Recently, Minh had some questions for James DuCanto on fiberoptics and airway management in general. Here were the questions:
- 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?
- 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?
- In an earlier post you mention having performed a needle cricothyrotomy and rescue jet oxygenation using a dedicated jetting device. It was successful?
- What about ketamine assisted awake intubation?
- 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
- Jim DuCanto's Intubating Videos
- Jim's Guide to the Cookgas
- Reference for Mouth, Screen, Mouth, Screen (Anesth Anal 2007;104:1611)
- My skills of laryngoscopy video
- Seth Manoach Cric-ing a Sheep
Additional New Information
More on EMCrit
EMCrit 127 – The Oxylator with Jim DuCanto(Opens in a new browser tab)
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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?
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… Read more »
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.
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.
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… Read more »
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… Read more »
I love the bougie + optical stylet for intubation through an EGA — sounds promising for use in an LMA
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… Read more »
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… Read more »
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… Read more »
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?”
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.… Read more »
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,… Read more »
Great article, Javier. All of the points in this article are fleshed out in Dr. Levitan’s lecture on this site.
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