Two OR Intubation Videos

 

If you’ve been reading the comments on some of the posts, you may have seen a new face: Jim DuCanto, MD. Jim is an anesthesiologist at the Medical College of Wisconsin. He has recorded 100′s of intubations in the OR. The above video shows two of them.

  • First case: the patient was intubated after 8 ml of topical anesthesia applied to vocal cords through the Air-Q mask itself.  Patient was anesthetized with inhalational anesthesia first, mask inserted, and Jim went from there.
  • Second case, he was simply practicing with the Levitan scope alongside DL (not a difficult airway).

You’ll be hearing more from Jim on the podcast soon.

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Comments

  1. I enjoy the EtCO2 tracing overlay prior to switching to the intubation.

    • I’m looking but I’m not seeing what you’re point out

    • James DuCanto, M.D. says:

      EtCO2 tracing and absolute number is of vital importance not only in Anesthesia, but in Emergency Medicine. How are you guys going to know if your CPR is working? The EtCO2 can be your guide. Consider asking your medical electronics department if you can obtain any of the discarded anesthesia gas analyzers that are being chucked out the window as many medical systems are finding them incompatible with electronic medical record keeping systems. These gas analyzers will give you not only EtCO2, but also end-tidal O2 concentrations (EtO2). EtO2 has become important to me clinically in that I use this parameter as a target with which to preoxygenate a patient during ramp up to induction and intubation. If I can achieve an ETO2 of 0.91 (91%), I know I have washed out the Nitrogen and filled as much of the FRC with O2 that is possible—so then I proceed with induction and intubation. We can talk more about that later if anyone’s interested.

      On the topic of the video collection technique (second video):
      Using a plug-in program for Apple i-Movie 6.0, I have been able to create picture in picture effects in my movies for almost 3 years now. What I enjoy doing (to convey the most information I can during these videos) is to capture the patient care monitor separately (synched to the camera on the clinical scene), and then overlay the second movie over the monitor so that the various vital signs can be read during the case. It’s like a “Dashboard” or a “head-up display” for clinicians.

      • Dr. DuCanto,

        You’ll be happy to hear that waveform EtCO2 is going strong in many EMS systems, and most high performing systems use it on any advanced airway placement (BIAD or ETT). In North Carolina, it’s required in any system utilizing RSI.

        And as you’ve noted, EMS often uses EtCO2 to benchmark CPR but also as a data-point for discontinuation of resuscitation in the field. Those with nasal cannula monitoring capabilities may use it on COPD/Asthma or even CHF patients.

        We don’t (yet?) have EtO2 measurements in the field, but that certainly would be helpful during preoxygenation! I’d love to hear more or read any papers you have.

  2. Minh Le Cong says:

    Jim, brilliant demo of the Levitan stylet. I really love your nifty digital camera attachment with the swivelling LCD display..is that custom made adaptor or did you find one off the shelf?
    that bending of the stylet I read about in a recent paper on using the Levitan scope as the sole intubating device..it seems to work really well in your hands..how do you do it..bend it into that shape?!
    I bow to you master!

    • James DuCanto, M.D. says:

      Thanks for the generous favorable feedback!

      If I could have only 1 advanced airway device with me, it would be the Levitan Optical stylet (with an Air-Q). It can intubate 5 different ways, it’s affordable and durable. I could live without video laryngoscopes, but that’s me, I’m an anesthesiologist, not an Emergency Medicine physician. Repetition to the point of exhaustion is needed to gain the skills and confidence to use an optical stylet in an emergency situation, so for those of you out there thinking of getting one, my advice is to use the device with every intubation that comes your way, so you grasp its essence.

      The camera system was sold by the USA manufacturer of the Levitan 4 or 5 years ago, and is comprised of a Canon A-series digital camera with an endoscopy adapter. In the years since I first bought this, I have been pining to buy another, but alas, to no avail. The UK distributer of the Truphatek optical laryngoscope blade was selling these snap on camera systems about 2 years ago (as a training aid to snap onto the Evo2), but they wouldn’t sell it to me over here in the USA. This distributer no longer offers the product, unfortunately, or you could likely buy it in Australia. There are endoscopy snap on cameras sold that would work for you, but would need an external monitor.

