Podcast 73 – Airway Tips and Tricks with Jim DuCanto, MD

Recently, Minh had some questions for James DuCanto on fiberoptics and airway management in general. Here were the questions:

  1. Some anaesthetists I talk to argue that if you are going to get an optical or video assisted airway device then having it in the same design or functional shape as your traditional devices like the Macintosh laryngoscope, makes more sense than having devices that are of different designs. The Levitan FPS stylet is clearly no Macintosh shape design. What are your thoughts on video laryngoscopes more akin to the traditional Macintosh device like the CMAC versus the Levitan FPS?
  2. We describe a technique of insertion of an intubating LMA then fibreoptic guided stylet assisted intubation. In what situations have you found this helpful, in your experience?
  3. In an earlier post you mention having performed a needle cricothyrotomy and rescue jet oxygenation using a dedicated jetting device. It was successful?
  4. What about ketamine assisted awake intubation?
  5. How do you intubate through a laryngeal tube airway?

and boy did Jim have answers.

Jim DuCanto is an incredibly prolific anesthesiologist from Wisconsin.

 

Links Mentioned in the Show

Minh Le Cong has a new podcast–check it out to hear a 1-hour Q&A with Jim DuCanto: prehospitalmed.com

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Comments

  1. That’s a pretty slick demonstration setup!

    Two of my Paramedic services are looking to add VL to our units (GlideScope Ranger vs. KingVision). So, given the difference in stylette requirements and tube delivery mechanics, does Dr. DuCanto have any suggestions for occasional intubators and the available video laryngoscopy options?

  2. Jimmy D says:

    I received a King Vision back in January , and I loved it, however, there were a few drawbacks to the device. Right now, I use the McGrath MAC, since the disposables are cheaper and I can train completely novice endoscopists (while monitoring their progress on video) with safety and peace of mind.

    The King Vision wins over the Ranger on economics (price), and really is very good on illumination and video quality, but has some peculiarities that cannot be overlooked. You can buy 12 Visions for the price of a single Ranger.

    For the occasional incubator, the King Vision delivers on performance, as with its integral guide channel, it sends the tube pretty much straight ahead. The Biggest mistake made with this device (i.e., the most frequent mistake I made) was to get too close to the larnyx, causing the tracheal tube to run into the right inferior aspect of the larynx (corniculate cartilage). The treatment for this is to withdraw the device and re-advance the tube.

    1. The built-in guide channel with the King Vision obviates the need for a stylet, but then requires the endoscopist to learn how to negotiate the trajectory of the tracheal tube as it enters the larynx. If the tracheal tube, for instance, runs into the left vocal cord on advancement, the endoscopist can re-direct the path of the tracheal tube by turning the endoscope to the right, or he/she can direct the tracheal tube by turning the 15 mm connector of the tracheal tube to the right.
    2. The overall curvature is a bit tight (greater that the Airtraq, which is 81 degrees), and oral insertion can prove difficult in some patients. I have been unable to place this scope in a patient (n=1) on one occasion due to the patient’s small mouth and this extremely tight curve.
    3. The device can be used to intubate very quickly. I will post a video example this week.
    4. A blade (by King) is available without the guide channel–perhaps that blade should be available for instances in which the channeled blade cannot make the oral insertion. You’ll need the stylet, of course.
    5. Batteries last a decent amount of time (triple A’s).
    6. Light weight device, you are less likely to use undue amounts of force with this device.
    7. Device must be held by the handle, not around the video screen (or you’ll dislodge it by lifting it out of its mount).

    • Thanks! We figured whatever we went with would require a big training investment. My experience with the King was on mannequins and in a cadaver lab setting and was impressed when compared with the Ranger (especially the cost).

      How cost effective are the McGrath MAC’s? We’ve played with the Series 5 but found the lens got dirty pretty easily, however, I’m not familiar with the MAC.

  3. Jimmy D says:

    The McGrath MAC blades are around 8 dollars each. Couple that with the battery use, and it’s 9 USD per intubation. Lens has reasonable resistance to “muck”, and respods well to cleaning should fouling of the lens occur.

