide the LMA over the hard
palate and soft palate into the hypopharynx until definite resistance is felt.
Inflate the LMA without holding the tube. (short outward movement is normal)
Ensure the ability to ventilate and then secure the LMA.

Sometimes the LMA can be obstructed by the back of the tongue on insertion. If this is the
case, it is often helpful to gently turn the LMA vertical, slide the LMA along the paraglossal
gutter and then turn it horizontal again once the posterior tongue has been bypassed.




NATCAT
14
For inserting a flexible LMA, it is necessary to place the index and middle finger on the cuff
of the LMA, either side of the tube and guide it into position. This is because the flexible
tubing does not have enough rigidity to advance the cuff when the tubing is advanced.

Inserting a proseal LMA (pLMA)


Three insertion techniques are commonly used to insert the pLMA:

1. Use of an introducer
The introducer is a removable metal device, which sits at the base of the cuff, runs on
the underside the tubing and connects to the proximal plastic circuit connecter. When
applied correctly, it allows for the pLMA to be inserted like a cLMA and once sitting
correctly, the introducer can be removed.

2. Digital insertion
The pLMA can also be inserted without an introducer. Like the flexible LMA, the cuff
then has to be guided directly by the fingers to ensure correct placement.

3. Gum elastic bougie (GEB) guided insertion
The drain tube of the pLMA is primed with the straight end of a lubricated GEB. Under
gentle laryngoscopy, 5-10cm of the straight end of the GEB is placed into the
oesophagus while an assistant holds the distal GEB and pLMA. The laryngoscope is
then removed and the pLMA advanced using the digital insertion technique. The GEB
is then removed while holding the pLMA in position.

Once the pLMA is inserted, it should be possible to pass a gastric tube down the drain
tube of the pLMA. If this is not possible, this suggests that the tip of the pLMA is either
folded over or not sitting over the oesophageal inlet and thus cannot reduce the risk of
aspiration or gastric insufflation.

Inserting an Intubating LMA (Fastrach LMA)

The ILMA should be inserted deflated and flattened. Often no head or neck manipulation is
required. As with other LMA insertions, the mask tip should be slid backwards along the
hard palate, following the curve of the soft palate and posterior pharyngeal wall to prevent
unfolding. The LMA should not be held while the cuff is inflated.
To achieve optimal ventilation, it may often be required to tip the handle slightly forward
and back in the sagittal plane to ensure a better position of the internal aperture with
relation to the glottic opening. Once this position is achieved, the chances of successful
intubation can be increased by applying slight anterior lift of the ILMA handle in order to
move the ILMA away from the posterior pharyngeal wall during intubation
11
(Chandy
manoeuvre). You should only proceed to intubation once an adequate airway is
obtained through the ILMA.
Intubating through the ILMA is covered in Practical Airway Management - Infraglottic
Approach




NATCAT
15
Infraglottic Approach
Equipment for intubation

In this section, we will review the equipment required to undertake tracheal intubation with
an endotracheal tube.
Laryngoscope Blades

Many different types of blades exist, each with their own particular advantages.
All blades consist of a:
Base for attachment to the handle
Tongue which can be straight or curved
Web which forms a shelf along one edge of the tongue, connecting the tongue to
the Flange and incorporating electric connections and bulb or fibreoptic bundle
Flange which runs parallel to the tongue and is usually only present for the proximal
1/3-2/3 of the blade




1. Curved blades

The Macintosch blade is the most commonly used curved blade in Australia and the
UK. The long axis of the blade is curved and the tongue, web and flange form a right-
angled, reverse Z shape in cross section. The web and flange are bulky, the tip is
atraumatic and the light source is shielded by the web.
This blade can be difficult to use in patients with limited mouth opening or prominent
incisors.
The two adult sizes most commonly used are sizes 3 or 4


2. Straight blades

The Miller blade is the most popular straight blade used in paediatric anaesthesia and
in adult practice, especially in the USA. The Miller blade differs from the Macintosh




NATCAT
16
blade in that the tongue is straight with a slight upward curve near the tip and the
flange, web and tongue form a C with the top flattened in cross-section.

The Straight blade is thought to be particularly useful in patients where intubation with
a Macintosh blade may be difficult due to the following patient features:

Limited mouth opening
A short thyromental distance
A large tongue
Prominent upper incisors
A long floppy posteriorly directed epiglottis

A precise technique with the straight blade is essential and there is a significant
learning curve in its correct use to obtain a view of the larynx.

Like the Macintosh blade, the two most commonly used adult sizes are sizes 3 and 4.





3. McCoy blade
The McCoy blade is a modified Macintosh blade, which has a hinged tip controlled by a
leaver on the handle. It can improve the view of some grade 2-3 patients by lifting the
epiglottis when the leaver is pulled, thereby bringing the larynx into view.

It is useful in patients with limited or no neck movement or in patients where neck
movement is undesirable e.g. c-spine injury.
It is much less useful in patients with a grade 4 view.





NATCAT
17


4. Kessel blade

The Kessel blade is similar to the Macintosh blade but with an altered angle of the
blade with the handle. The increased angle of the Kessel blade of about 110 degrees
with the handle may allow for easier insertion of the laryngoscope blade in patients with
antesternal space restriction e.g. pregnant patients, morbidly obese patients
This can be used in conjunction with a short laryngoscope handle, also designed for
such patients.

5. Non-standard laryngoscopes and rigid fibreoptic intubation aids

Rigid fibreoptic intubation systems can be classified into 3 groups
15
:

i. Videolaryngoscopes which allow indirect laryngoscopy and then require
independent endotracheal tube +/- stylet for intubation e.g. Glidescope, McGrath
and C-MAC (pictured in that order below):






ii. Devices for indirect laryngoscopy with an optical blade and a conduit for the
endotracheal tube e.g. Airtraq and Pentax-AWS (pictured below)




NATCAT
18



The videolaryngoscopes in i and ii can also be divided into those based on a standard
Macintosh blade design e.g. C-Mac, McGrath Mac and those with a hyperangulated
blade e.g. Glidescope, Airtraq, C-Mac D-blade. This is more of a functional
classification, as the shape of the blade will influence the technique employed when
using the device. This is covered later in the notes.




iii. Fibreoptic optical stylets placed within the endotracheal tube e.g. Levitan and
Bonfils (pictured below)






The techniques required to use these devices differ from one device to the next and
there does appear to be a learning curve associated with their use initially.
Evidence is still lacking to support the replacement of standard laryngoscopes with
non-standard devices for routine or difficult intubations and the results of large
multicentre trials of new devices are required
16















NATCAT
19
Endotracheal tubes (ETT)

Modern endotracheal tubes are made of PVC and consist of a cylindrical tube, an
inflatable cuff at the distal end and a side vent near the distal end of tube known as a
Murphy eye. This was created to prevent complete respiratory obstruction in the event that
the open end of the ETT were to become sealed by contact with the tracheal wall or
occluded by a mass or mucus.

ETTs can be inserted orally or nasally and can be cuffed or non-cuffed, the latter normally
being used in paediatrics. Endotracheal tube sizes are based on their internal diameter in
mm and range from 2mm to 10.5mm. Common adult sizes are 7-8mm
Cuffed ETTs
Various types of cuffed endotracheal tubes exist but they all have essentially 2 functions:
1. To create a seal against the tracheal mucosa to prevent aspiration
2. To facilitate positive pressure ventilation by preventing air leakage around the tube.

Care must be taken not to over inflate the cuff as this may cause mucosal injury.
Clinically, the cuff should be inflated until such time as a leak ceases to be present
when positive pressure is being applied to the ventilatory circuit.

We will briefly review some of the more commonly used cuffed endotracheal tubes in
anaesthesia today:


1. RAE tubes (after their inventors Ring, Adair and Elwyn, also called polar
tubes)

These are endotracheal tubes that are manufactured with preformed bends and are
designed to facilitate surgery of the head and neck. They come in a variety of sizes and
are either shaped for nasal (north facing) or oral (south facing) intubation. When inserted
correctly, the preformed bend should sit either at the chin (oral) or external nares (nasal).
Their advantage in head and neck surgery over standard ETTs is that:

They are less likely to kink when positioned correctly
The tube connector is situated further away from the surgical field
The tube fits the contours of the face so it can be secured well with a reduced risk
of moving

When used, the following points need to be remembered:
Due to the bend, suctioning of these tubes is more difficult
The location of the bend and hence the intra-airway length, is based on the tube
diameter, which may result in either endobronchial placement or the tube not being
advanced sufficiently into the trachea.
Flexion or extension of the head once the tube is secured may result in accidental
endobronchial intubation or extubation








NATCAT
20
2. Reinforced or armoured tubes

These are tubes that contain a spiral of metal in the wall to allow for greater flexibility of the
tube. This helps to reduce the risk of kinking or occlusion of the tube if it were to be twisted
or compressed, such as can occur when a patient is placed prone for surgery.

There are a few important differences between reinforced and normal cuffed tubes which
should be remembered:

The tubes are longer than standard tubes so they can be used orally or nasally. If
used orally, care must be taken to avoid endotracheal intubation
If the patient bites the tube it may stay compressed. Always insert a bite block or
equivalent if an oral tube is inserted.
The connector is welded to the tube and cant be removed as with standard tubes.
As a result, these tubes cant be cut and shortened.

3. Microlaryngoscopy Tubes (MLT)

These were designed for use in patients undergoing laryngeal surgery to optimise the
surgical field by allowing the use of a smaller sized tube in an adult patient. They come in
internal diameter sizes 4-6mm but with adult cuff sizes and are slightly longer than
standard adult endotracheal tubes. Because of the narrowed internal diameter, they are
not optimal for prolonged spontaneous ventilation.





4. Double Lumen Tubes (DLT)

A DLT is a single endotracheal tube, consisting of two individual lumens, side by side,
each lumen having their own connecter and cuff. The two lumens are not the same length
and are designed to sit in different parts of the lower airway.
The shorter lumen is known as the tracheal lumen and when the DLT is inserted correctly,
its cuff (the proximal cuff) should lie in the trachea. The other longer lumen is known as the
endobronchial lumen and when the DLT is positioned properly, its cuff (the distal cuff)
should lie in the desired mainstem bronchus.

Examples of various endotracheal
tubes (from left to right):
Oral RAE
Nasal RAE
Size 4 MLT (note length)
Size 6 reinforced tube





NATCAT
21
DLTs are classified as either right or left sided and this refers to the longer
endobronchial portion of the DLT i.e. in left sided DLTs, the longer lumen should extend
into the left main bronchus and shorter lumen into the trachea. The situation is reversed
with right sided DLTs.

The most common DLTs used in Australia are the disposable, plastic PVC
Bronchocath/Mallinkrodt DLTs (pictured below). With these DLTs, the lumens are colour
coded with the shorter tracheal lumen having a clear cuff and the longer bronchial lumen
having a blue cuff.

DLTs are usually used in thoracic surgery because:
They protect the dependent lung from blood and secretions.
They allow independent control of ventilation to each lung.
They improve surgical access.

The sizes of these tubes are given in Charriere (CH) gauge which is equivalent to French
(Fr) gauge and relate to the external diameter of the tube. One Fr is equal to approx.
0.33mm hence a 39Fr has an external diameter of roughly 13mm.

The sizes of Bronchocath/Mallinkrodt tubes which are commonly used are:
41 and 39Fr for men
37 and 35Fr for women

Apart from the differences between right and left sided DLTs, which have already been
described, a further difference exists and this is best understood while actually examining
a left and right-sided Bronchocath/Mallinkrodt DLT simultaneously. Due to the early takeoff
of the right upper lobe from the right main bronchus, it is often easier to correctly position a
left sided tube. For this anatomical reason, right-sided Mallinkrodt tubes have a right upper
lobe opening and a doughnut shaped cuff around the bronchial lumen which pushes the
tube away from bronchial wall. The cuff does not extend between the right upper lobe
opening and the distal end of the tube. This allows the right upper lobe to be ventilated
from the distal end of the tube as well as through the upper lobe opening.

The correct positioning of DLTs in the airway should always be assessed using
clinical means and confirmed using a fibrescope, as incorrect positioning can be
potentially catastrophic.








NATCAT
22

5. Bronchial Blockers (BB)

Although bronchial blockers are not endotracheal tubes per se, now is a good time to
discuss them briefly.
BBs are balloon tipped catheters, which are maneuvered through a single lumen tube into
the appropriate main or lobar bronchus. This is normally achieved with the aid of a
fibrescope. The balloon is then inflated to isolate the lung or lobe from ventilation at which
time the isolated lung/lobe will slowly collapse.

There are 2 main types of BBs available:

1. Cook blockers either Arndt (wire guided) or Cohen (tip-deflecting) endobronchial
blockers
2. Univent tube

Have a look at the following websites for more information on BBs and on their insertion:

http://www.youtube.com/watch?v=Tru-vVO6s3w&feature=related

http://cucrash.com/Handouts05/MillerH%20Bronchial%20Blockers.pdf

BBs should be considered in the following situations:
Patients requiring lung isolation who have difficult airways. In such cases,
intubating with a DLT could be very difficult.
Patients with a permanent tracheostomy.
Patients who are already intubated with a single lumen tube and in whom
removing the ETT is potentially hazardous e.g. trauma patients & ICU
patients.
When only isolation of a lobar bronchus is required.


Generally, they are more difficult to place correctly when compared to DLTs. It is also
more difficult to intermittently ventilate the collapsed lung if required and if done, this will
result in the loss of lung isolation as the cuff has to be deflated to achieve this.
It is also very important to be aware that a BB, which is fully inflated and then migrates
proximally into the trachea, may cause complete tracheal obstruction, which if not
identified early, may be catastrophic. Simply deflating the balloon can relieve this.














NATCAT
23

Aides in tracheal intubation

There are numerous devices that can aide our ability to intubate the trachea. The majority
of them are cheap, portable and fairly easy to use and a good knowledge of them is
important when managing airways.

Intubating stylet

The intubating stylet comprises a malleable metal rod, which is able to fit into an ETT. Its
distal end should sit just within the distal tip of the ETT (cuffed end) and its proximal end
should protrude out the proximal end of the ETT. Once placed, the ETT and stylet can be
bent into the desired shaped simultaneously. Once bent, the ETT should keep the shape
until such time as the stylet is removed.
The stylet is useful in patients with an anterior larynx as an anterior bend at the tip can
facilitate intubation. Once the tip of the ETT is through the cords, the stylet should be
removed.
Care must be taken to ensure the distal end does not protrude beyond the distal tip of the
ETT as this may cause mucosal injury.

Bougies

A bougie is a 60-70cm long malleable device, which is inserted through the vocal cords
into the trachea and over which an ETT can be railroaded.
The distal 2.5 cm is angulated and this facilitates insertion through the vocal cords when
only the epiglottis (Grade III view) or tip of the arytenoids (Grade II view) can be visualised.
A 2nd operator then threads the tube over the bougie.

Numerous types of bougies are available. Some of the more common ones available in
Australia are:

Eschmann gum elastic bougie - a beige coloured bougie. Standard length
is 60cm with a15Fr (5mm) external diameter. Suitable for ETT sizes 6-11. A
paediatric bougie is also available 70cm long, 10Fr (3.3mm) external
diameter and is suitable for adult DLT insertion
Cook Frova bougie - a blue 65cm long bougie with 14Fr (4.7mm) external
diameter. It is essentially a hollow tube with a distal opening and comes with
a Rapi-fit leur lock connector, which allows for jet ventilation in an
emergency. A yellow 8 Fr (2.6cm) , 35 cm long paediatric bougie is also
available for ETT sizes> 3mm


Cook exchange catheters

These are long, hollow semi rigid tubes that allow for an exchange of an ETT i.e. prior to
extubation, an exchange catheter is inserted down the airway, the ETT is then removed
and the new ETT railroaded over the exchange catheter into the airway. Being hollow, they
also enable the operator to oxygenate the patient. This can be done via:





NATCAT
24
i. A detachable 15 mm adaptor for connection to an anaesthetic circuit or air viva.
This adaptor comes with the catheter
ii. A leur lock connection, which is suitable for jet ventilation. This also comes with the
catheter
iii. Oxygen tubing which is able to be connected directly onto the catheter


There are a few sizes available, each with differing external diameters but of similar length
(83-100cm long). The most common size used in adult anaesthesia is the 19 Fr with an
external diameter of 6.3mm which is suitable for a size 7 ETT or greater.