      On to the issue of bending the stylet:

      The first video shows a stylet that is the big brother to the Levitan, i.e., the Shikani, bent into a “Sigma” shape to match the contour of the Air-Q airway. This optical stylet is sold as the “Air-Vu Plus” here in the United States, and is a non-malleable version of the Shikani meant specifically to function through the Air-Q. Here is a link to that stylet: http://mercurymed.com/catalog2/index.php?type=2

      The second video shows the natural “factory shape”, i.e., the contour of the stylet as delivered from the factory. For over a year now, I have used the Levitan set to the factory shape, but have recently re-contoured my stylet to something approximating the sigma shape. Here is a link to the description of the sigma shape:

      {http://journals.lww.com/anesthesiology/pages/articleviewer.aspx?year=2007&issue=05000&article=00039&type=fulltext}

      Thanks again for asking–I love talking about this stuff.

      Jim

      • Like Jim, we bent our bonfils stylet to the exact shape of the AirQ Curve in vivo. We didn’t add the retroverted backwards bend on the prox end to make true sigma. Ours is just a gentle arc that slips down the AirQ like butta’.

        Doing the actual bending was petrifying though as the bonfils is even less malleable than Levitan.

        • Can you show picture of your set up….very interesting. Been try before buy the air-vu for a week now. It is very nice!

  3. Minh Le Cong says:

    thanks Jim!
    What you use now, the shikani setup with the camera, looks very much like the new Clarus video system? Would you consider that instead now?

    Also a few years back Greenland from my neck of the woods in Brisbane, did an operative anaesthesia comparison study of the Levitan and the bougie..finding little performance difference? Do you have any comments?

    do you think that if a patient is deemed to require RSI, you would still consider the technique of placing a sGA and tubing via the sGA? I guess I am hinting at the RSA technique that Darren Braude espouses even in the prehospital setting. IN this case , push RSI drugs, drop in a Second generation SGA that you can tube via, improve oxygention then tube using optical stylet via the SGA?

    • James DuCanto, M.D. says:

      I actually do own the Clarus Video system. It’s pretty neat, and I used to carry it around with me, but nowadays, I carry the Levitan. Technique-wise, the Levitan is better with DL because of its length and setup with eyepiece. As I DL, I am close to the patient’s face, scoping over the top of the eyebrows. The Levitan swings in, and as it comes around the base of the tongue, the eyepiece falls naturally into line with the eye. With the video system, I need almost 2 1/2 feet between me eye and the viewscreen to use it effectively, and this effectively means I must pull my eyes and head out of alignment with the direct laryngoscopy (DL) procedure. It requires extra time and movement to benefit from the video feature.

      Comparison of bougie and Levitan—-Equivalent? I would need to read the study and find out what he did with it. The Levitan is so versatile, he may have used it alongside DL, and found out that he is such a good DL endoscopist with so much experience and skill with a bougie that the two devices were essentially equivalent in his hands–that’s my hunch. Optical stylets require repetition to see their benefit, so be careful who you listen to about their utility–that goes both ways. Those with little experience with them likely will not think much of them, they being unable to benefit from the device due to lack of familiarity and skill, and those with considerable experience will espouse their superiority, without admitting that the learning curve is steeper than most would like to admit.

      The first time I ever saw a bougie, it was an Irish born, Irish trained anesthesiologist who removed it from the shirt pocket of his scrubs to use it to handle a difficult airway. We were so enamored with flexible bronchoscopes during my anesthesia residency that no one taught us about bougies (circa 1993-1996). I lack experience with bougies, although I have used them. I did teach Seth Manoach (see podcast on cricothyrotomy) that it is far easier to intubate a sheep with a bougie, followed by a tracheal tube than with a styletted tracheal tube alone, though. We did that sheep cric study together, in which we cric’d the sheep with the Levitan. The hard palate of the sheep has hard ridges that are used to grind up plant matter, and these ridges easily tear tracheal tube cuffs if inadvertantly rubbed against the roof of the mouth during intubation. Using a bougie, you can hit the moving target of the spontaneously breathing sheep’s larynx, then carefully avoid the roughened portions of the sheep pharynx while advancing the tracheal tube.

