What Trach for Difficult Airway Cart?

Scott from Colorado writes to ask:

I was wondering what size Shiley you recommend for stocking a difficult airway cart. Most surgical airway descriptions, such as Ron Walls’ book, recommend a no. 4 tracheostomy tube. However, to employ the bougie technique Dr Braude demonstrates, need a no. 6 Shiley.

According to SunMed their adult bougie will accomodate size 6-11 Shiley and their ped bougie will take size 4-6. I have played with them and fit an adult bougie through a no. 4 Shiley without too much difficulty.

We stock about a dozen 6.0 mm Portex trachs. I like the portex b/c they will work even if you drop the inner cannula on the floor. The are super easy to slip over an adult-size bougie, and most important–they are cuffed.

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  1. Minh Le Cong says

    Hi Scott
    In the RFDS QLD section, we carry the Melker 5mm cuffed seldinger kit
    You can use it seldinger style or with open cric technique .It also fits perfectly over our Frova bougie
    A senior resident on our retrieval service had to deal with an upper airway obstruction case secondary to angioedema just a few days ago. He found the patient hypoxic on air but alert with gross face and neck swelling. Decided to first do no harm and scoop and run from the country hospital back to the tertiary base hospital. Patient coded during loading onto aircraft. CICV. Open surgical airway done by another accompanying retrieval resident doctor. Patient still did not survive.
    The obvious question I got asked was “Should we have done something before leaving the hospital and if so , what?” Is the awake airway the safest airway in the deteriorating patient or is it delaying the inevitable?Intriguingly, would anyone have just setup for full RSI and surgical airway(the double setup ) and pushed drugs and done their best ,knowing full well you would be likely inducing a CICV situation?

    • says

      Tough case.

      Awake Cricothyrotomy set-up; one try at awake bonfil or fiberoptic; if that attempt fails awake cric is what I would have done. Of course, I have no idea what the pt looked like or the true feel for the situation.

  2. Minh Le Cong says

    yeah that was my initial suggestion too. I spoke to a couple of anaesthetists about it,one who does retrieval work as well, and they totally disagreed with an awake surgical airway attempt. Their arguement was do what you are best at, assuming you do more RSI than awake surgical airways!
    The strategy they suggest is that in airway obstruction cases who are deteriorating ( this patient had a SaO2 of 90% on 15 L/min at time of leaving hospital for airport), with limited resources and staff, you gotta do something earlier rather than later when the obstruction is worse to give yourself the best chance of success. your best attempt if you are most familiar with RSI, is in fact RSI. But ideally you would have a second operator setup to go through the neck if CICV is created by your RSI. I found this intriguing and searched to see if there were any case reports or literature to support this concept.And guess what there is! On Airway World http://www.airwayworld.com they have a webinar entitled Airway M&M in which a case is presented of airway obstruction and the concept of the”Forced to act RSI” is talked about. Essentially its a one shot airway deal as they call it. Have your best attempt orally and if no good, go through the neck. And I do remember Dr Levitan publishing a case report about doing something very similar in a morbidly obese patient who was deteriorating
    Levitan RM, Chudnofsky C, Sapre N. Emergency airway management in a
    morbidly obese, noncooperative, rapidly deteriorating patient. Am J Emerg
    Med 2006; 24:894–896

  3. says

    Agree with all of that for most ED / anesthesia folks. For people who have specialized in difficult airway; you have more options as you have more things that you are best at. I would fault nobody for attempting RSI in this case and then putting in an LMA to see if you can get even a cc or two of oxygen in while you move to the neck and perform immediate cric whether it be needle or knife.

  4. Dean Burns says

    Hi Scott and Minh

    Great podcast. I’ve been invited to work with stocking our difficult airway trolley and wanted to clarify your recommendation of the 6mm Portex tracheostomy tube. The tube you recommend is not a percutaneous tracheostomy set but a simple tracheostomy tube, yes?

    If so, do you combine it with a scalpal/bougie kit you’ve made up yourself or do use utilise a commercially available all-in-one perc tracheostomy kit for your emergency cricothyrotomies.

    I’m trying to choose the best kit to store on the difficult airway trolleys throughout the hospital and wanted to get your thoughts on any simple, foolproof kits which would make a good choice to stock on our DATs.]


    Consultant in Emergency Medicine and Intensive Care

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