For exchange of a DLT, smaller sizes are required:
11F external diameter 3.7mm (appropriate for DLT size 35& 37)
14F external diameter 4.7mm (appropriate for DLT size 39& 41)

Aintree Intubating catheter (AIC)

This is a very similar device to the Cook airway exchange catheter but is specifically
designed to fit snugly onto the length of an adult 4mm fibrescope leaving the flexible 3cm
tip of the scope unsheathed. It was initially designed to facilitate intubation using a
fibrescope through a LMA by:

Loading an AIC over a fibrescope
Passing the fibrescope through a correctly positioned LMA, down through the cords
to the carina and then sliding the AIC off the fibrescope
Removing the fibrescope and LMA whilst holding the AIC in place
Railroading an ETT over the AIC.

It is 56cm long with an internal diameter of 4.8mm and an external diameter of 19Fr
(6.3cm), which allows its use with size 7 and greater ETTs.
It too comes with a detachable rapi-fit leur lock device which allows for ventilation if
required.


Left:
Intubating stylet, Frova intubating
bougie and Aintree catheter
Below:
Aintree Catheter and Frova bougie
with their 15mm Rapi-fit
connectors attached




NATCAT
25
Endotracheal Intubation Techniques

Endotracheal intubation can be performed in a variety of ways and to assist with intubation
we can use a variety of devices on their own or in combination:

1. Laryngoscopes with a variety of blades with or without the use of a bougie.
2. An intubating conduit e.g. ILMA, cLMA
3. A fibreoptic endoscope
4. Nothing, as for a blind nasal intubation

In this section, we will review intubation via direct and indirect laryngoscopy using as well
as intubation through a LMA. Awake fibreoptic intubations will be covered in module 2.

Intubating using a laryngoscope

Optimal positioning

Before a laryngoscope is picked up, it is imperative to optimise the chances of a
successful first time intubation by positioning the patient appropriately.
Optimum positioning involves achieving a line of sight from the maxillary teeth to the larynx
and this has classically been described in the 3 axis alignment theory which involves
lining up the oral, pharyngeal and laryngeal axes as best as possible.
More recently however, Greenland et al
4
have attempted to describe the optimum position
on the basis of a two-curve theory and we encourage you to review the article.

The sniffing position is the time honored best position and this involves 35
0
neck flexion
and 15
0
face plane extension
4
. Practically this can be achieved by placing the patients
head on a pillow to achieve neck flexion and then once induced, the head can be gently
extended before intubation. Sometimes further flexion i.e. another pillow or lifting the head
off the pillow can improve the view.

In obese or pregnant patients, elevation of the shoulders and head may be necessary and
can be achieved by using multiple pillows or blankets positioned under the shoulders.
Ideally, the sternum of the patient should be at the same horizontal level as the
tragus or angle of the jaw. This is illustrated below using the 3 axis alignment theory
where the oropharyngeal axis (OA), laryngeal axis (LA) and pharyngeal axis (PA) should
align as close as possible.





NATCAT
26




Using the laryngoscope

Macintosh blade

The Macintosh blade is introduced from the right side of the patients mouth and is used to
sweep the tongue to the left while introducing the blade into the vallecula. The
laryngoscope is then lifted upwards to expose the vocal cords which lie behind the
epiglottis. It is important to be conscious of lifting the laryngoscope upwards and not
levering it at the wrist - this levering action will not enhance your view and will
increase the chance of damaging the patients teeth.


Straight blade
8


The paraglossal technique
12
described to use a straight blade successfully is vastly
different to that of a Macintosh blade and there is a significant initial learning curve in its
correct usage. It is not a blade that you want to use for the first time in an emergency
situation.

The patients head should be fully extended (remove the pillow) and turned to the left. The
mouth should be opened as wide as possible and the laryngoscope positioned as far
lateral in the mouth as possible. The blade should be advanced over the paraglossal gutter
to the right of the tongue. The tip of laryngoscope is passed posterior to epiglottis and a




NATCAT
27
sufficient lifting force is applied to achieve maximum elevation of the epiglottis. An
assistant retracting the corner of the mouth often helps.
An alternative technique is to advance the laryngoscope into the oesophagus and then
elevate and withdraw slowly until the glottis is seen.

Often the view can be lost when intubation with the ETT is attempted. This problem can be
overcome be initially intubating with a bougie and then railroading an ETT over it.

McCoy blade

As for the Macintosch blade, the exception being that once the tip has been placed in the
vallecula and the laryngoscope lifted, further elevation of the epiglottis can be achieved by
pulling the leaver on the handle, which moves the tip of the blade anteriorly.

Videolaryngoscopes

Reviewing the technique associated with every device is beyond the scope of these notes
however anecdotally; a few general principles do apply depending on the type of
videolaryngoscope used.

For those scopes based on the standard Macintosh blade e.g. C-Mac, McGrath Mac,
direct laryngoscopy should be performed as usual and the epiglottis identified if possible.
Only then should the image on the monitor be viewed, laryngeal position optimised and
intubation attempted. Keeping the image of the larynx in the middle of the monitor appears
to be helpful with these devices. Tube delivery with these devices is very similar to
standard Macintosh blades.
For those scopes with hyperangulated blades e.g. Glidescope, AirTraq, C-Mac D-Blade,
direct laryngoscopy is generally not attempted and locating the epiglottis (epiglottoscopy)
is done on the monitor or in the viewer. The blade is then elevated to expose the larynx.
With these blades, optimising the view of the larynx to the center of the monitor may
paradoxically make intubation more difficult due to the angle of the blade. Rather,
intubation may be easier if the tip of the blade is not advanced too close to the larynx and
the image of the larynx is kept in the top half of the monitor. This will help with visualising
the tube as it is advanced towards the larynx. Depending on whether the device has a
dedicated channel through which the tube is advanced, a stylet may be required. A
common problem with this is that the styletted tube catches on the cricoid cartilage or high
tracheal rings anteriorly, preventing tube insertion. One solution is to remove the stylet
once the tip of the tube is through the cords. Another option is to rotate the hyperangulated
stylet to the right 90 degrees clockwise. This will help better align the tip of the rotated tube
with the tracheal axis instead of pointing upwards. The tube and can be further advanced
before the stylet is withdrawn.

A recent article Observations on the assessment and optimal use of videolaryngoscopes
by Greenland, Segal, Bradley et al, Anaesthesia Intensive Care 2012; 40: 622-630 reviews
the specific techniques associated with the more common videolaryngoscopes on the
market today.








NATCAT
28
Describing the view of the larynx achieved during laryngoscopy

Traditionally, the best laryngeal view achieved during direct laryngoscopy is described
using the Cormack and Lehane grading system(see below). This is a grading system
based on how much of the laryngeal inlet is visible following direct laryngoscopy. This is
important in order to facilitate communication of this information to other relevant medical
personnel.

With the advent of videolaryngoscopes and indirect laryngoscopy, it has become apparent
that a grade 1 view of the larynx on the monitor does not necessarily translate into
passing a tube through the cords easily. As a result, there is a push for the formation of an
indirect laryngoscopy grading system to account for this. Although a few classifications
have been suggested, none have met with universal acceptance. Until such a
classification is agreed upon, whenever intubation has been successful via indirect
laryngoscopy it would be prudent to note:

1. The device used
2. The view obtained on the monitor (using the Cormack and Lehane grading system)
3. Mechanism used to pass the tube e.g. bougie, pre-shaped stylet
4. Difficulties in passing the tube

For those scopes based on the standard Macintosh blade e.g. C-Mac, McGrath Mac, it
would also be useful to perform and note the best view on direct laryngoscopy.



The Cormack and Lehane grading system











Grade I: most of glottis is seen

Grade II: only posterior portion
of glottis can be seen

Grade III: only epiglottis may be
seen (none of glottis seen)

Grade IV: neither epiglottis nor
glottis can be seen






NATCAT
29
Strategies to improve the view of the larynx when using a laryngoscope:

1. Ensure position is optimised (as discussed earlier)
2. External laryngeal manipulation (ELM)
This can be backward pressure or BURP (backward upward rightward pressure)
applied directly on the thyroid cartilage
Practically it is best achieved by asking your assistant to manipulate the larynx with
their right hand whilst you perform laryngoscopy and asking them to hold the
position when a best view is obtained.
3. Consider an alternate blade
4. Assess if the patient is adequately relaxed or if a further dose of relaxant/
propofol is required

Ideally, the ability to achieve at least a grade 3 laryngeal view is desirable as this may
allow intubation with the help of a bougie.


Use of a bougie to facilitate/assist intubation

The majority of patients with a grade 1, 2 or 3 laryngoscopic view of the larynx can be
intubated with a laryngoscope and a bougie. Patients with a grade 4 view are much less
likely to be intubated simply with a laryngoscope and bougie and if successful, it is likely to
take significantly longer.

When using a bougie:

The view of the larynx should be optimised and maintained as discussed above.
When using a Macintosch blade, the larynx should lie in the midline behind the
epiglottis.
The tip of the bougie should be manually bent to the desired angle to improve
success. Sometimes curving the entire bougie may also help. It should then be
gently passed behind the epiglottis and then anteriorly between the cords. It is
often beneficial to gently run the tip of the bougie along the underside of the
epiglottis.
Sometimes the tip will meet resistance once under the epiglottis. If this is the case,
gently rotate and remove/advance the bougie until through the cords.
Successful placement through the cords should be accompanied by the feeling of
the bougie passing over the tracheal rings (clicks) and potential resistance when
the carina is abutted
Once through the cords, a previously prepared ETT can be railroaded over the
bougie while the laryngoscopic view is maintained. It is important that
someone is continually holding the bougie while the railroading takes place.

If resistance is met when trying to pass the ETT through the cords:

Rotate the ETT 90 anticlockwise as you advance.
Consider a smaller ETT, a reinforced ETT or ILMA ETT.
Consider releasing cricoid pressure if applied.







NATCAT
30
It is important to remember that:

1. Second attempts at intubation should not be performed without
every effort being made to improve the probability of success.
This should be done by assessing where the difficulty lay in the
first attempt and making the appropriate changes for the second
attempt i.e. changing the blade, optimising position, use of a
bougie. Repeated attempts at intubation without making changes
will lead to ongoing failure and airway trauma.

2. Repeated attempts beyond the second attempt increases the risk
of airway trauma and hence the risk of losing the ability to
ventilate the patient.

3. Always revert back to bag-mask ventilation when a difficult
intubation scenario is encountered.





























NATCAT
31
Intubating through a LMA

Intubating through a LMA can be performed:
Blind
Using a fibrescope with or without an Aintree Intubating Catheter

Blind
Blind intubation through any LMA besides the ILMA is often unsuccessful. The ILMA has
been designed for this specific role and should be used whenever possible if a blind
intubation is envisaged.
However, if another type of LMA is used to perform this manoeuvre e.g. cLMA, pLMA the
user needs to be aware of the following potential problems:

The LMA used may often be too long in that when a standard ETT is fully inserted
into a LMA, the cuff may sit in the cords and not be able to inserted further into the
airway. Methods to overcome this problem include using an ILMA ETT, a
reinforced ETT, a warm nasal RAE ETT or a MLT as these ETTs are often
longer than standard ETTs.

Only smaller diameter tubes are able to be passed through the cLMA/pLMA i.e. a
size 3 and 4 LMA will accommodate a size 6 ETT with difficulty and a size 5
ETT easily. A size 5 LMA will accommodate a size 7 ETT

If a cLMA is used, the bars at the glottis opening may cause obstruction when
attempting to pass the ETT down the LMA. This can be overcome by either slightly
withdrawing the ETT and then rotating the ETT as you advance it or cutting the bars
before the LMA is inserted.


If the ILMA ETT is used with the ILMA, the issue of the ETT being too short does not
occur. As well as this, all 3 sizes of the ILMA are able to accommodate a size 6, 7 or
8 ETT.

Blind intubation through the ILMA

This should ideally only be attempted once an adequate airway is obtained through
the LMA
Choose the correct sized tube and ensure that lubricant is applied onto the tip of
tube and then pass it in and out of ILMA to lubricate the shaft of the ILMA
(important).
Ensure the longitudinal line on the tube is facing the operator i.e. facing upwards.
Insert the tube into the ILMA until the horizontal black line is in line with the proximal
end of the ILMA. This indicates that the distal end of the tube is at the level of the
epiglottic elevator bars.
At this point, the ILMA handle should be elevated a few millimeters to lift the ILMA
away from the post pharyngeal wall and align the opening better with the glottis.
Resistance will be felt as the tube is advanced through the cords. The cuff should
be inflated and confirmation of tracheal placement obtained. If unsuccessful, the




NATCAT
32
cuff should be deflated, the tube removed and ventilation re-established through the
ILMA.

Redirection and re-manipulation of the ILMA handle may enhance successful passage of
the tube during future intubation attempts

Fibrescope assisted intubation through a LMA

A fibrescope can be used to guide an ETT through the cords, using the LMA as a conduit.
Once again, the ILMA is the optimal device to use in this setting and if another type of LMA
is used, the problems that were described in the blind intubation through a LMA section
will also be encountered (see above).

In the majority of cases, the larynx can be seen from within the bowl of the LMA when a
fibrescope is passed down a LMA. The view may also be improved by using head and
neck movements e.g. chin lift, jaw thrust or cricoid pressure under direct vision.
Anecdotally, using a fibrescope through a pLMA often results in a better view of the glottis
compared with the ILMA or cLMA. This is due to the presence of the EEB in the ILMA and
aperture bars in the cLMA.
Intubation through a LMA can be performed with or without the use of an Aintree
Intubating catheter. Both techniques will be described:

Using only a fibrescope

Prepare an appropriately sized LMA and ETT.
Prepare a 4 mm fibrescope - using a bigger scope will result in difficulty in passing
it through a size 6 or 6.5 ETT.
Insert a LMA and confirm the ability to ventilate.
Insert the fibrescope through the ETT so that the distal end of the fibrescope lies
just within the distal end of the ETT.
Ensure the outside of the ETT is lubricated.
Insert both into the LMA and advance together.
If ILMA used: advance so that the ETT elevates the EEB after which the fibrescope
is advanced through the cords and the ETT railroaded over it into the trachea
If cLMA/pLMA used: once the glottis is visualized, advance the fibrescope through
the vocal cords (first through the aperture bars in the cLMA) and railroad the ETT
into the trachea. The aperture bars should be flexible enough to allow the ETT
through when using a cLMA otherwise they can be cut before insertion of the
LMA.
Advance the ETT over the fibrescope until its adaptor is flush against the adaptor of
the LMA and then remove the fibrescope.
Ensure the ability to ventilate through ETT.
The LMA may be deflated and left in situ or may be removed. Removal may risk
accidental extubation.

If ventilation is required during intubation, then a fibrescope adaptor can be inserted into
the circuit attached to the ETT (see picture below). The tight fit of the ETT into the LMA will
allow for the application of IPPV during intubation.