      I think that Darren Braude’s RSI with SGA idea makes sense in that it places ventilation/oxygenation FIRST, which is where we all should be heading in the modern day and age. Going with a second generation SGA with RSI that you can tube through makes sense, following the pre-requisite period of controlled ventilation. Placing the tracheal tube via optical stylet through the SGA is going to be the way as well. I have found it far faster and easier to use an optical stylet than a flexible fiberscope through the Air-Q, because you lead with the tracheal tube instead of the endoscope when you do it this way. I support you fully on this idea. I have essentially RSI’d patients in this manner in the past when I have encountered recognized difficult airways.

      To intubate successfully through an SGA, you’ll need to make sure that the curve on your Levitan is at least 40 degrees from the tip to the shaft. I no longer agree with Rich Levitan about his “straight to cuff” shape of the Levitan when used in DL. Most certainly, that straight to cuff shape will give you more problems than they’re worth when you attempt to intubate through an SGA with the Levitan. I have gone to the sigma shape, as I communicated earlier. I realize you may not want to bend your Levitan that much, though.

      Sincerely, Jim

  4. Minh Le Cong says:

    thanks for the advice on the Clarus Video System..makes sense.
    I have to ask. How do you go about sterilising the Levitan in between cases? We were recommended using the Starrad technique but I have heard some clinicians just clean it in standard endoscopy sterilising solution. The issue for training with it is how often you can use it during a standard theatre list. You are right in that it requires dedicated practice and deliberate technique with DL to use the Levitan effectively. I agree if you put in the dedicated practice you will be rewarded handsomely. What we have found is that training with it on mannikins is quite different to training with it in real patients. So getting a good amount of practice in precious theatre time is important..hence the issues around sterilisation in between cases.
    About the bougie, it is used a lot here in Australia and is simple yet incredibly effective in grade 3 laryngeal views. hence the study by Greenland comparing the two. I agree with your comments..if you are good at DL anyway there is probably little difference to note between the two devices . the advantage as you point out is its use in intubating via a SGA. Do you really believe that DL will be superceded by intubation via SGA technique?

    • For myself and one of my colleagues, the bonfils is a pleasure and I would agree with Jim if you are in the community where you do your own tubes (rather than supervise residents) the Levitan may be the ultimate device along with an intubating SGA.

      The moves to use a fiber stylet are radically different than bougie or laryngoscope intubation. If you can intubate with a bronchoscope, stylets are easy. If you are doing stylets for the first time, you need someone to show you the tricks.

      Stylet through AirQ is dead simple if you lube properly as Jim’s video demonstrates.

  5. Jim, welcome to EMCRIT. I thank Scott all the time for this internet vehicle he has created in allowing some of us who aren’t in critical care fellowships, to keep on learning how to take care of the sickest of the sick patients. I can’t wait for you to show some videos regarding the Oxylator that you use.

  6. Minh Le Cong says:

    thanks for the advice
    You both have reinvigorated my enthusiasm to research and teach advanced techniques with the Levitan stylet.

