My favorite supraglottic airway is the Cookgas Air-Q; it was created by an anesthesiologist, Dr. Daniel Cook. He just created a new device that allows the placement of an esophageal blocker through the laryngeal airway. I gave him a call to hear about the new product and in the course of that conversation, he gave me a ton of tips on the placement of laryngeal airways. Part II will specifically discuss the new device.
Placement of the ILA
- Put the patient in sniffing position
- Lube it really well (get the bottom, the cuff, and the horizontal ridges up front)
- Dr. Cook recommends an insertion using a tongue depressor to pull the tube forward. He inserts straight back instead of riding the hard palate. If the LMA doesn’t quite turn the corner, he inserts his left index finger just posterior to the tip and flexes his finger to get the LMA to make the curve into the lower pharynx
- He gently advances until the LMA comes to a rest—don’t push too hard
- At this point he puts 4-5 cc of air in for the 4.5 size and 3-4 cc of air for the 3.5 size (same amount of air as the size of the LMA)
Blind Intubation through the ILA
- First step is to lube the inside of the ILA. Use the ET tube itself—put a big glob of lube on the distal portion of the ETT and then advance it until it is just about to pop out of the keyhole opening of the ILA. This distance will be 20 cm in the 4.5 size and 18 cm in the 3.5 size (keep subtracting 2cm for each downsizing)
- Now readvance the ETT to that same point, put your index finger on the top and use it to ever so slowly advance the ET. You can have a hand over the cricoid to feel the ETT as it passes.
- Inflate and confirm by listening over the stomach and looking for End-Tidal CO2.
- If you missed, pull back to that same point that is just before the opening of the cuff and inflate the ETT cuff with 1-2 cc of air. You can now reoxygenate the patient before your next attempt.
- The second attempt should probably be with a fiberoptic device or a bougie.
Bougie Intubation through the ILA
- First lube the ILA using the ETT, then remove the ETT
- Advance the bougie using the coude end with the coude facing towards the ceiling.