NATCAT
33



Using a fibrescope and Aintree Intubating Catheter (AIC)

The AIC is a very similar device to a Cook airway exchange catheter but is
specifically designed to assist intubating through a LMA by fitting snugly onto the
length of an adult 4mm fibrescope leaving the flexible 3cm tip of the scope
unsheathed.
The AIC is loaded onto the fibrescope, which is then passed down the LMA and into
the trachea as described above.
The fibrescope and then the LMA are withdrawn leaving the AIC in the trachea.
A standard ETT can then be railroaded over the AIC whilst performing
laryngoscopy.
The smallest ETT that can be used is a size 7mm as the AIC is 19F i.e. it has
an external diameter of 6.5mm

It is important to note that the Supreme LMA, the disposable version of the
pLMA, is NOT reliably compatible with the Aintree catheter

If there is any difficulty in railroading the ETT over the AIC, it may be used as a
oxygenation device in the same way as the Cook catheter, as it comes with 2 detachable
15mm Rapi-fit connectors that connect to standard anaesthetic circuits/ air vivas






NATCAT
34
Removing the ILMA once the patient is intubated

The manufacturers advise that prolonged placement of the ILMA in situ may lead to an
impairment of mucosal perfusion of the posterior hypopharyngeal wall. As a result, they
advise that the ILMA be removed once the patient is intubated. This process can
sometimes be difficult and there is always the risk of accidental extubation while trying to
remove the ILMA. As a result, the risk of mucosal injury should be weighed up against
the risk of accidental extubation in the particular case before commencing the
removal of the ILMA, once the patient is intubated.

The technique of removing the ILMA is as follows:

Disconnect the circuit with the ETT connector attached to the circuit i.e. not
attached to the ETT. This prevents misplacement of the ETT connector!!
Fully deflate the ILMA.
Ease out the ILMA by reversing the insertion procedure, while applying counter
pressure to the tip of the tube with index finger.
When the proximal end of ETT is flush with proximal end of the ILMA, insert the
stabilising rod and slide the ILMA out over the rod. Ensure that the ETT does not
move with the ILMA i.e. ensure the stabilising rod is held stable!
Remove the stabilising rod when the ILMA is clear of the mouth and the ETT is able
to be held at its most distal point (closest to the patients mouth)
Hold the ETT tightly while the inflation line and pilot balloon are unthreaded from the
ILMA. Some airway practitioners advocate deflating the ETT pilot balloon in
order to make this step easier to perform and to decrease the risk of shearing
the pilot balloon off the ETT as the ILMA is removed.
Reattach the circuit to the ETT, re-inflate the ETT and ensure the ability to ventilate.






















NATCAT
35
Surgical Airway Devices

Surgical airway management takes the form of either a cricothyroidotomy or tracheostomy.
From an anaesthetic viewpoint, a cricothyroidotomy is easier, safer and quicker to perform
and as a result, it forms the final step in the DAS algorithm. It is however, important to
know a little about tracheostomy tubes, as you may be faced with a patient with one in situ
who may be experiencing respiratory difficulties.
Cricothyroidotomy devices

A cricothyroidotomy can be performed quickly using a:
14g cannula inserted through the cricothyroid membrane or
A surgical scalpel, bougie and size 6 ETT or
A Melker Emergency Cricothyrotomy Catheter Set, which contains components for
inserting a cricothyroid catheter via a Seldinger technique.
We will now review each of the techniques individually:
Emergency Cricothyroidotomy

Many different techniques have been described to perform an emergency
cricothyroidotomy but there is very little evidence to support one technique over another.
With this in mind, Dr. Andrew Heard, an anesthetist, published the following paper:

Heard AMB, Green RJ, Eakins P. The formulation and introduction of a cant
intubate, cant ventilate algorithm into clinical practice. Anaesthesia 2009;64:601-
608

In it, he attempts to set out an algorithm that anaesthetists could follow if ever faced with a
cant intubate, cant oxygenate (CICO) situation. He has based his algorithm on 4 years
of observing wet labs where junior and senior anaesthetic staff practice performing
emergency cricothyroidotomies. Due to the rarity of a CICO situation, this paper is
currently the best evidence we have available and as such, we will use the algorithm as a
guide in reviewing the potential techniques available when performing an emergency
cricothyroidotomy.

We acknowledge that the algorithm set out below is just a guideline and not the definitive
answer to which technique to use. It has been written with anaesthetists in mind, the
majority of whom are NOT surgically trained and relies on the fact that anaesthetists are
more familiar with using a needle and syringe than with making an incision with a scalpel.
We are aware that this may not be the case with airway practitioners who work in the
critical care and emergency setting.

We will review the advantages and disadvantages of each method but the important
point to make is that, after consideration of all factors involved, you decide on a
technique or algorithm that you would use in a CICO situation, practice the
technique or algorithm and be prepared to carry it out should you find yourself in a
CICO situation. The decision to proceed to an emergency cricothyroidotomy is already a
psychologically difficult one and it is one that can potentially be made more difficult if you
are unclear about which method to employ when faced with the stress of a potentially
catastrophic situation.




NATCAT
36







The algorithm advocates 4 techniques to perform a cricothyroidotomy namely:

1. Cannula cricothyroidotomy
2. Melker tube insertion
3. Scalpel bougie technique
4. Scalpel finger technique

Dr. Heard discusses the following techniques and the CICO algorithm on You Tube.
Search: DrAMBHeard

We will now consider each one in turn:
Heard AMB, Green RJ, Eakins P. The formulation and introduction of a cant intubate, cant
ventilate algorithm into clinical practice. Anaesthesia 2009; 64:601-608





NATCAT
37
Cannula Cricothyroidotomy

The initial priority in a CICV situation is to achieve a safe, simple and fast method
of oxygenation (SSFO). Oxygenation is the important consideration; elevations in
CO2 are of little concern in this setting. Sometimes a cannula cricothyroidotomy and
oxygenation is all that is needed until the patient resumes spontaneous ventilation or until
the airway can be secured in a more timely fashion. Otherwise cannula cricothyroidotomy
allows SSFO and acts as a bridge to a definitive airway with a Melker tube via the
Seldinger technique.

As can be seen from the algorithm, it is suggested that needle or cannula
cricothyroidotomy be the initial technique employed when attempting to perform an
emergency cricothyroidotomy.

Some of the advantages to this technique include:

It is a safe, simple and quick procedure to perform
The ability to provide oxygenation quickly
Non-surgically trained practitioners are more familiar with the equipment used
Minimal blood loss
Enables stabilisation of the situation to facilitate further planning
Facilitates insertion of a Melker tube
Once transtracheal oxygenation is established, it may facilitate further intubation
attempts from above, as air from below may escape though the glottis, potentially
making identification of the glottis on laryngoscopy easier
More options are available if this technique fails

Some of the disadvantages included:

It is not a definitive airway
The cannula may kink or block with secretions or blood
An unrecognised improperly positioned cannula through which jet ventilation has
commenced may result in surgical emphysema
Transtracheal oxygenation provides oxygenation, not effective ventilation. The
patient will become hypercapnoeic if a definitive airway is not established
A time lag of potentially 60 secs may occur before the patients oxygen saturations
improve after commencing transtracheal oxygenation


Performing a cannula cricothyroidotomy
13

The cricothyroid membrane is located 1.5 - 2 cm below the thyroid notch. This membrane
and not the lower trachea is generally preferred for the immediate surgical airway.
However, if it cant be located, dont delay; use the lower trachea or failing that,
cannulate in the midline.





NATCAT
38
1. Identify the cricothyroid membrane and stabilize it with the non-dominant hand. The
index finger of the non-dominant hand should palpate the membrane and the thumb
and middle fingers should stabilise the trachea.

2. Hold a 5 ml syringe (containing 1 - 2 ml saline) connected to a 14G cannula in the
dominant hand, with fingers between the flange and the plunger. A 5ml syringe is
preferred because with 10 or 20 ml syringes, the hand is too far from cricothyroid
membrane and with the 3ml syringe the barrel aspiration volume is too small. Filling the
5ml syringe with 1-2 ml of saline best demonstrates the endpoint of bubbles when the
airway is entered.

3. Insert the needle through the skin at approximately 45
0
caudally. In patients with
deep airway anatomy you may need to insert to cannula perpendicularly or there may not
be enough cannula length to reach the airway.

4. Aspirate as you advance into the airway. Stop advancing immediately once air is
aspirated. Only aspirate on the way in as false flashbacks of air can occur on withdrawing
if the cannula and trochar are slightly separated.

5. The endpoint is free aspiration of air up the full barrel of syringe. Aspirate all the
way up the barrel.
6. Stabilise the cannula hub with the non dominant hand and then release the plunger of
the syringe held by your dominant hand. If tip of the cannula is incorrectly placed, you will
see the plunger being sucked back into the syringe barrel by the vacuum created by
aspirating outside of the airway. NO VACUUM INDICATES CORRECT PLACEMENT.
7. Place the dominant hand underneath the syringe, holding the needle in a pencil grip
with the hand resting against the chin or neck to immobilise the cannula.

8. Advance the cannula over the needle into trachea with non dominant hand and
remove trochar. It should advance as easily as an IV. Do not remove the needle
before you advance the cannula otherwise the cannula will kink.

9. HOLD THE CANNULA SECURE.

10. Using a syringe with saline, repeat the full free aspiration of air from cannula. The
lack of recoil of plunger confirms airway placement. If the initial aspiration fails then the
slight withdrawal of the cannula while aspirating will correct this as the cannula may
be against posterior tracheal wall. AGAIN, NO VACUUM INDICATES CORRECT
PLACEMENT.
11. Attach an appropriate oxygen supply source and begin oxygenation. It is important to
concentrate on oxygenation and not trying to achieve ventilation at this point.
Oxygenation through the cannula can be achieved either via a jet ventilator or via oxygen
tubing connected to an oxygen flowmeter.





NATCAT
39
Oxygenation via a transtracheal cannula

1. Jet oxygenation: via the Sanders injector or Manujet jet ventilator

Safe jet oxygenation is crucial to achieving SSFO via a cannula (or bougie).
The jetting devices can deliver wall pressure which is 400 kPa = 4 bar (58 psi). When
jetting through a 14G cannula, this provides flow rates that are sufficient to achieve normal
oxygenation and normocarbia (if patent upper airway) for prolonged periods if required. It
is important to start at low pressure around 1 bar and slowly increase. Normally 2.5 bar is
sufficient.

During jet ventilation, exhalation relies on the elastic recoil of the lungs through a patent
upper airway. It is crucial that the patient achieves full expiration before a new jet
inspiration is delivered. Stacked jet ventilator breaths in which there is insufficient time for
the expiration can result in bilateral pneumothoraces and cardiovascular collapse.
Attempts should be made to maximise upper airway patency e.g. by use of chin lift and jaw
thrust, the use of airways or LMAs. Complete upper airway obstruction is considered
a contraindication to jet ventilation.
It is also very important that the cannula being used for jet ventilation is correctly placed.
Jet ventilating into a cannula incorrectly placed in subcutaneous tissues or a vessel can
be rapidly fatal, hence the importance of aspirating the full barrel of the syringe and
ensuring no vacuum effect on placement.

With all jets, the operator needs to watch for chest rising and also for chest falling.

A failure of chest rise means that the cannula position needs to be adjusted. This
usually is due to a kink introduced where the cannula comes out of the skin and can
be rectified by relaxing your hold of the cannula and withdrawing a millimeter at a
time whilst aspirating on syringe, until air flows freely up the syringe barrel again.
A failure of chest falling means that no further jet ventilation should be delivered
to avoid pneumothorax and cardiovascular collapse. Frequency of jet ventilation
may be as low as one per minute, which will still deliver 1000ml of oxygen in that
minute.





Manujet jet
ventilator attached
to a 14 G cannula




NATCAT
40
2. High flow oxygen delivery

Numerous systems can provide transtracheal oxygenation by delivering high flow oxygen
from a high-pressure source (e.g. wall oxygen outlet, oxygen cylinder) through a cannula
cricothyroidotomy.
These methods may provide oxygenation but they quickly result in hypercarbia and
should not be regarded as a long-term airway solution, but merely as a bridge to
establishing a definitive airway.

We will review 2 such systems:


I. ENK flow modulator

The ENK flow modulator device consists of a short, noncompliant tube with 5 openings
located at opposite sites in front of a syringe connecter, which is connected between a
transtracheal needle or intravenous catheter and an oxygen delivery system flowing at a
rate of at least 15 l/min. It allows manually controlled oxygen flow by performing
intermittent occlusion of the openings. Occlusion of all 5 holes is required for effective
insufflation. The frequency of opening occlusions should be guided by the patients
chest rise & fall as well as by their oxygen saturations.






II. Oxygen tubing connected to a flowmeter
9


Many different methods of performing percutaneous transtracheal oxygenation, using
systems that deliver high flow oxygen and that can be quickly and easily assembled, have
been described.

One such method is described below:

Equipment required:
1. High pressure source of oxygen e.g. hospital piped oxygen, oxygen cylinder
2. Oxygen flow meter that can be attached to the high pressure source
3. A normal length of normal oxygen tubing




NATCAT
41
4. A 3 way tap
5. A 14G cannula

Attach the one end of a normal length of oxygen tubing to an oxygen flowmeter and
the other end onto a 3-way tap. This may require some force.
Once the transtracheal cannula has been inserted, the 3-way tap is then attached
to the cannula. All of the 3-way taps should be in the open position.
The oxygen flowmeter is then opened to between 12-15l/min. In children, the
oxygen flow in liters/min is equal to the childs age. If the chest does not rise, then
increase the oxygen flow in increments of 1 L/min.
The tap that is open to air is occluded in inspiration and then un-occluded when
the patient is being allowed to exhale via their patent upper airway. Occluding the
open to air tap for 4 seconds at flow rates of between 12-15l/min through a 14G
cannula should deliver between 800-1000ml of oxygen.
The risk of barotrauma is high in an airway that is fully occluded, as air is
unable to escape. Watch for chest fall. If the chest does not fall, it would be
prudent to turn the oxygen flow off to allow for venting of air from out of the chest
through the open tap. Once chest fall is observed, the oxygen may be turned back
on and the open tap occluded.
The frequency and duration of tap occlusion should be guided by the
patients chest rise & fall as well as by their oxygen saturations.


Another method describes excluding the 3-way-tap from the system completely and
merely opposing the end of the oxygen tubing, with oxygen flow at 15l/min, to the
transtracheal cannula during oxygenation. Un-opposing the oxygen tubing from the
cannula would allow for venting of air from within the chest, out, through the cannula.
Again, the frequency of inspiration should be guided by the patients chest rise
& fall as well as by their oxygen saturations










NATCAT
42
Inserting a surgical airway via the Seldinger technique

Melker Tube Insertion
13
The Melker tube kit (Cook) contains all the equipment required to insert a
cricothyroidotomy or tracheotomy tube via the Seldinger technique. Melker tubes are
available as either 5mm cuffed tubes or 6mm, 4mm or 3,5mm uncuffed tubes. It is
recommended that you insert a cannula and achieve SSFO, as described above,
prior to embarking on the second part of the Seldinger technique i.e. inserting
the wire etc.
1. Pass the cannula through the cricothyroid membrane as for the Cannula
Cricothyroidotomy Technique described above. Oxygenation should be
commenced via jet or oxygen flowmeter.

2. Once the patients saturations have stabilised, insert the wire through the
cannula. Pass a generous length of wire to prevent accidental wire removal. If
unable to pass the wire, reconfirm cannula position using a syringe with saline.

3. Remove the cannula and HOLD ONTO THE WIRE.

4. Make a 2 cm stab incision caudally with a scalpel. Ensure that the wire is able to
move within the incision with no skin tags to stop the insertion of the Melker tube
and dilator.

5. Pass the Melker tube-dilator device over the wire. Hold the device in the
dominant hand making sure that the dilator is fully advanced in the tube.

6. Advance into the airway - moderate to heavy force may be required. If unable to
advance, ensure the dilator is fully advanced in the tube and consider
lengthening the incision. If the wire becomes kinked then readvance
cannula over wire, jet oxygenate and then replace with a CVC wire and re-
attempt Melker insertion.