    There is no doubt in my mind that cost wise, you could easily afford both a lEvitan stylet and king vision video laryngoscope and still have spare change compared with other video systems out there like GLidescope, Pentax and CMAC.

    intubation via SGA using an optical stylet is potentially a very resilient technique in the ED and even prehospital. Attention has been diverted away from it in recent years with the whole range of video laryngoscopes spewing out onto market. this has not helped progress a best practice approach to emergency airway management.

    the paradox is that DL in experienced hands is incredibly difficult to beat. to get that experience does take dedicated time in practice and devices like the Levitan and King vision provide affordable options in resilient airway techniques whilst you are on that learning curve. For example if you fail DL, you would then drop in a intubating sGa, reoxygenate and then have options to either intubate via sGa using stylet or repeat DL or proceed to surgical airway. This addresses one of the main problems when learning DL and you are on that curve towards proficiency…previously you were always nervous because you lacked confidence in DL and were relying upon it to be the mainstay of your airway intervention..in other words, everything hinged upon successful intubation for safety. Now you can practice DL with more confidence knowing you have resilient techniques as backup, that give you options in addition to the surgical airway approach. It does mean you have to invest time and money into getting these devices and practising. But its like buying insurance…we are all willing to spend some money initially to be prepared for that rainy day!But now the insurance does not have to mean selling one of your children!
    Air Q disposables are cheap as chips
    So are IGels
    You could buy 3Levitans stylets and 3King Visions for the price of one Glidescope

  7. Exactly. Bonfils or Levitan are a useful adjunct to the armamentorium and Minhs argument is well reasoned

    Made my decision to go with KingVision and Levitan some weeks ago…the discussion on this thread reinforces it

  8. James DuCanto, M.D. says:

    Sorry for the delay in getting back to you guys—home, holidays and call duties built up over the past 2 weeks.

    Minh, your ideas are spot on. If DL doesn’t work, going to an SGA for ventilation, then using that SGA as a guide for optical stylet driven intubation attempts is a very sound plan. This is the usual progression for me in my practice. The King Vision is a good endoscope—-as good as any other out there, and is now reasonably priced. The high prices of the videolaryngoscopes are related to the systems they have been traditionally competing with (Flexible Bronchoscopes, which cost 10k-14k).

    I have the first of the Air-Q blockers that are being sold commercially, and have used them clinically. This add-on to the Air-Q turns it into a “Second Generation SGA” that blocks the esophageal inlet with a balloon tipped catheter that inflates to the size of a Laryngeal tube’s distal balloon, and allows connection of the esophageal catheter to suction.

    Jose, I promise some Oxylator videos in the near future. I have slowed down recently making recordings to learn the electronic medical record systems we are required to use (Epic).

  9. Minh Le Cong says:

    Jim, I missed you mate! I was searching online for where to buy a box of the new AIr Q blockers so what a coincidence! Can you post a link to where you bought your AIrQ blockers..I can’t find anywhere to spend my money on getting them!
    I managed to get a spare Levitan FPS, bend it into that sigma shape and practice with an IGel, so I now want to try it out with the AirQ blockers
    I have an idea I want to work up in regard to aeromedical retrieval of agitated patients using what we have discussed. It is fairly standard practice that intubation is one way of managing the highly combative patient. With the SGA concept I believe there is an alternative strategy, in particular with second generation SGAs like the Air Q blocker that can give you the benefits of both worlds. You give a propofol induction and drop in a AirQ blocker. If it works well you might choose to just transport with that in place. If you are not happy, you can then proceed with a controlled intubation via the AirQ using the Levitan stylet. And if you have followed the latest debate on emcrit regarding paralytics, you dont even have to necessarily use paralytics to do all of that!

    Jim whats your opinion of that debate on paralytic or not in MICU intubations??

    • James DuCanto says:

      I will get the name of the rep in Australia and get back to you in the next couple days–I know the people who make and distribute the product here in the US, and they’ll get back to me shortly.

      Most certainly you do not need paralytics to place and ventilate through the Air-Q or any other SGA, and that can be an advantage, as it permits spontaneous ventilation, which decreases the impact on hemodynamics that often accompanies positive pressure ventilation. Transport on SGA alone is reasonable with a second generation SGA. The US military has this in their transport plan, but they use Combitubes for helicopter use.

      Tell me again what MICU is the acronym for?

      • James DuCanto, M.D. says:

        OK I figured out MICU.