  4. Minh Le Cong says:

    Folks, listeners, Jimmy D fans, there is more awesomeness from the man coming up on EmCrit and PHARM so stay tuned

    I concur with Jim’s King Vision comments. Inserting it into the mouth can be an issue as it is a long device when fully assembled. We have of late taken to inserting the blade only then connecting the video handle and that seems to help.

    Believe it or not the price range for disposable VL devices has dropped even further and I have been testing a new device called the Vividtrac that debuted at ACEP late 2011 meeting. It is like an Airtraq yet costs less and has a USB output to any device that will take USB and display a camera image : netbook, laptop..they even have a working model connected wirelessly to iPhone or Ipad. Imagine that..a disposable VL costing less than $100 that you use with your iPhone! I sent Jim a sample and he might film some cool demo videos of it. VL technology is getting affordable at a personal level now. It will pay you well to understand the options out there and how a solution might suit you..or not.

    Now Jim and I receive no sponsorship or financial incentives from Vividtrac company. I receive sponsorship from the Australian distributor of King Vision systems for airway courses I have been running in 2012.

  5. Mike Techentin says:

    Scott,

    I love the concept, that Minh and Jim introduced to us, of using apneic ox or jet ventilation through an angiocath in the cricothyroid to “buy time” to fix a failed airway. In the event that an orotracheal airway could still not be established, it seems that that catheter could serve one last purpose. If you could drop a guide wire (out of a Melker or central line kit) into the trachea, it ought to provide some help in converting to an open surgical technique. Do you have any thoughts on how to perform such a maneuver? It’s certainly not rigid or thick enough (like a bougie) to ram a tube down, but it would be a shame to waste such a great landmark in the trachea.

  6. I love the bougie + optical stylet for intubation through an EGA — sounds promising for use in an LMA

  7. seth manoach says:

    To all:

    Jim and I discussed this a bit last week so my jumping in here is somewhat less impromptu than it may appear.

    I share Jim and Minh’s sentiments about the value of combining the step-back-and-wipe-the-sweat-off-my-brow safety maneuver of providing rescue ventilation through an SGA or paraglottic device WITH subsequent intubation. As an ER doc and intensivist I think Jim is one of a very small group of anesthesiologists who is addressing the salvage issue with ICU/ED assumptions — i.e. the patient with e.g. large volume aspiration, terrible CHF, or diffuse alveolar hemorrhage – pick your poison — can`t tolerate long interruptions in ventilation/oxygenation. That`s the value of cross-specialty talk. Scott and Rich Levitan`s high flow nasal cannula technique helps with the DL part, but once the lma or king lt is in, that`s done. This is another step toward removing that terrible apneic and/or desaturating interval from emergent airway management.

    All that said, Minh mentioned the lma fastrach. I am still unhappy that this is the most underutilized device in airway management. Personal experience, reams of published data, etc. shows that if you do two very easy manuevers that were not well known when the device was introduced and are still ignored by many — ie up and down post fastrach placement and chandy at the time of tube passage — you get intubation rates way up in the mid 90`s with close to 100% ventilation. These maneuvers are easy, and don`t require any special body english, but people don`t do them and blow off the best desert island device we have (straight blade with bougie comes close in the no fancy dials or optics dep`t but takes way more skill).

    But, to paraphrase Jim, you ain`t gonna get people to use devices they don`t want to use, for whatever reason (we are visual animals, period, sometimes for better, sometimes for worse). Given that, using whatever is around, in this case a bougie, whatever sga or pga a glidescope or mcgrath, etc. etc. — that`s good stuff.

    One last note: just messing around with the airsim we had reasonably good luck getting the stiffer sun med blue bougie to make that curve over the arytenoids coming out of the lma or king.