7. Remove the wire and introducer, inflate cuff and attach tube to circuit or self-
inflating bag.






NATCAT
43
Scalpel Bougie Technique
13
(Consider when palpable neck airway anatomy present)

According to Heard, the scalpel bougie technique should be considered if there has
been failure of cannula cricothyroidotomy and the patients neck anatomy is palpable.
Anecdotally however, many practitioners favour this technique as their preferred
approach to performing a cricothyroidotomy. We will consider the advantages and
disadvantages of this technique:

Advantages:

Quick to perform
A definitive airway can be achieved quickly with the ability to ventilate
Minimum equipment is required

Disadvantages:

Blood!. Potentially lots of blood!!
Making an incision with a scalpel may be an unfamiliar act for non surgically
trained personnel
Psychologically a bigger step than cannula cricothyroidotomy
Possible to create a false track
Difficult to perform another technique if this fails


For this technique all that is needed is a:
Scalpel and blade
A bougie (ideally one that will permit insufflation of oxygen if required)
A size 6mm ETT
A method of oxygenating down the bougie if available

1. Identify the cricothyroid membrane and stabilise it with the non-dominant hand.

2. With the scalpel in the dominant hand, make a horizontal stab incision through
the cricothyroid membrane.

3. Rotate the blade through 90
0
so that the blade points caudally and then pull the
scalpel towards you, thereby creating a triangular hole.

4. Swap hands so that the non-dominant hand holds the blade.

5. With the dominant hand, hold the Cook Frova bougie near the bent tip so that the
straight end is pointing away from you and is parallel to the floor. Insert the tip
into the trachea, using the blade face as a guide to the hole.




NATCAT
44

6. Rotate and align the bougie through 90
0
to allow the bougie to follow the line of the
trachea and advance the bougie. Feel for the tracheal rings and hold-up at the carina.
The bougie insertion should require minimal force.
7. Withdraw the bougie so that a maximum of 10cm is in trachea (the first marking on a
Frova bougie) and oxygenate via the bougie. This can be achieved by using various
methods, the safest being:
Using the rapi-fit 15mm connector and a standard circuit or self inflating bag or
Alternatively using a leur lock style rapi-fit connector or 14 G cannula inserted
down the bougie attached to jet oxygenation device. Remember that the rules
for safe jet oxygenation still apply.
It is important to attempt to oxygenate the patient via the bougie and reverse
hypoxia before proceeding onto the next step
8. Railroad a 6 mm ETT over the bougie rotating it as it is advanced and then remove
the bougie.

8. Ventilate via a circuit or self-inflating bag.

Scalpel Finger Cannula Technique
13
(Consider when palpable neck anatomy absent)

According to Heard, this technique should be considered when there has been failure
of cannula cricothyroidotomy and the patients airway anatomy is not palpable.
It essentially involves making a 6 cm vertical incision up the midline of the neck,
through the skin and subcutaneous tissue, to enable the airway anatomy to be palpated
and then a cannula cricothyroidotomy performed.

Technically, this is likely to be the most difficult procedure to perform due to the large
incision, blunt dissection and large amount of blood that would invariably result.

All that is needed to perform this is a:
Scalpel and blade
14G cannula, 5ml syringe and saline

1. Stabilise the neck in the midline with the non-dominant hand.

2. Make a minimum 6cm vertical midline incision- caudal to cranial- through the
skin and subcutaneous tissue down to the strap muscles using the scalpel.

3. With fingers (not scalpel) separate the strap muscles by blunt dissection. If the
strap muscles cant be identified, a deeper incision may be required with the scalpel.




NATCAT
45

4. Identify the airway structures and hold them with the left hand.

5. Insert a14 G cannula as in the cannula cricothyroidotomy technique, then jet
oxygenate and proceed to placing a Melker tube.



Tracheostomy devices
(17,18)


Tracheostomy tubes are small rigid, curved tubes that are normally cuffed at their distal
end. They are inserted into a tracheostomy stoma such that the distal end lies above
the carina and the proximal flange lies flush with the skin. They can then be connected
to a breathing circuit or the patient can breathe room air. They are usually graded
according to their internal diameter (as for ETTs) and when inflated, the cuff protects
against aspiration.
They normally come with an introducer, which fits, into the lumen of the tracheostomy
tube. The introducer provides a smooth rounded tip to assist with the passage of the
tube and is removed once the tube is positioned.

Some tracheostomy tubes have an outer cannula, which is the main tube that sits in
the trachea, and an inner cannula, which is a removable tube that fits inside the outer
cannula. The inner cannula is regularly removed and cleaned to try and prevent the
buildup of secretions.






A cuffed tracheostomy
tube with purple
insertion trochar in situ.
The insertion trochar is
removed once the
tracheostomy is
inserted.
A cuffed tracheostomy
tube with inner
cannula removed




NATCAT
46

Fenestrated and uncuffed flange tubes

Fenestrated tubes have single or multiple holes on the outer curvature of the tube and
are used as a weaning tool and to facilitate speech. As a result of the consequent air
leak, they cant be used for positive pressure ventilation. The air leak may be overcome
by placement of a non-fenestrated inner cannula





Uncuffed tubes are similarly inserted for weaning and to facilitate speech and like the
fenestrated tubes, are ineffective for positive pressure ventilation.

Above the Cuff Suction Tracheostomy Tubes

Some cuffed tubes can have an additional suction port to remove secretions above the
cuff. The additional lumen terminates above the cuff in a rectangular opening, allowing
subglottic drainage. Reports suggest that aspiration of subglottic secretions can prevent
or delay the onset of ventilator-associated pneumonia. Aspiration of subglottic
secretions is performed intermittently using a syringe attached to the proximal end of
the suction lumen or continuously using suction pressure of 15-20cmH20


Fenestrated
tracheostomy
tube with inner
cannula removed
Above the cuff suction
tracheostomy tube.
Note the opening above the
cuff




NATCAT
47

Tracheostomy tubes are commonly secured with tracheostomy ties, to facilitate prompt
removal of the tube in an emergency. They can also be sutured in place.

Sometimes tracheostomy tubes may have one of the following devices attached:

Speaking valves are one-way valves that allow inspiration through the
tracheostomy tube but not expiration. Expiration must therefore occur around the
tube and as a result, air passes through the vocal cords to achieve phonation.
Occlusion caps are weaning devices that stop all airflow through the
tracheostomy. Clearly, to use either of these devices, the cuff must be
deflated.
Heat & moisture exchanges can be connected to the tracheostomy tube to act
as a surrogate nose and assist in humidification. They should not be used if
there are significant secretions as they can easily be occluded.

If there is any concern about any of these devices causing obstruction of the
patients airway, they should be able to be easily removed from the tracheostomy
tube.




Passy-
Muir
speaking
valves




NATCAT
48

References

1. Kheterpal et al. Prediction and outcomes of impossible mask ventilation: A
review of 50000 anesthetics. Anesthesiology 2009; 110:8917
2. Heard AMB, Green RJ, Eakins P. The formulation and introduction of a cant
intubate, cant ventilate algorithm into clinical practice. Anaesthesia
2009;64:601-608
3. Campos J. Which device should be considered the best for lung isolation:
double-lumen endotracheal tube versus bronchial blockers. Current Opinion in
Anaesthesiology Feb 2007; volume 20(1),27-31
4. Greenland KB, Edwards MJ, Hutton NJ, Challis VJ, Irwin MG, Sleigh JW.
Changes in airway configuration with different head and neck positions using
magnetic resonance imaging of normal airways: a new concept with possible
clinical applications Br. J. Anaesth. (2010) 105(5): 683-690
5. McGee JP,Vender JS. Nonintubation management of the airway: mask
ventilation. Benumofs Airway Management, Hagberg CA, pg 345-370, Mosby
2007
6. Kovacs G, Law JA. Airway management in emergencies McGraw Hill 2008
7. Calder I, Yentis SM. Could safe practice be compromising safe practice? Should
anaesthetists have to demonstrate that face mask ventilation is possible before
giving a neuromuscular blocker? Anaesthesia 2008;63:113-115
8. Henderson JJ. The use of paraglossal straight blade laryngoscopy in difficult
tracheal intubation. Anaesthesia. 1997;52:552-60.
9. Ryder IG, Paoloni CC, Harley CC. Emergency transtracheal ventilation:
assessment of breathing systems chosen by anaesthetists. Anaesthesia 1996;
51: 7648.
10. Bould MD, Bearfield P.Anaesthesia. 2008 May;63(5) Techniques for emergency
ventilation through a needle cricothyroidotomy.:535-9.
11. Ferson DZ,Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A. Use of the
intubating LMA-Fastrach in 254 patients with difficult-to-manage airways.
Anesthesiology 2001; 95:1175-1181
12. Henderson JJ. The use of paraglossal straight blade laryngoscopy in difficult
tracheal intubation. Anaesthesia 1997;52:552-560
13. Heard AMB, Green RJ, Eakins P. The formulation and introduction of a cant
intubate, cant ventilate algorithm into clinical practice. Anaesthesia
2009;64:601-608
14. Devit JH et al The LMA and PPV, Anesthesiology 1994;80:550-555




NATCAT
49
15. Mihai R,Blair E, Kay H, Cook TM. A quantitative review and meat-analysis of
performance of non-standard laryngoscopes and rigid fibreoptic intubation aids.
Anaesthesia 2008;63:745-760
16. Frerk CM, Lee G. Laryngoscopy: Time to change our view. Anaesthesia
2009;64:351-354
17. Cameron T ed. Tracheostomy Care Resources: A Guide to the Creation of Site
Specific Tracheostomy Procedures and Education. Austin Health 2006
18. Russell C, Matta B eds. Tracheostomy, a multiprofessional handbook.
Greenwich medical 2004
19. Barker KF, Bolton P, Cole S, Coe PA. Ease of laryngeal passage during
fibreoptic intubation: a comparison of three endotracheal tubes. Acta
Anaesthesiol Scand 2001; 45: 6246




















Equipment Reference Sheet

Endotracheal tubes

All endotracheal tubes (except DLT): size is of the internal diameter in mm

Double Lumen Tubes (DLT): size is of the external diameter in French gauge (Fr).
1Fr = 0.33mm

Sizes of the internal lumens of DLT (as a guide to fibrescope/bougie use)
3
:
Size 35Fr = 4.3 - 4.5mm internal diameter (tracheal>bronchial)
Size 37Fr = 4.5 - 4.7mm internal diameter (tracheal>bronchial)
Size 39Fr = 4.9mm internal diameter
Size 41Fr = 5.4mm internal diameter

Arndt endobronchial blockers:
7Fr blocker needs >= size 7.5 ETT using a 4mm scope
9Fr blocker needs >= size 8 ETT using a 4mm scope

Laryngeal Masks

cLMA sizes:
Size 3 able to accommodate a size 5.5 ETT easily or 6 with difficulty
Size 4 able to accommodate a size 5.5 ETT easily or 6 with difficulty
Size 5 able to accommodate a size 7 ETT

ILMA sizes
Sizes 3,4,5 all able to accommodate up to size 8 ILMA ETT


Fibrescopes

Fibrescope sizes: Sizes based on the external diameter of the scope
4mm scope suitable for placing DLT and intubating through a LMA
5.2mm scope invariably requires a 7.5mm ETT for successful intubation

Bougies/intubating catheters

Sizes based on external diameter

Cook Frova bougie: a blue 65cm long bougie with 4.7mm external diameter.
Suitable for ETT sizes 5.5+




NATCAT
51
Eschmann gum elastic bougie (adult): a beige colored bougie. Standard
length is 60cm with a15Fr (5mm) external diameter. Suitable for ETT sizes 6-
11. Not suitable for DLT insertion
Eschmann gum elastic bougie (paed): a paediatric bougie is also available.
70cm long, 10Fr (3.3mm) external diameter and is suitable for DLT insertion
Cook exchange catheters: 83 - 100cm long, common adult size has 19Fr
(6.3mm) external diameter: suitable for size 7+ ETTs.
For exchange of a DLT, smaller sizes are required:
11F (3.7mm) external diameter: appropriate for DLT size 35 & 37Fr
14F (4.7mm) external diameter: appropriate for DLT size 39 & 41Fr
Aintree Intubating catheter: 56cm long, internal diameter of 4.8mm and an
external diameter of 6.5mm. Suitable with size 7+ ETTs.
Fits onto a 4mm scope

All of the above are suitable for oxygenation through a central lumen via a rapi-fit
connector.









NATCAT
52






MODULE 2


Fibreoptic Intubation









NATCAT
53

Introduction to the fibreoptic endoscope

A fibreoptic endoscope is a hand-held device consisting of tiny glass fibres, arranged in
bundles, to carry light source illumination to the distal end of the scope and reflect light
from objects in front of the endoscope back to the eyepiece. Each glass fibre has an
outer coating to prevent light escaping.

There are a few key components of a fibreoptic endoscope that will be described in
more detail:

Eyepiece/Camera

The eyepiece is at the proximal end of the scope and it is here that the image is
magnified and focused. Correct focusing can be achieved by turning the eyepiece
clockwise or anti-clockwise whilst simultaneously looking down the scope at an object,
until the image becomes crisp and clear.
When one looks through the eyepiece, one may see an orientation indent on the
periphery of the image. With the endoscope in a neutral position, the indent should lie
at the 12 oclock position and indicate the plane of flexion of the tip.
Some endoscopes may have a camera head fitted onto the endoscope. In this
instance, the orientation of the video camera and endoscope should be aligned and any
adjustment in focus done using the camera head.

Angulation lever

The angulation lever is normally positioned on the back of the handle and is commonly
manipulated by the thumb.
A downward movement of the angulation lever causes an upward movement of the tip
of the endoscope and vice versa. The plane of movement of the tip will be in the 12o
clock or 6 oclock position when the endoscope is held in a neutral position i.e. in the
plane of the orientation indent.

Working and suction channel

The working and suction channels are essentially 2 separate lumens running down the
scope and exiting at the distal tip end. Their proximal openings are normally in close
proximity to the eyepiece. They allow for the use of suction and the ability to inject
substances or pass wires down the endoscope whilst the endoscope is in use.
In smaller endoscopes, the 2 channels are combined into a single channel.







NATCAT
54





Insertion cord diameter

The greater the diameter of the endoscope, the greater the number of glass bundles
and the better the optical features of the endoscope. A greater diameter also allows for
larger, more effective working channels.
When endoscopes are used to assist in intubation however, the diameter of the
endoscope becomes an important feature. The endoscope needs to be able to fit into
the airway comfortably and it also needs to be able to have an endotracheal tube
railroaded over it.
Endoscope sizes are described according to their external diameter and
endotracheal tubes according to their internal diameter e.g. a size 5 endotracheal
tube should fit onto a 4mm scope etc.
The common endoscope sizes used for adult fibreoptic intubations range between 4mm
and 6 mm.

Light source

Light sources can be portable, battery-powered units which connect directly onto the
endoscope or conventional light sources which plug into the mains. Both types should
be adjusted to maximize view and minimize glare.









NATCAT
55
The basic movements of the fibreoptic endoscope

In order to be able to successfully intubate using a fibreoptic scope, it is essential to be
familiar with the basic endoscope movements in order to drive the endoscope to
where you want it to go.

The good news is that there are only 3 movements required to maneuver a scope
successfully:
Tip flexion
Handle rotation
Cord insertion/ retraction


Tip flexion

Pulling the angulation lever down will flex the endoscope tip up.
Pulling the angulation lever up will flex the tip down.

Handle rotation

Rotation of the endoscope handle causes rotation of the endoscope tip and this is
achieved by flexion and extension of the wrist.
N.B: The shoulder is not used in this movement.


Cord insertion/retraction

The hand not holding the endoscope handle (the lower hand) controls the advancement
of the scope by gently pulling or pushing the endoscope cord as required.