        Intubating only on propofol (controlling hemodynamics to offset the hypotension)? What is needed here is either a collossal dose of propofol to know out the brain and the spinal cord reflexes (think gag, laryngospasm), or the concomitant administration of an analgesic to provide proper anesthesia for the procedure (like ketamine).

        I think that (propofol alone) is a technique for anesthesiologists—we know the effects of the medication at different doses, and can anticipate how to limit those side effects, like with pressors for instance. Too many variables for a non-anesthesiologist. A more reasonable approach is a smaller dose of propofol followed by a moderate dose of ketamine (0.5 mg/kg).

        I support muscle relaxant use in many situations, except in cancer (of the airway), massive edema and infection of the tissue around the tongue and larynx. Those require topical anesthesia and a sedated or frank awake approach. Or a surgical airway without any intervening nonsense.

        Topical anesthesia injected through the SGA is extremely effective, if the SGA is in proper position (so that the local anesthetic can reach the larynx). Following SGA placement, an endoscopy with your Levitan stylet can reveal if the mask is in proper position for intubation, and also in proper position to receive topical local anesthesia.

        The video of the 208 kg patient concerns a patient intubated through the Air-Q without muscle relaxants (spontaneous ventilation preserved). It was achieved with 8 ml of 4% lidocaine diluted to 20 ml and injected through the Air-Q in two separate 10 ml increments. The patient did not flinch or resist me. More on this later.

        Videolaryngoscopes make physicians of all specialties overconfident. What I respect about Emergency Medicine physicians is their understanding and readiness to go to surgical airways. Really bringing second generation SGA’s that serve as intubation conduits into the mainstream of Emergency Medicine will further reduce the surgical airway rates.

        One question for you–would it be useful if I created a monograph on how to perform the intubation procedure through the Air-Q, including ways to interpret proper mask position, and re-adjust if necessary?

        • Jim,

          At least my opinion is that such a work would be enormously useful. Especially on the specifics of the AirQ rather than the fasttrach.

          If you added in some videos from your archives it would be amazing. Happy to put it up here on the blog if you’d like.

        • Minh Le Cong says:

          is the Pope a Catholic? Absolutely would love to see a monograph from you Jim on tubing via the AirQ blocker using the Levitan FPS!
          Its good to hear you write on how transporting with second generation SGA is reasonable and the US military have a plan for this. This has been my conclusion for a while based on some cases and it aligns with what Dr Darren Braude teaches and has published on.

          I trained extensively with the Fastrach ILMA and I love it but must admit it is not intuitive at all for many. Exploring the AirQ blocker and Levitan FPS combo technique gives the benefits of both worlds. I tried getting the Levitan down the Fastrach in my experiments but it just is not made for that angle.

          I agree with you on the propofol issue. Ketamine is much more forgiving at various dosing levels. But I still would not intubate just with ketamine sedation.

  10. Minh Le Cong says:

    Jim, Scott. I managed to get a box of 4.5 AirQ ILA from US. I have been testing it on the Trucorps mannikin today using the Levitan FPS. I agree, at least on the mannikin , its a pretty smooth technique. I tried intubating using the Levitan with a Fastrach silicone tip wire reinforced 7.0 ETT loaded on, with the connector removed. It makes it the right length for the Levitan with the tip of the stylet just emerging from the end of the ETT. Nice you don’t have to cut the ETT length. I must admit it seems to be a superior technique to the blind Fastrach ILMA intubations I am used to. For the cost of < $2500 AU you have two devices that complement each other well and make a very resilient airway combination. And like the Fastrach..you always have the option after intubation of leaving the laryngeal airway in situ and using it as a bridge to extubation during recovery or in my case just leaving it in for aeromedical transport..you have best of both worlds. A laryngeal airway in for backup but also a cuffed ETT below the cords. The AirQ is nicer in that there is no big handle getting in the way of things if you decide to leave the laryngeal airway in situ, making connecting to a ventilator easier with the AirQ if you decide to leave it place. I can only imagine the AirQ Blocker device can only be better. Thanks for all your suggestions and advice on this. very nice

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