    Seth

  8. Minh Le Cong says:

    thanks Seth! For those who might be confused, Seth, Jim , Scott and I have been conducting an email discussion of these airway concepts and I mentioned the Fastrach.
    I fear that if the four of us ever meet in person, we will end up trying to film a video of us intubating ourselves using a SGA and bougie..or a Fastrach..whilst awake. Seth you would have seen that infamous Youtube video of Chandy Verghese being intubated awake with a Fastrach!
    I am going to post Jims next video in which he demonstrates in detail the concept of intubation via the common SGAs using a bougie and video laryngoscopy or optical stylet. Since Jim has taught me this recently, I have performed it with a LMA Supreme, bougie and King Vision, using the endoscopic swivel connector to provide continuous ventilation throughout. It required some laryngeal manipulation but since you are still ventilating via the swivel connector attachment. you can take your time. since you can see with Your VL the position of the LMA tip, you know if you are blowing air into the oesophagus.

    Why not just tube using the VL you say instead of this intermediary step of inserting a SGA and using a bougie ?? I call it the Mount Everest strategy.
    Can you climb Everest in one quick ascent? Unlikely. Why? Hypoxia will kill you either on the way up or during descent. So how do you do it. Do it in stages and take oxygen with you. Some people can climb without extra oxygen but they all still do the ascent in stages to acclimatise physiology.

  9. That Everest analogy is a good one. Got a vividtrac demo on its way…anyone had any experience recently…slaving it to a monitor on the anaesthetic machine would make sense to me, I am getting a bit too much like a propellor head with all these VLs and associated laptops/camera gear cluttering up my workspace.

    Someon ementioned the McGrath…I really like the idea of a VL that requirs same technique as direct laryngscopy ie same blades…m one criticism of KingVision is this. But I found the McGrath to be a bit crap in sunlight compared to KingVision and also lack of a video out port wasa deal breaker for teaching/training.

    Still, I reckon in a year or so we will have a device that combines all the best aspects

    – a VL that handles like DL but allows intubation in any position
    – robust
    – affordable
    – reliable
    – recyclable
    – video out or allow recording, wireless

  10. I think the VL/DL combos are the most promising- as Levitan argues (of course) that gives you important failsafe/ belt & suspenders. Not only are the skills that much more similar, but the biggest weakness is the tiny cameras can be blinded by a speck of vomit, mucus, or blood- that would render an angulated blade useless, but VL/DL combos can still be used as DL

    • Especially for teaching programs, Macintosh shaped VL are almost a must. They allow the screen to only face the attending-residents get DL skills while attendings can actually teach instead of shouting, “what do you see?”

      • Minh Le Cong says:

        What we need to design is a disposable kit that you can strap or slip onto any DL to convert it into a VL function. It would only have to involve the mini CMOS camera and USB cable, like the Vividtrac. The light source comes from the DL already. The monitor would have to be something like a laptop or net book or even your iPhone wirelessly as they have tested for the Vividtrac.

        If you can get the Vividtrac working commercial model for $65 each, a disposable conversion kit for any DL would be able to be cost comparative.
        You could then make a very cheap CMAC VL type system, disposable and using your current DL devices…and not worry about losing expensive devices or having to replace costly parts.

        All the technology is currently available and off the shelf but spread amongst several VL systems.

  11. Javier Benítez says:

    Great discussion, thank you all. I don’t know if it has already been mentioned, but I think this article by Richard Levitan is a good introduction to this topic.

    The Complexities of Tracheal Intubation With Direct Laryngoscopy and Alternative Intubation Devices
    Richard M. Levitan, MD, James W. Heitz, MD, Michael Sweeney, CRNP, Richard M. Cooper, MD

    http://www.annemergmed.com/article/S0196-0644(10)00560-3/abstract

    from the article: tracheal intubation involves 3 distinct challenges 1. Laryngeal view, 2. Delivering the tube, 3. Advancing the tube beyond the target and into the trachea.

    I know the discussion here is very advanced, but this article will help understand the concept, advantages, and complications of using video lanryngoscopy.

  12. Angel R Cancel says:

    Great Podcast, I have performed many difficult intubations thinking “Outside the box”, including cephalad needle cricoid placement and passing a guide wire the pops out the nose, then sliding an ET tube over this wire( no fiberoptic available, on a hospital ship in Africa). I have also used an LMA to mantain my airway then under video assist guided bougie or cath wires into the trachae and then intubated over these wires. Suprisingly easy and useful technique

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