Oblique movements can be performed using a combination of the above 3 movements.


Successful endoscopic maneuvering

Successful maneuvering of the endoscope requires constant adherence to the
3 step rule:

1. STOP
2. CENTRE
3. MOVE






NATCAT
56
STOP: once you have moved the endoscope, it is important to stop and identify where
it is that you want to advance the scope to next.

CENTRE: once you have identified your target, you should ensure that the target is
placed in the centre of the endoscopes field of view by using the 3 movements
described above. The endoscope should not be advanced until this has been achieved.

MOVE: only once centered, should the scope then be advanced until such time as the
target moves out of the centre of the field of view, at which time, one should repeat the
cycle again - stop, centre and move.

When one first starts using a fibreoptic endoscope, one should consciously focus on
making very small movements with the endoscope, which will result in a better
adherence to the stop, centre, move dictum and a greater success rate. Speed will
come with greater endoscopic experience and should not be the primary objective
when first starting out using an endoscope. The goal is precision and safety, not speed.

Other tips to successful endoscopic maneuvering

Ensure that the endoscope is kept as straight as possible and that a loop doesnt
form. Loop formation decreases the ability to rotate the tip of the endoscope, as
all wrist rotation will be transmitted to the loop and not the tip. Practically this
may require you to position yourself on a platform or lower the height of the
patients bed. Also having your assistant make you aware of any loop formation
while you are looking down the endoscope can be helpful.
Dont bend the endoscope beyond its natural curve as you will damage the
delicate glass bundles in the scope.
Avoid shoulder movement. All movement should come from only the wrist. Any
other movement makes maneuvering the endoscope harder and increases the
chance of loop formation.
Ensure the endoscope is properly lubricated, either with silicone spray or water
based lubricating jelly.
Ensure the endoscope is properly focused before you start.
If the view down the endoscope becomes unclear because of secretions or
condensation, gently touch the tip of the endoscope against normal mucosa
and this often clears the view. Aggressive contact with the mucosa can result in
bleeding and a substantial worsening of your view.
One can stand behind or in front of the patient when performing a fibreoptic
intubation. When standing behind the patient, relative orientation is preserved
i.e. your left is the patients left and the upper part of the visual field represents
the anterior part of the patient. This situation is reversed when standing in front
of the patient. It is a good idea to try and become familiar with both positions.








NATCAT
57
Performing an awake fibreoptic intubation

There are a few steps in performing a successful awake fibreoptic intubation (AFOI). It
is important to develop a system so that a particular step is not omitted as this may
make successful intubation that much more difficult to achieve.

Below is a suggested order of events when undertaking an AFOI. We will expand on
each step:

Pre-procedural assessment
Patient explanation
Procedural preparation
Anti-sialogogues
Positioning
Topicalisation
Sedation
Intubation

1. Pre-procedural assessment

A thorough airway examination needs to be performed prior to contemplating an AFOI.
Fibreoptic intubation is best suited to the non-emergency management of expected
difficult airways. It is particularly indicated if bag and mask ventilation and intubation
are predicted to be difficult. Commonly, fibreoptic intubation is performed if there is a
history of previous difficult intubation.

Fibreoptic intubation is best employed in cases with:

Pathology present outside the airway when the normal airway anatomy is
maintained e.g. trismus, radiation scarring, cervical spine injury, morbid obesity

Pathology in the upper airway above the larynx e.g. cellulitis, tumours, upper
airway burns


The following situations are associated with difficulties in AFOI and should be
considered contraindications to AFOI
1


Very difficult/ impossible in uncooperative patients.
Bleeding in the airway makes vision very difficult. The technique should also be
used with great caution when there are haemorrhagic lesions in the airway
because of the risk of bleeding and airway compromise
It is difficult in situations of gross airway distortion in the laryngo-pharynx e.g.
laryngeal tumours.
Fixed laryngeal obstruction e.g. from laryngeal tumours with stridor implies an
airway diameter of 4mm or less. A fibreoptic bronchoscope with an




NATCAT
58
endotracheal tube loaded on will not be able to pass through this obstruction
even if the cords were able to be identified.
Airway topicalisation and instrumentation can cause complete airway
obstruction, therefore great caution must be exercised in using this approach in
a patient who presents with significant respiratory distress or airway
compromise.

AFOI in patients with a full stomach
3

There was initially a concern about topicalising the airway to intubate patients with a full
stomach because of the concern that it may be exposing them to a risk of aspiration.
Topicalisation and awake techniques have been used extensively and apparently with
safety. As in all patients with a full stomach, sedation should be used very judiciously.


2. Patient explanation

It is essential that the whole process is fully explained to the patient in a step-by-step
manner. It should be done in a confident manner and any questions answered.
It is important to gain the patients confidence during this time as a failure to achieve
this will result in poor conditions for the endoscopist, a bad experience for the patient
and theatre staff and future reluctance of both parties to repeat this procedure in the
future, however clinically indicated.

Specific points to be addressed
5
:

1. The reasons why you are going to do an AFOI and the issue of it safety and comfort.
2. The topicalisation process including the metallic local anaesthetic taste.
3. The saw-dust like, dry throat from the glycopyrolate and local anaesthetic.
4. If any light sedation is going to be used and awareness of the procedure.
5. The timeframe for the process.
6. The in-theatre process, personnel and monitoring.
7. The pressure or slight discomfort when passing the ETT through their nose (if nasal
route chosen).
8. A coughing sensation when the endoscope is passed through the vocal cords.
9. The subjective feeling of not being able to breath when the ETT is passed through
the cords.
11. Approximate timeframe of 15 seconds before drifting them off to sleep with either a
volatile agent or iv induction agent.
12. Assure them that you will be constantly communicating and telling them what you
are doing as you proceed.
13 Obtain their consent.








NATCAT
59
3. Procedural preparation

Ensure you have the correct equipment required to perform the procedure:

a. Appropriately sized and fully functioning fibrescope
b. Epidural catheter down working port if desired
c. Attaching oxygen or suction to the suction channel as required

Most adult endoscopes have separate working and suction channels. Down the
working channel, we will discuss passing an epidural catheter while down the other it is
common practice to attach either oxygen tubing or suction.

There is no real evidence to suggest which is better or what makes AFOI easier,
however anecdotally, applying suction through a small bore channel is not very
effective at clearing your view for an AFOI. Blowing oxygen down the working channel
has the effect of blowing away secretions in close proximity from the endoscope and
essentially clearing your path, while at the same time, insufflating oxygen into the
patients airway.


d. Appropriate tube selection
4


One of the most common problems associated with performing AFOIs is that of having
difficulty in feeding the ETT over the scope, through the cords. This occurs when the tip
of the ETT moves posterior to the glottis and gets caught up on the arytenoids.
Many studies have shown that ETTs with a soft, rounded, bullet tip such as the ETT
that accompanies the Fastrach LMA or a Parker Flex-Tip tube have a much lower rate
of this complication and as a result, are much easier to insert during an AFOI.



If the above 2 ETTs are not available, the next best choice would be that of a reinforced
ETT as the tip is slightly rounder and softer than a standard ETT. Other options also
would include a warmed nasal RAE tube (to increase its malleability) or to use a MLT.
A Parker Flex-Tip
tube. Note the
rounded, bird beak
tip




NATCAT
60

For a nasal intubation, smaller endotracheal tubes are often used in an attempt to make
the intubation more comfortable for the patient and reduce trauma to the nose. For
anaesthesia, normal adult patients can be managed with a size 6 for women and a size
7 for men. In the event of a case where success via the nasal route is an absolute
priority, the smallest tube that will pass over the scope, yet that is long enough to reach
the trachea via the nose, should be used. Once the airway is secure, further plans to
change the tube can then be made, if required.

One of the other frequent problems associated with nasal intubation is the situation
whereby the ETT that has been selected, isnt able to fit through the chosen nostril
despite the fibrescope having been successfully maneuvered through the cords!
Many airway specialists have tried, with varying success, to prevent this from occurring
by:
Serially dilating the chosen nostril with nasopharyngeal airways coated in
lignocaine gel to ensure that the chosen nostril can accommodate a
nasopharyngeal airway which approximates the size of the chosen ETT
Inserting a portion of the ETT into the nasophayrnx before the fibrescope is
introduced into the nasopharynx to ensure that the ETT fits

Airway specialists tend to be divided on the above issues, however, with many airway
specialists citing the increased risk of causing an epistaxis as the main reason why they
dont perform the above maneuvers prior to a nasal intubation. They also argue that
nasopharyngeal airways are soft and pliable and do not ensure passage of a similarly
sized ETT. Rather, if performing a nasal intubation, they tend to choose the smallest
ETT as discussed above.

e. Airway conduits if required e.g. Berman airway (discussed later)
f. Monitoring as required

Before commencing, the patient should be fully monitored in an environment where the
airway can be managed in an emergency, usually an operating theatre

g. Communication of your airway plan with your anaesthetic and surgical
team

4. Anti-sialogogues
2


Anti-sialogogues reduce the production of secretions which improves the view during
fibreoptic intubation and improves sensory blockade. It is very difficult to topicalise
mucosa that is covered in secretions.
If glycopyrolate is used intravenously, it should be administered in a dose of 4mcg/kg
(max 400mcg) at least 15 minutes before commencing topicalisation. If it is being used
intramuscularly, it should be administered at least 30 minutes before commencing
topicalisation. Peak effect is at 1 hour.





NATCAT
61
5. Positioning
5


AFOI may be performed with the patient in the semi-recumbent or where not practical,
the supine position. Ideally practitioners need to be proficient at both. When using a
fibreoptic stack system, the light cable to the fibrescope is relatively short and also
relatively heavy. This becomes more noticeable when presented with a time
consuming, difficult airway. Having the equipment optimally positioned will help reduce
operator fatigue and improve success.

Semi recumbent
The preferred position for an AFOI is with the patient sitting up and the anaesthetist
approaching the patient from the front. Many patients with airway compromise are most
comfortable in this position as it avoids airway obstruction and aids drainage of
secretions. Situational awareness is improved and the operator is able to maintain eye
contact and reassure the patient throughout. Topicalisation is also more effective since
gravity aids local anaesthetic migration into the trachea and surrounding structures. If
the operator scopes right-handed (operator utilises the thumb of their right hand to flex
the scope), it is simplest to have the monitor and operator on the same side of the
patient i.e. both on the patients right. If the operator scopes left-handed, then it is
easiest to have the monitor on the right hand side of the patient whilst they stand on the
patients left.






Supine
Sitting is not always possible e.g. trauma, C-spine injury. In the supine position, the
operator approaches from behind the patient. A variation on this theme is to have a
reverse Tredenleburg so that the head is still slightly above the body and so the
anaesthetist can still be positioned facing the patient if so desired. As mentioned
previously, it is important to keep the scope tort and avoid loop formation. The trolley or
operating table should be lowered as necessary and a step or platform available if




NATCAT
62
required. It is easiest to have the monitor on the left hand side of the patient regardless
of whether they scope right or left-handed. This is because the light cable
attaches to the left side of all fibreoptic bronchoscopes. To avoid the light cable
crossing in front of the scope and patient, it is better to have the light source on the left
of the anaesthetist.

You should always practice a technique for elective AFOIs that you can reproduce if
required in an emergency scenario. This allows you to develop confidence in your
technique which you can rely on in the emergency scenario when failure will possibly
lead to a lost airway rather than just cancellation of surgery. Developing a fixed plan
with a sheet to remind you of the steps is a very valuable resource, no matter how
many AFOIs you have performed




6. Topicalisation

Along with being able to maneuver the scope, adequate topicalisation of the airway with
local anaesthetic is crucial in being able to perform a successful awake fibreoptic
intubation.
There is no perfect way to topicalise an airway and there are many methods
described. A few of the more popular methods will be described here:

a) Nebulisation of local anaesthetic

Sedation and anti-sialagogue
Nebulise 4% lignocaine either via a Hudson mask with the vents covered or via a
mapleson B circuit. Current evidence suggests that 8 - 9mg/kg of nebulised
lignocaine is safe and will not result in dangerous blood levels. However, this
dose should probably be decreased if nebulising lignocaine via the mapleson B




NATCAT
63
circuit as it appears that a lot more of the nebulised does is absorbed via this
method.







If preparing for a nasal intubation: spray the desired nostril with co-phenylcaine
spray or serially dilate the nostril with nasopharyngeal airways coated with 2%
lignocaine gel. Pledgets soaked in 2ml 5% cocaine solution and inserted into the
nasopharynx can be used in place of co-phenylcaine spray. The safe dose for
cocaine is 1.5mg/kg. Some anaesthetists ensure that they are able to pass the
desired sized nasopharyngeal airway easily before commencing nasal
intubation i.e. a size 7 nasopharyngeal airway if using a 7 ETT

b) Atomisation of local anaesthetic


Many different types of atomisers exist which convert liquid into finer particles which
allow for easier and better spread down the airway. The two commonest devices are
the:
I. DeVilbiss atomiser and
II. The Mucosal Atomiser Device (MADgic atomizer-Wolf Troy Medical INC)

The DeVilbiss atomiser

Fill the DeVilbiss atomiser with 12ml of 4 % lignocaine (bear in mind the safe dose.)
The average patient requires about 8 - 10ml. Connect the device to oxygen/suction
tubing with a small vent cut into the tubing, near to where it connects to the device.
Connect the other end of the tubing to oxygen at 8 L/min. To spray, occlude the vent
with your thumb. Spray to the posterior third of tongue, arch of soft palate and posterior
Mapleson B circuit with
nebuliser added to the circuit.
Notice the oxygen inlet on the
metal T-piece has been
covered by pink sleek tape.




NATCAT
64
oropharynx. The spray should be directed to the glottis and synchronized with deep
inspirations. Adjust the spray tip downwards as tolerated. The end point is an absent
gag reflex and voice change. Do not exceed the 8 9 mg/kg TOTAL dose of
lignocaine.





The Mucosal Atomiser Device

The MADgic device is a disposable latex-free device that releases 30 - 100 micron
particles through its nozzle. The particle is larger than that produced by the
DeVilbiss glass atomiser and may reduce the absorption of local anaesthetic from
the distal airway.

The MADgic device can either be connected to a syringe only or preferably
connected to a 3-way tap which itself is connected to a leur lock syringe containing
the desired volume of local anaesthetic and oxygen tubing. To spray turn on
Oxygen to 1 2 L/min while applying pressure to syringe plunger. Direct the nozzle
of the device as for the De Villbiss above. The end points are the same as for the
De Villbiss atomiser.
If preparing for a nasal intubation, the nozzle should be directed into the patients
nostril, the patient instructed to breathe deeply and the local anaesthetic injected
through the device.
The vocal cords can be directly topicalised via the epidural catheter method which
will be described next, if desired.






NATCAT
65



c) Spray as you go technique

A fibrescope can be used to apply local anaesthetic to the laryngeal inlet and the
tracheal mucosa. After the oral or nasal mucosa has been anaesthetised, a fibrescope
is inserted and the tip is advanced under direct vision to just above the epiglottis. Local
anaesthetic is then injected through the working channel of the fibrescope.
Insertion of an epidural catheter through the working channel is an alternative to
facilitate a diffuse spread of local anaesthetic and may reduce the local anaesthetic
requirements further as the delivery may be more accurately applied. This is described
below:

Cut the tip off an epidural catheter so that there is only a single side port left at
the end of the catheter and insert the catheter into the working channel of the
endoscope. Feed it through and once visible at the distal end of the endoscope,
pull it back slightly so that it lies within the working channel. Now secure the
catheter to the endoscope with tape at its proximal end.
When the vocal cords are in view, remove the tape holding the catheter at its
proximal end and advance the catheter slightly so that its distal end is visible at
the distal end of the endoscope. Spray 2ml of 4% lignocaine onto the cords
before passing the ETT through the cords.


d) Gargling

Gargling targets the glossopharyngeal nerve as it traverses the oropharynx and is
extremely useful for suppressing the gag reflex. After gargling, excess solution is
expelled. This prevents the excessive systemic absorption. Since this method only
anaesthetises the oropharyngeal surface, further topicalisation is required to
anaesthetise the larynx and the trachea. It is useful in conjunction with any technique
when gagging remains troublesome.

e) Recurrent Laryngeal Nerve Blocks and trans-tracheal puncture

Details of these can be found in any standard anaesthetic textbook.





NATCAT
66
Practical topicalisation regimes if the DeVilbiss Atomiser is
unavailable:
(Examples worked for a 70kg person using 9mg/kg limit = 630mg max)


Oral

Nebulise 4ml 4% lignocaine at 4L/min (encourage deep inspiration) (160 mgs)
Attach nasal prongs with 2 L/min oxygen
Atomiser (MAD) 5.5 mls 4% Lignocaine (220 mgs)
Down Scope spray 2 mls 4% Lignocaine (x 3)" (240 mgs)
Epiglottis, vocal cords left and right. Repeat as necessary if cords react.
No further LA required below the cords as this will have already trickled down from
previous sprays
Total: (620 mgs)

Nasal

Nebuliser 4ml 4% Lignocaine at 4 L/min (160 mgs)
Encourage nasal breathing. Patients should not speak to anyone until it has finished
Attach nasal prongs with 2 L/min oxygen in mouth
Identify best nostril using fibrescope (identify largest space below the inferior turbinate)
Co-phenylcaine: 3 sprays to best nostril (15 mgs)
MAD 4 ml 4% Lignocaine (160 mgs)
Patient sniffing on spraying. Aliquots of 0.5mls advancing slowly posteriorly!
MAD 2.5 ml 2% Lignocaine (Oral) (50 mgs)
U-bend the plastic so sprays are directed down towards the vocal cords
Down Scope sprays 2 ml 4% Lignocaine (x3) (240 mgs)
Epiglottis, vocal cords left and right. Repeat as necessary if cords react.
No further LA required below the cords as this will have already trickled down from
previous sprays
Total: (625 mgs)




7. Sedation

Use of sedation in patients having an awake fibreoptic intubation can improve the
patients experience and the quality of intubating conditions. However, great caution
must be exercised to avoid respiratory depression and excessive sedation. As
with any procedure one person should be responsible for sedation while the
other manages the airway. In some circumstances in which the airway is
threatened, avoiding sedation will be the best course of action. Multiple agents
have been used successfully.






NATCAT
67
a) Remifentanil

Remifentanil has gained popularity for use in sedation for fibreoptic intubation.
Remifentanil sedation alone has been demonstrated to provide better intubating
conditions than midazolam and fentanyl and it has a very rapid offset, the context
sensitive half-life of remifentanil being less than 4 minutes. It should be used at a low
dose range of between 0.05 - 0.1 mcg/kg/min.
It must however, be remembered that remifentanil is a potent respiratory
depressant and the patients respiratory rate must be closely monitored during
its use and that naloxone should be immediately available. In patients older than
65 years, a dose reduction of at least 50% may be required. It is sensible to start a
remifentanil infusion early and avoid bolus doses to prevent apnoea.


b) Fentanyl & Midazolam combination
5


Fentanyl is a highly lipid soluble opioid with a slower onset and longer duration of action
than remifentanil. It has been successfully used, often in combination with midazolam,
for conscious sedation for fibreoptic intubation. These drugs are familiar and easily
titratable, however, the synergistic effects can produce excessive sedation with further
adverse consequences.
Fentanyl should be given as a bolus dose of 1 - 1.5 mcg/kg. Midazolam can be given
as bolus dose of 25 - 50mcg/kg up to a max of 5mg. These doses are merely a guide
and may need to be modified according to the patients age and condition.
Importantly they can be reversed. Naloxone (1 - 2mcg/kg iv) is used to reverse fentanyl
and flumazenil (10 - 20 mcg/kg iv) can reverse the effects of midazolam.

c) Propofol
5


Propofol can be administered by either continuous infusion with a fixed rate or by
target-controlled infusion. The Schnider pharmacokinetic model is available in many
infusion pumps for target-controlled infusion of propofol. The initial concentration target
at the effect site is 0.5 mcg/ml. The desired level of sedation is then achieved by
changing the effect site concentration by 0.1 - 0.2 mcg/ml increments.
The short duration of action and anxiolytic properties make propofol appear, at least
initially, like a good agent for sedation for fibreoptic intubation. However, propofol
requires careful titration to avoid apnoea or airway obstruction given its narrow window
between sedation and general anaesthesia. Propofol does not have a reversal
agent.


d) Dexmedetomidine
5


Dexmedetomadine is a short-acting highly selective alpha-2 adrenergic receptor
agonist. It has both sedating and analgesic properties with minimal respiratory
suppression, even in deep sedation and this differentiates it from benzodiazepines and
opioids.




NATCAT
68
Patients sedated by dexmedetomidine are able to communicate and cooperate with the
clinician. It also has anxiolytic and antisialogogue properties, the latter a favourable
feature for fibrescope visibility.

The dosing regime is as follows:
1 mcg/kg loading dose over 10 minutes followed by 0.5 mcg/kg/hour
infusion, titrating to effect

It is worthwhile pointing out that dexmedetomidine is not rapidly titratable and has none
of the antitusive properties afforded by the opiates. Bradycardia and hypotension are
some of the potential problems with dexmedetomidine and can be seriously detrimental
to patients with cardiac disease. The initial bolus should be infused over 10 minutes to
avoid the bradycardia. Currently dexmedetomidine does not have a reversal agent.

e) Ketamine
5


Ketamine can provide analgesia and sedation without causing significant impact on the
respiratory drive. A bolus dose of 0.2 - 0.5 mg/kg can be used as a sole agent or at
reduced doses in combination with midazolam. Secretions however, may be increased
and be problematic and maintaining verbal contact with the patient becomes unreliable.

8. Intubation

Dont forget to pre-load the tube onto the endoscope before you begin!

For oral intubation, the use of a Berman airway is recommended. This is like a Guedel
airway but with a large caliber central channel and with a slit in the side. It comes in 3
lengths: 8cm for children, 9cm and 10cm for adults. Anecdotally, a smaller size tends to
be better tolerated by patients.
Following topicalisation, the Berman airway is placed in the patients mouth and they
are then asked to bite on it. It is important to ensure that it stays in the midline. The
fibrescope is then introduced into the Berman airway and the vocal cords will ideally be
visible on exiting the distal end of the Berman airway. The flange of the airway can be
tilted back and forth to improve the view.
Once the tip of fibrescope has been inserted a short distance into the trachea, the
endotracheal tube can be guided into trachea over the endoscope.
After induction of anaesthesia and securing of the ETT, the Berman airway should be
prized open (lateral opening right side, hinge on left) and removed from the mouth.





NATCAT
69


If a Berman airway is not available, the following maneuvers can assist in getting
a good view of cords:

1. Jaw thrust from the front: fingers of both hands under the angles of the
mandible, thumbs opening mouth.
2. Lingual traction: using forceps or gauze.
3. Deep breaths: asking the patient to take deep breaths appears to elevate the
tongue from the posterior pharyngeal wall and significantly improve the airway
view.

Usually jaw thrust and lingual traction performed together requires two extra operators.

Often it can be difficult to advance the fibrescope while maintaining the midline position
in an oral intubation. This can be overcome by holding the fibrescope between the
ring and little finger and advancing/withdrawing the fibrescope with the index finger
and thumb of the proximal hand.

For nasal intubations, ensure the fibrescope, tube and nostril are well lubricated and
take care not to get lubricant onto the tip of the fibrescope. The fibrescope should be
inserted and navigated posteriorly, below the inferior turbinate and along the floor of the
nose under vision. The main passage is below the inferior turbinate. Care must be
taken not to traumatize the nasal mucosa as blood in the oropharynx makes intubation
exceedingly difficult.


Correct positioning of the ETT in the trachea

The tip of the tube should be 2 cm above the carina. This can be confirmed by moving
the tip of fibrescope to the carina, gripping and holding the fibrescope with the index
finger and thumb at the proximal end of ETT. The fibrescope is then withdrawn until the
distal end of the ET tube is in view. The distance at this point between the proximal
end of the tube and where the index finger and thumb are gripping the fibrescope is the
height of the tube tip above the carina.



Berman
airway




NATCAT
70
Difficulties in advancing the endotracheal tube over the endoscope
4


Surprisingly, despite successful placement of the fibrescope into the trachea, there can
be difficulty in railroading the ETT into the trachea. This is particularly an issue with oral
intubations.
The following measures can be performed to improve the successful passage of an ET
tube over the fibrescope:

During preparation:

1. Use a relatively big scope and small tube (small gap between two)
2. Use of a flexible tube: anecdotally the ILMA tube is best.
3. Warming the tube (but no clear evidence for this)

When passing the tube:

1. Altering the airway position i.e. release of cricoid pressure, release of jaw
thrust, flexion of the neck.
2. Inserting a laryngoscope whilst advancing the tube over the scope
3. As for railroading over a bougie: rotation of the tube in an anti-clockwise
direction


























NATCAT
71
Practical hints for successful awake fibreoptic
intubation

1. Ensure that the patient consents to and understands the plan. Having an
uncooperative patient makes the whole process extremely difficult if not
impossible.

2. Be honest with the patient. Explain that with some light sedation and
topicalisation the majority of discomfort will be alleviated but that there still may
be periods of discomfort e.g.
Coughing when the endoscope passes through the cords
Pressure when the ETT is inserted through the nose.
A sensation of difficulty in breathing when the ETT is railroaded over the
endoscope through the cords.

3. Ensure that you have adequate help.

4. Ensure that you have all the required equipment ready to go. Do not proceed
until such time as this is the case.

5. Ensure that your team is aware of the plan.

6. Ensure that you have a Plan B and that your team and surgeon (if required) are
aware of this plan.

7. Try to minimize the time between topicalising the airway and commencing with
the intubation.

8. Try to be in constant verbal communication with the patient throughout the
intubation. Constant reassurance and explanation gives the patient a sense of
being in control whilst at the same time focuses their attention on you, acting
as a distraction strategy.


References

1. Mason RA, Fielder CP. The obstructed airway in head and neck surgery.
Anaesthesia 1999; 54:625-8
2. Hung O, Murphy MF. Management of the Failed and Difficult Airway,
Second edition, pg 53, McGraw-Hill Medical
3. Ovassapian A, Krejckie TC, Yelich SJ, Dykes MHM. Awake fibreoptic
intubation in the patient at high risk of aspiration. BJA 1989;62:13-16
4. Asai T, Shingu K. Difficulty in advancing a tracheal tube over a fibreoptic
bronchoscope: incidence, causes and solutions. BJA 2004;92:870-81
5. Topicalisation & Sedation for Awake Fibreoptic Intubation iPhone App,
Bradley et al, iPhone APP Store




NATCAT
72







MODULE 3

Airway Assessment &
Practical Airway
Management










NATCAT
73
The Focused Airway Examination

A difficult airway can be defined as an airway through which the provision of safe
oxygenation and/or ventilation using conventional means is known or predicted to be
difficult. Generally, conventional airway management falls into one of 3 broad
categories:

Bag mask ventilation (supraglottic)
LMA insertion (supraglottic) or
Intubation via direct laryngoscopy (infraglottic)

The surgical airway, the fourth category of airway management is generally reserved
for times when all 3 of the above methods are predicted to be difficult (the awake
tracheostomy or cricothyroidotomy done under local anaesthetic), failure of the above 3
methods or for prolonged intubation in ICU.

The aim of an airway examination is, therefore, to try and identify those patients
who have a known or predicted difficult airway and to then manage them as such
by:
Ensuring that the appropriate personnel/ help/ advice is available if
required
Ensuring that the appropriate equipment is available
Moving to an appropriate location if indicated
Reviewing the need for intubation

Once we are able to identify a patient with a potentially difficult airway, we can better
develop an appropriate airway plan. Managing an expected difficult airway for
which we have planned is far more desirable then having to manage an
unexpected or unrecognised difficult airway with a desaturating patient.

The basis of the focused airway exam that we advocate is to divide the exam into the 4
separate parts: the first 3 dealing with the 3 conventional airway management
techniques i.e. bag-mask ventilation, intubation and LMA insertion, the final dealing with
the surgical airway. Doing this enables one to focus on each individual airway
management technique such that by the end of the exam, one may be able to
predict which of the airway management techniques may be difficult to execute.
Multiple predictors of difficulty within 2 or 3 of the management techniques should alert
one to the real possibility of potential airway difficulty.

There are many mnemonics that have been developed to try and assist clinicians to try
and remember the various signs that may predict a difficult intubation (LEMONS),
difficult bag-mask ventilation (MOANS), difficult LMA ventilation (RODS) or difficult
cricothyroidotomy (SHORT). However, rather then using mnemonics that need to be
memorised, we advocate simply understanding the specifics of the airway maneuver




NATCAT
74
being undertaken and what is trying to be achieved. With this approach, one can
predict difficulty by understanding the maneuver rather then by rote learning.

We will now review the signs associated with difficulty pertaining to each individual
airway management technique. We will then discuss possible ways to overcome some
of these difficulties and then provide an example of a systematic airway exam that can
quickly be performed by the bedside










































NATCAT
75
Predictors of difficult bag-mask ventilation

The features predictive of difficult bag-mask ventilation can be remembered by
understanding what is required to achieve successful bag-mask ventilation, namely:

1. A good mask seal on the face
2. A patent oropharynx.



1. History of difficult bag mask ventilation
When and why?

2. Difficulty achieving a good seal
The presence of a facial beard
Edentulous patient
Age>55/ loose check skin tone
Facial trauma- distorted anatomy

3. Indicators of potential oropharyngeal obstruction:
Obstructive sleep apnoea/ severe snoring
BMI>30
Mallampati III or IV
Severely limited jaw protrusion
Neck radiation/ burns




NATCAT
76
Predictors of a difficult intubation

History and presentation

A history of difficult intubation - previous anaesthetic notes can be helpful in this
case. Important facts to look for:
o When was the difficult intubation?
o Why was it difficult?
o Who was performing the intubation?
o Where was it being performed?
Presence of a condition associated with a difficult intubation. Be aware of any
syndrome and the possibility that it may be associated with a difficult intubation
e.g. Pierre Robin Syndrome
Trauma to the airway- blood, disrupted anatomy, tracheal injury

Features of a difficult intubation

Remembering the features that may predict a difficult intubation is easy if you consider
the steps involved in performing successful direct laryngoscopy and intubation. To
perform successful laryngoscopy, one needs to be able to:

1. Insert the laryngoscope into the mouth
2. Move the tongue to the side to be able to see past it
3. Place the tip of the laryngoscope into the vallecula and lift the epiglottis to be
able to see the vocal cords
4. Pass the endotracheal tube through the cords

All this needs to be done in a stepwise fashion. It is difficult to successfully move
onto the next step of laryngoscopy if the preceding step has not been
successfully completed.

Similarly, this logical, stepwise process can be used as the basis of our airway exam to
determine the potential difficulties associated with PLAN A by identifying the features
which may predict difficulty at a particular step in the laryngoscopy and intubation
process. The features that are associated with each step are described below:







NATCAT
77


1. Difficulties in introducing the laryngoscope
! Mouth opening/ inter-incisor distance <3cm.
! Long upper incisors

2. Overcrowding within the mouth obstructing view
! A high arched or narrow palate
! Big tongue
! Foreign body

3. Predictors of a difficult view of the larynx
! A Mallampati score of 3 or 4.
! Receding chin/ thyromental distance <6cm.
! Inability to protrude the mandible beyond the maxilla
! Limited neck extension: <20 degrees
! A neck circumference >44cm.

4. Laryngeal oedema/pathology- difficulty passing tube
! Stridor/ difficulty swallowing secretions
! Hoarse voice

The presence of signs suggesting laryngeal oedema/pathology should alert one
to the very high possibility of a difficult intubation and potential difficult airway!!



1
2
3
4
3




NATCAT
78
Mallampati Classification









This is performed with the patient sitting up, with maximal mouth opening, while protruding
their tongue without phonation

Class 1 Faucial pillars, soft palate and uvula visible
Class 2 Faucial pillars and soft palate visible
Class 3 Soft palate visible only
Class 4 Soft palate not visible

Predictor of difficulty: Class C>B>A





NATCAT
79
Thyromental Distance



















The distance from the tip of the chin to the thyroid cartilage with the neck fully
extended. A distance of <6cm should alert one to the possibility of difficulty.





NATCAT
80
Predictors of difficult LMA ventilation

The features predictive of difficult LMA ventilation can be remembered by
understanding the steps involved in achieving successful ventilation via a LMA.



1. A history of difficulty in placing a supraglottic device
When and why?

2. Difficulties in inserting the device
Limited mouth opening - approximately 2 cm is required for LMA insertion

3. Difficulties in the device sitting correctly
Abnormal airway anatomy increases the risk of the device not sitting well.
Absence of teeth

4. Difficulties in ventilating
Laryngeal obstruction/pathology
A BMI >30 may affect the ability to ventilate
Non compliant lung mechanics (restrictive or obstructive lung disease)







NATCAT
81
Predictors of difficult cricothyroidotomy

1. A history of previous difficult cricothyroidotomy

2. A flexed neck preventing access to the cricothyroid membrane

3. Thickened skin on the anterior neck
Burns
Neck radiotherapy
Neck scarring

4. Distorted/impalpable anterior neck anatomy
Obesity
Neck haematoma, tumour, subcutaneous collection
Neck radiotherapy


On completion of the airway exam, one should review and be aware of the positive
predictive features of difficulty that are present for each airway management technique.

There is no magic number of positive predictive features of difficulty above
which managing the airway in that particular manner will definitely be difficult.
Rather, the more positive predictive features of difficulty that are present within a
specific technique, the more likely that that particular technique will be difficult to
carry out
In a large study performed in 2006
5
, if a single risk factor for difficult bag-mask
ventilation was present, that patient was 6.3 times more likely to be a difficult bag mask
ventilation compared to a patient with no predictive features present. Similarly, a patient
with 3 predictive features of difficult bag-mask ventilation factors was 19.6 times more
likely to be a difficult bag-mask compared with a patient with no positive features

Multiple positive predictive features of difficulty that are present in more then one
airway technique should alert one to the high likelihood of a difficult airway.













NATCAT
82

The Predicted Difficult Airway

Once a potential difficult airway has been identified it is imperative to:





How difficult and why? Which components of the airway
strategy are likely to be difficult?

How urgent?

Do I need help? Should I be doing this, right here, right
now? Can I call a senior colleague?

IF I HAVE TO PROCEED, HOW CAN I INCREASE MY
CHANCES OF SUCCESS?

We will now consider some of the more common technical issues associated with each
form of airway management and suggest a few possible solutions.


& THINK!




NATCAT
83
Troubleshooting Common Technical Airway Issues

Predicted difficult bag-mask ventilation
Problem Issue Solution
1 Difficulty achieving a
good seal


! Ensure correct size mask!
Beard

! Tegaderm/ tape over
beard
! Shave beard
Edentulous ! Keep dentures in if
possible
! 2 person technique
pharyngeal airway

2. Age>55
Poor cheek tone
! 2 person technique
pharyngeal airway
2 Features of potential
oropharyngeal
obstruction
" Early pharyngeal airway &
2 person technique
















NATCAT
84
Predicted difficult intubation
Problem Issue Solution
1 Difficulty in
introducing a
laryngoscope

Prominent front
teeth
! Ensure good head position:
neck flexion at C6-C7,
head extension at C1-C2,
tragus in line with sternum
! Try a smaller Macintosh
blade,
! Try a straight blade
Small mouth
opening: Trismus
! Muscle relaxant

Small mouth
opening: Physical
obstruction
CAUTION!!
2 Overcrowding within
the mouth

Big tongue ! Ensure good Macintosh
blade technique,
! Try a videolaryngoscope
bougie
! Try a straight blade
3 Predictors of a difficult
view of the larynx
" Ensure proper positioning
" Ensure good technique
with Macintosh blade
bougie +- external
laryngeal manipulation
" Try a Videolaryngoscope
" Try a McCoy blade
bougie external laryngeal
manipulation
" Try a Straight blade





NATCAT
85

Problem Issue Solution
4 Laryngeal
oedema/pathology

CAUTION!!
Ideally done in theatre!!!
" May need a combination
of the above to view the
larynx
" Smaller tube may be
necessary
microlaryngoscopy tube is
ideal if severe glottic
narrowing suspected

Predicted difficult laryngeal mask ventilation
Problem Issue Solution
1 Difficulty in inserting
the device
Mouth opening <2cm

! CAUTION!!
! Ensure cuff fully deflated,
flat and lubricated on the
dorsal cuff surface
! Try a classic LMA or
smaller LMA size
2 Device not sitting
correctly
Abnormal airway
anatomy


! CAUTION!!!
! Inflate/deflate cuff slightly,
! Insert/ remove LMA
slightly
! Jaw thrust
Edentulous ! Hold/ secure LMA in
midline
3 Difficulties in
ventilating
Laryngeal
obstruction


! CAUTION!!!
! Inflate/deflate cuff slightly,
! Insert/ remove LMA
slightly
! Jaw thrust
Raised BMI>30
Poor lung
compliance
! Use ILMA or Proseal
! CAUTION with BMI>>30




NATCAT
86

An Example of a Systematic Airway Exam

The following is an example of a thorough systematic airway exam that can be done in
a very short time.

An assessment of a patients airway is not unlike any other clinical patient assessment
in that it should contain:
A history
An examination
A review of special investigations

History

On history we want to assess for:
A history of previous difficult airway management/ intubation (dont forget to
check the patients previous anaesthetic chart if present.)
The presence of any condition known to be associated with a difficult airway
*(see list at the end of this module)
Any recent history of:
1. Voice change
2. Difficulty swallowing
3. Stridor
4. Inability to lie flat

Examination

This should be done in a structured manner and with the patient sitting up:
It should include examination of the:

1. Patients general features
2. Patients airway with their mouth open as wide as possible
3. Patients airway with their mouth closed

The features which may predict a difficult airway if found on examination are listed
below:










NATCAT
87
Airway examination red flags as discussed earlier

On general examination look for:

1. Receding jaw
2. Facial hair
3. Short thick neck (bull neck)
4. Any sign of radiotherapy in the peri-oral or neck region
5. Any neck mass e.g. goiter
6. A syndromic appearance or airway deformity
7. High BMI


With the mouth open as wide as possible look for:

1. Inability to open the mouth > 2-3cm (inter-incisor distance)
2. Prominent upper incisors
3. Large tongue
4. Obvious intra-oral mass e.g. tumour, abscess
5. High arched palate
6. Mallampati class 3 or 4

With the mouth closed look for:

1. Thyromental distance <6cm (ensure neck is fully extended)*
2. Inability to protrude the mandible beyond the maxilla
3. Painful or limited neck extension/flexion

Special investigations:

A recent X-Ray, CT scan or MRI may help define potentially difficult anatomy and guide
management.






NATCAT
88
Examples of Diseases / Conditions that may be Associated with a Difficult Airway
Congenital Syndromes
Pierre Robin syndrome
Goldenhar syndrome
Treacher-Collins syndrome
Downs syndrome
Achondroplasia
Turner syndrome
Mucopolysaccharidoses

Trauma
Trauma to face / neck / larynx / jaw /
oropharynx
Burns to face / neck
Cervical spine trauma

Infections
Quinsy / peritonsillar abscess
Epiglottitis
Retropharyngeal abscess
Neck infections



Endocrine disorders
Acromegaly
Thyroid disease

Neck swellings / masses
Tumour
Bleeding

Known airway disorders
Foreign Bodies in / near airway
Tracheal / Laryngeal disorders e.g.
laryngeal oedema, laryngomalacia,
tracheal stenosis

Chronic Inflammatory/Connective
Tissue Diseases
Rheumatoid arthritis
Ankylosing spondylitis
Scleroderma

Post-Radiation therapy of
face/neck/airway
Obesity
Pregnancy








NATCAT
89

Practical Airway Management

In this section we will present the Difficult Airway Society (DAS) algorithms for the
unanticipated difficult airway. We will also discuss by means of problem based learning
scenarios, some of the issues involved in planning for the management of an
anticipated/ known difficult airway and end with a structured approach to solving the
problem of difficult ventilation through an ETT/tracheostomy tube.

The Unanticipated Difficult Intubation

The DAS algorithms set out below, gives a recommended plan of action for the
unanticipated difficult intubation for both routine and rapid sequence inductions
(RSI). The last DAS algorithm deals with a failed intubation associated with
increasing hypoxaemia and difficult ventilation. This algorithm should take
precedence whenever a hypoxaemic situation arises.

The algorithms for the unanticipated difficult intubation are logical and simple and
based on the following 2 underlying assertions:

1. That oxygenation is the priority if difficulty is ever encountered
2. That there are only 4 ways in which an airway can be managed i.e. bag-mask
ventilation, intubation, LMA ventilation and a surgical airway


Although the algorithms are simple, it is vital that you familiarise yourself with them
such that you are able to perform them in times of stress, when they will invariably be
required to be implemented and also bear the following points in mind:


1. An airway assessment SHOULD ALWAYS BE PERFORMED before any airway
plan is executed. The airway assessment should be used to try and predict a
potential difficult airway and enable one to formulate plans to overcome the
potential difficulty.

2. The airway strategy must be communicated between all team members before
any airway plans are commenced.

3. Pre-oxygenation is an integral part of PLAN A and should be optimised before
intubation is attempted.





NATCAT
90
4. Following a failed intubation attempt, always ensure the ability to oxygenate
via bag mask ventilation before attempting further intubation attempts.

5. Call for help early

6. Before any subsequent intubation attempt, try to ascertain why the initial
intubation attempt failed and attempt to rectify it. AVOID repeated attempts at
intubation without changing any aspect of your intubation technique or
equipment to help overcome the difficulty

7. No more than 3 attempts at intubation in total

8. People die from a lack of oxygenation, not because a particular device or
plan has failed. Avoid becoming fixated on a particular plan. If a plan has
failed, move quickly onto the next plan.


With reference to the unanticipated difficult intubation algorithms, a quick comment
regarding the place/ role of videolaryngoscope or rigid fibreoptic intubation aids is now
appropriate. The current guidelines do not specifically mention these devices and
where they fit in when an unexpected difficult intubation is encountered. However,
current opinion would suggest that, assuming the person managing the airway is
familiar with the device they are intending to use, they should be incorporated into the
Plan A: Initial tracheal intubation plan, either as the primary intubating device or as a
backup device.

The CICV algorithm discussed during the NATCAT course differs slightly from that
shown on the above-mentioned DAS algorithms. The CICV algorithm presented after
the DAS algorithms is taken from Heard et als article, which has been discussed in
detail in module 1. Dr Heard has formulated the algorithm to assist anaesthetists in
performing a cricothyroidotomy in a CICV scenario. We encourage you to read the
article from which the algorithm was taken.









NATCAT
93





NATCAT
94


The following algorithm is that taken from:
Heard AMB, Green RJ, Eakins P. The formulation and introduction of a cant intubate, cant
ventilate algorithm into clinical practice. Anaesthesia 2009;64:601-608

This algorithm assumes that you have reached a CICV situation (Plan D) after having followed
the: Failed intubation, increasing hypoxaemia and difficult ventilation in the paralysed, anaesthetised
patient: Rescue techniques for the can't intubate, can't ventilate situation DAS algorithm shown on
the previous page.
As explained in module 1, it gives some guidance as to how to go about securing a surgical airway in a
CICV situation.



The Anticipated Difficult Airway

Much like the unanticipated difficult airway, formulating an airway plan for the
anticipated difficult airway relies on having a Plan A with a Plan B and even a Plan
C if the earlier plans were unexpectedly to fail.

In the expected difficult airway, 3 basic choices exist as to how to achieve a definitive
airway i.e. placement of a tracheal tube. Obviously not all the methods listed below will
be viable options in all clinical scenarios encountered, hence the need to formulate a
specific airway plan, case by case. The 3 basic choices are:

1. With the patient awake and spontaneously breathing:
Awake fibreoptic intubation (AFOI)
Direct laryngoscopy and intubation following full topicalisation
Intubation via supraglottic devices following full topicalisation
Cannula secured through the cricothyroid membrane
A controlled surgical tracheostomy performed under local anaesthetic

2. With the patient asleep and spontaneously breathing:
Gas induction and direct laryngoscopy
Gas induction and blind nasal intubation

3. With the patient asleep and spontaneous ventilation ablated:
A rapid sequence induction using suxamethonium or Rocuronium (with
sugammadex available)
IV induction, test bag-mask ventilation and if able to ventilate, administration of a
short acting muscle relaxant. If unable to bag-mask ventilate, wake the patient.
Be careful of this plan fraught with danger!

When formulating an airway plan in such cases, it is important:

To identify the main issues relating to the airway which may
direct the choice of technique used e.g. aspiration risk, blood in
the airway, limited mouth opening
To not make the situation worse then it was before the plan was
initiated.
To ensure that the technique chosen is within the technical
ability of the airway operator and that all the appropriate
equipment and assistance is available.
To ensure that all members of the anaesthetic team and
surgical team (if involved) are aware of the plan that has been
formulated.






NATCAT
97
The following 2 scenarios are based on real cases. The suggested
answers/management plans given below are by no means all inclusive or the only
possible options. They are just some of the more commonly used techniques and only
some of the options available.


Scenario 1

You are the anaesthetist on call at a regional hospital and are called to the ED to
assess a 53 year old male presenting with a 10 day history of a dental abscess which
needs to be drained that evening.
Besides a raised BMI, he has no significant medical or surgical history of note. He is
anxious and clearly in pain. He last ate 20 hours ago but feels nauseated.

On examination of his airway:

No stridor audible
There is swelling over the angle of his right mandible
Painful limited mouth opening around 2.5 - 3cm
You are unable to assess his Mallampati score
TMD 7.5cm
Unable to protrude his mandible beyond his maxilla
Normal range of neck movement

What the airway issues related to this patient?

The main issues are:
the need for a general anaesthetic in a patient with limited mouth opening
the possibility of pharyngeal oedema secondary to inflammation which may
complicate airway management
a fasted but nauseated patient-> unclear aspiration risk
a procedure where the anaesthetist and surgeon must share the airway

What is a possible airway management plan for this patient?

Plan A: Intubation
Ideally, intubation would be the optimal way to manage his airway based on the issues
mentioned above. The application of cricoid pressure would depend on your
assessment of his aspiration risk. It should be applied once consciousness is lost.

Plan B: Bag-mask ventilation and wake the patient/ LMA insertion
An alternative, if bag-mask ventilation looked/ was easy, would be to place a LMA. If
placement was successful and an adequate airway obtained, it could be used as a
conduit for intubation.






NATCAT
98
Plan C: LMA insertion
Should result in the following of the DAS algorithm i.e. placement of LMA and wake the
patient.

Plan D: Failed LMA-now a CICV scenario- Emergency cricothyroidotomy


The use of a LMA as a Plan A in this case would not be ideal for the following
reasons:
The LMA is not a definitive airway. Intra-operative loss of the airway, which is
already difficult, shared and now bloody from the surgery could be catastrophic.
The LMA does not protect against aspiration.

How should this patient be intubated?

Broadly speaking, intubation in this patient can be achieved in 2 ways:
1. Intubation while the patient is maintaining his own spontaneous
ventilation.
2. Intubation following induction and the use of a short acting muscle
relaxant.

Because of the uncertainty surrounding his airway and the ease of intubation, it would
be preferable to keep him spontaneously ventilating thereby allowing him to be woken
from anaesthesia if intubation is difficult.

How can intubation be performed whilst the patient is maintaining his own
spontaneous ventilation?

This can be done with the patient either:
1. Awake via an AFOI or
2. Asleep via a gas induction

How is a gas induction and intubation performed?

A gas induction is performed, by allowing a patient to spontaneously breathe on a
circuit containing volatile gas and oxygen. The volatile agent needs to be non-irritant
and well tolerated and so for this reason, Sevoflurane is the volatile of choice for gas
inductions. (Halothane is the other volatile agent that can be used for gas inductions.)

The goal of a gas induction in an anticipated difficult airway is to get the patient
anaesthetised deeply enough, whilst maintaining their own spontaneous ventilation, to
enable laryngoscopy and intubation. The benefits of this are:
No bridges have been burnt: -the patient continues to breathe spontaneously
and so can be woken if laryngoscopy/intubation is difficult.
If the airway is easily controlled, it may allow for an asleep fibreoptic intubation
or intubation via a LMA.




NATCAT
99
Practically, there are a few issues which the airway operator needs to be aware of
when performing a gas induction:

1. As the patient gets more anaesthetised, they may go through a stage of
irregular breathing and breath holding. The airway may also be lost as
some pharyngeal tone is lost. This may require the operator to assist their
ventilation and use a pharyngeal airway. It is important not to take over
their ventilation completely as the benefits of a spont vent induction
will have been lost. If test bag-mask ventilation is performed, it should
be brief.

2. Introduction of a pharyngeal airway before the patient has reached a
sufficient depth of anaesthesia may lead to coughing and laryngospasm.
Topicalisation of the airway before commencing the gaseous induction
may decrease the incidence of this as will prophylactic placement of a
pharyngeal airway. Nasopharyngeal airways tend to be better tolerated
then oropharyngeal airways but have a greater risk of causing epistaxis.

The method described below is an example of just one of the ways of performing a gas
induction:

Preparation
Prepare the nose with topical local anaesthetic e.g. cophenylcaine so that a
nasopharyngeal airway can be passed in the early stages.
Consider if it is appropriate to topicalise the airway i.e. larynx. Topicalisation of
reactive airways with stridor may precipitate full obstruction and is best avoided.
Avoid opiates because of their respiratory depressant effects.
Ensure an airway plan is formulated.

Conduct of gas induction
100% oxygen.
Start with a low concentration of Sevoflurane and gradually increase.
Anecdotally, this decreases the incidence of breath holding.
As the patient deepens, assist their ventilation if required. Briefly attempt to test
bag-mask ventilate (if desired) and then continue to allow spontaneous
ventilation.
Loss of the airway may occur. This may require a nasopharyngeal or
oropharyngeal airway.
It often takes a prolonged period to achieve a sufficient depth of anaesthesia,
especially in a partially obstructed airway. Signs of a sufficient depth of
anaesthesia include:
1. Regular small tidal volumes
2. Abdominal breathing
3. Pupils are now central (rather than diverging) and pupils are mid-size
rather than dilated or pin-point.

Attempt laryngoscopy:




NATCAT
100
1. If a good view is obtained: intubation can normally be performed while
spontaneously breathing. If confident that bag-mask ventilation is possible and
that intubation should be easy, consider a dose of suxamethonium which will
provide the best intubation conditions.
2. If poor view but good airway: consider asleep FOI or placement of LMA and
intubation through it.
3. If poor view and poor airway, wake patient

What happens if the airway is lost midway through the gas induction?

Try and hand ventilate while optimising the airway i.e. maximal airway
maneuvers, airways, CPAP. Controversial as to whether to deepen or lighten
anaesthetic.
If unsuccessful, have an attempt to intubate.
If unsuccessful, follow the DAS algorithm for unexpected difficult intubation


How would the plan change if the clinical risk of aspiration was high e.g. he had
eaten recently?

A discussion with the surgeons would be appropriate to determine the urgency
of surgery and the potential to delay surgery till the fasting guidelines had been
met.
If the procedure was an emergency, the same airway plan would apply:
1. AFOI: as mentioned in module 2, topicalisation and awake techniques in
patients at high risk of aspiration have been used extensively and
apparently with safety. Positioning the patient head up 30 degrees may
help in decreasing the risk of passive reflux. As in all patients with a full
stomach, sedation should be used very judiciously.
2. Gas induction: After explaining the process of cricoid pressure to the
patient, it can be applied at the initial phase of the gas induction.
A gas induction with the patient in a left lateral position is often
described for such a scenario but it should not be undertaken for the
first time when dealing with a difficult airway











Scenario 2




NATCAT
101

You are in PAC assessing a very anxious 57-year-old female patient for your list
tomorrow. She is having a right neck dissection for a recurrence of a floor of mouth
tumour. She complains of slowly worsening stridor over the past few weeks, which is
present at rest but worse on exertion. She has also noticed some voice change
recently. The rest of her history is as follows:

Past History
Floor of mouth squamous cell carcinoma. Diagnosed 2yrs ago for which she
received surgery and radiotherapy
Diabetes
Ex. Smoker quit 2 year ago at time of initial diagnosis
Hypertension


Past Surgical history
Tongue resection and left neck dissection 24 months ago: no anaesthetic
problems, grade one laryngoscopy.
Lap cholecystectomy
Appendix

On examination:
Mouth opening 4-5 cm
Mallampati 2
TMD 6 cm
Unable to protrude mandible beyond maxilla
Sats 94% on room air

What are her issues that will affect your airway management plan for this case?

The presence of stridor at rest along with some change of voice suggest a
laryngeal lesion
Previous significant airway surgery
Previous radiotherapy to her airway

How does the presence of stridor affect your plan?

The presence of stridor at rest implies that there is a reduction in the airway diameter of
at least 50%

Stridor can result from a lesion in 3 potential areas in the airway:
1. Supraglottic
2. Laryngeal
3. Subglottic

Before formulating a plan, we need to establish at what level the lesion is as this will
affect our plan.




NATCAT
102

What investigations should this patient have before surgery?

This patient requires:
A nasal endoscopy
CT scan of the airway

A nasal endoscopy, is performed by an ENT surgeon as an outpatient or on the ward. It
requires only topicalisation of the nose and involves the patient sitting up and viewing
the larynx from above through the nose, using a 2.7mm short endoscope. No
topicalisation of the larynx is required.
From this investigation, the ENT surgeon can give us a good idea of what the larynx
looks like i.e. size, oedematous, visibility
If an adequate view of the larynx cannot be obtained via nasal endoscopy, it is likely
that tracheal intubation will be difficult.

A CT scan is helpful in assessing the subglottic region. With the patients history of
radiotherapy to the neck, this may show us some subglottic stenosis or narrowing if
present.

A nasendoscopy and CT scan of the airway have already been performed. The
nasendoscopy shows an easily visible larynx that is narrowed secondary to
tumour infiltration. The CT shows no subglottic narrowing. What is your airway
plan?

Plan A:

Keep the patient ventilating spontaneously and perform a gas induction with the ENT
surgeons scrubbed and ready to perform a tracheostomy/cricothyroidotomy if plan A
fails.

Plan B

A tracheostomy/cricothyroidotomy performed by the surgeons. A LMA could be inserted
while this is being performed to ensure ongoing oxygenation

Why is a rapid sequences induction and the use of suxamethonium not a good
option in this case?

The use of a muscle relaxant in the setting of a compromised airway i.e. stridor is
not one that should be taken lightly. Removing the patients own spontaneous
ventilation in trying to intubate a potentially difficult airway has a high chance of turning
a stable situation into an emergency one!!








NATCAT
103
Why is an AFOI not a good option in this case?

An AFOI is not a good choice for a laryngeal lesion causing stridor because of the
following:
A patient with stridor is very unlikely to be calm and the use of sedation in a
patient with a narrowed airway is dangerous
Often the anatomy would have been affected by the lesion making a AFOI even
more difficult
Tumours are friable and prone to bleeding which will make an AFOI almost
impossible
The larynx is narrowed which may result in a corkinbottle situation where the
fibrescope may occlude the whole airway even before the ETT is railroaded over
it. This will lead to a very agitated patient and hypoxia if not removed
immediately.

I refer you to a great article on the subject:
Advanced upper airway obstruction in ENT surgery, Rees L, Mason R, BJA CEPD
reviews, volume 2 number 5, pg 134-138




NATCAT
104
An approach to the problem of difficult or impossible
ventilation through an ETT or tracheostomy tube

If high pressures are required to ventilate a patient through an ETT or tracheostomy
tube, then it is important to identify the cause and implement treatment, if required.

For either an ETT or tracheostomy tube, the potential sites of the problem can be
divided into 3 areas:

1. The circuit proximal to the ETT/tracheostomy i.e. the ventilator, the circuit
tubing and the filter.
Kinked circuit tubes, blocked filter

2. The ETT/tracheostomy tube
Incorrect tube position e.g. endobronchial intubation or oesophageal
intubation
Blocked tube e.g. kinked tube, herniated cuff, patient biting on
tube(not tracheostomy)

3. The patient
Within the airways e.g. foreign body, mucous plug, atelectasis,
bronchospasm, pulmonary oedema
Within the lung interstitium e.g. lung fibrosis
Outside the lung e.g. pneumothorax, coughing, increased intra-
abdominal pressure

When faced with such a problem, it is vital to have a structured approach with the
above potential causes in mind.


Approach to the problem of difficulty ventilating through an endotracheal tube
1,2


1. Exclude the ventilator, the circuit and the filter
This is done by disconnecting the circuit at the patients ETT (including the filter)
and then connecting to an air viva:
If unresolved: then problem is in the ETT or the patient so proceed through the
problem-solving pathway.
If resolved: then problem is in equipment above the ETT.

2. Exclude the ETT as the problem
This can be done by:
Checking tube depth at the lip to ensure the tube has not moved.
Performing laryngoscopy if it is possible that the tube is in the oesophagus.




NATCAT
105
Suctioning down the catheter to try and ascertain the patency of the tube or
presence of a mucous plug.
Deflating the cuff to exclude cuff herniation.
If there is any concern about the ETT, remove it, bag-mask ventilate and reintubate
with a new tube.

If the ETT seems OK, rapidly consider patient causes.

3. Consider patient causes
This can be done by:
Feeling that the trachea is midline
Auscultating the chest, listening for a silent chest, wheeze, creps
Look for patient coughing or bucking
Look for signs of anaphylaxis

If no obvious patient problem, reconsider the possibility that the tube is blocked or
incorrectly positioned and remove the ETT.

In patients in whom replacing the ETT will be difficult because they are difficult to
intubate or because of poor access to the patient, then passing a fibrescope down the
tube to define the problem will be a more sensible way to proceed before removing the
ET tube. Alternatively, inserting a Cook exchange catheter before extubating may
enable ongoing oxygenation and assist in a future intubation attempt.

















NATCAT
106

Approach to the problem of difficulty ventilating through a
tracheostomy tube
3,4

The approach is very similar to that for an ETT.

1. Exclude the equipment above tube
Disconnect anything attached the tracheostomy tube and connect an air viva to
the tracheostomy tube
If unresolved: then problem is in the tracheostomy tube or patient so proceed
through the problem-solving pathway.
If resolved: then problem is in the equipment above the tube.

2. Exclude tube problem
Remove the inner cannula if one is present. Ensure speaking valves/HME are
also removed.
Suction down tracheostomy tube.
Deflate cuff and suction again.

If tube is the problem: it needs to be removed and the patient ventilated with an air
viva via bag-mask while occluding the stoma.
A decision can then be made on how to proceed i.e.
Intubate orally if possible
Reinsert tracheostomy tube

If the tube seems OK: very rapidly consider patient causes. If a patient cause cannot
immediately be found then the tube may still be have to be removed


3. Consider patient causes
As for difficulty ventilating via an endotracheal tube.

In the following situations below, it may be worth considering an immediate
fibreoptic examination down the tracheostomy tube before removing the tube, as
in these circumstances, reestablishment of a patent airway after tube removal may be
very problematic:
Non patent airway i.e. pt post laryngectomy
Difficult upper airway especially in the setting of a newly formed tracheostomy
stoma. Tracheostomy sites older then 7-10 days are likely to be well
established while stomas less then 3 days old are poorly established and
the risk exists of losing the stoma tract once the tube is removed. To decrease
the risk of this occurring, a bougie or Cook catheter should always be used to
change a tracheostomy tube.







NATCAT
107



References

1. Watterson L. Effective Management of Anaesthesia Crises; instructors manual.
July 2003 (version 1.3)
2. Gaba DM, Fish KJ, Howard SK. Crisis management in anesthesiology. Churchill
Livingstone. 1994
3. Cameron T ed. Tracheostomy Care Resources: A Guide to the Creation of Site
Specific Tracheostomy Procedures and Education. Austin Health 2006
4. Russell C, Matta B eds. Tracheostomy, a multiprofessional handbook.
Greenwich medical 2004
5. Incidence and Predictors of Difficult and Impossible Mask
Ventilation, Kheterpal et al. Anesthesiology 2006; 105:88591




































NATCAT
108
Equipment Reference Sheet

Endotracheal tubes

All endotracheal tubes (except DLT): size is of the internal diameter in mm

Double Lumen Tubes (DLT): size is of the external diameter in French gauge (Fr).
1Fr = 0.33mm

Sizes of the internal lumens of DLT (as a guide to fibrescope/bougie use)
3
:
Size 35Fr = 4.3 - 4.5mm internal diameter (tracheal>bronchial)
Size 37Fr = 4.5 - 4.7mm internal diameter (tracheal>bronchial)
Size 39Fr = 4.9mm internal diameter
Size 41Fr = 5.4mm internal diameter

Arndt endobronchial blockers:
7Fr blocker needs >= size 7.5 ETT using a 4mm scope
9Fr blocker needs >= size 8 ETT using a 4mm scope

Laryngeal Masks

cLMA sizes:
Size 3 able to accommodate a size 5.5 ETT easily or 6 with difficulty
Size 4 able to accommodate a size 5.5 ETT easily or 6 with difficulty
Size 5 able to accommodate a size 7 ETT

ILMA sizes
Sizes 3,4,5 all able to accommodate up to size 8 ILMA ETT


Fibrescopes

Fibrescope sizes: Sizes based on the external diameter of the scope
4mm scope suitable for placing DLT and intubating through a LMA
5.2mm scope invariably requires a 7.5mm ETT for successful intubation

Bougies/intubating catheters

Sizes based on external diameter

Cook Frova bougie: a blue 65cm long bougie with 4.7mm external diameter.
Suitable for ETT sizes 5.5+
Eschmann gum elastic bougie (adult): a beige colored bougie. Standard
length is 60cm with a15Fr (5mm) external diameter. Suitable for ETT sizes 6-
11. Not suitable for DLT insertion




NATCAT
109
Eschmann gum elastic bougie (paed): a paediatric bougie is also available.
70cm long, 10Fr (3.3mm) external diameter and is suitable for DLT insertion
Cook exchange catheters: 83 - 100cm long, common adult size has 19Fr
(6.3mm) external diameter: suitable for size 7+ ETTs.
For exchange of a DLT, smaller sizes are required:
11F (3.7mm) external diameter: appropriate for DLT size 35 & 37Fr
14F (4.7mm) external diameter: appropriate for DLT size 39 & 41Fr
Aintree Intubating catheter: 56cm long, internal diameter of 4.8mm and an
external diameter of 6.5mm. Suitable with size 7+ ETTs.
Fits onto a 4mm scope

All of the above are suitable for oxygenation through a central lumen via a rapi-fit
connector.