EMCrit Wee – Airway Outsourcing and Suction Henching

A comment by Sean Marshall (scroll all the way down) got me thinking about bimanual larygoscopy. I realized, when I am doing fiberoptic laryngoscopy, I don’t need to really perform too bimanual anymore. Big paradigm shift since I strongly espoused the virtues ever since I learned the technique from Rich Levitan.

I now outsource external laryngeal manipulation to my assistant; or I do it for the intubator when one of my residents is that intubator. This outsourcing concept was first introduced to me by my friend, Reuben Strayer. He realized you could outsource suctioning. It was a natural progression for me to start outsourcing thyroid manipulation and now tube-prepassage.

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  1. Sean Marshall says

    Hi Scott,
    I am humbled that my comments merited their own wee from the master resuscitationist…

    So, I agree with everything you said but it is predicated on the notion that you are using video laryngoscopy (and probably a system with a screen on a stand, not the handle) rather than the classic Macintosh blade.

    Minh’s concept of having resilient practices strikes a cord here, ie. your team can adapt to other methods of getting a tube in. So I still feel that training the intubator to reach for the larynx every time is a better approach.

    With a classic metal larynoscope, the assistant can’t see and so can’t safely suction or manipulate the larynx as well as you can, so that approach is out in those cases. I still don’t see the issue of being unable to maintain a glottic view with a video scope being an issue to change my practice for. With the glidescope, I find i mostly have a great view and when I don’t I don’t, not the peak-a-boo vocal cords scenario you seem to be worried about. Of course tube passage can be a separate issue and I don’t know if per-passage helps this any.

    Does this arise from the glidescope teaching of “look in mouth to insert blade, look at screen, look in mouth to insert tube, look at screen”? I could see why you might want to streamline the approach. Bougie pre-insertion by an assistant might help here. Might this be less of an issue for a Mac shaped VL you think?

  2. Minh Le Cong says

    Scott, Sean, this is quite a thought provoking issue you raise.
    In many ways, we are defining and describing a new paradigm in emergency airway management. bougie prepass, criccon, DSI, RSA, suction outsourcing..these are all things still quite alien to the OR anaesthesia setting.
    even RSI checklists are not standard in the OR.
    so the question is what should be the standard of emergency airway training curriculum for the frontline provider? Is it gained and set in the OR, ICU or ED? Does it matter?
    There is room and a necessity for evolution and innovation in emergency airway management , of that I have little doubt. DSI is par exemplar. It is virtually unheard of in the OR. But it suits critical care situations well though. The best analogy I can apply is that of unarmed hand to hand combat. Critical care airway management is akin to no holds barred, no rules, no referee, no time limits, fighting. Its gladiatorial in nature. OR anaesthesia airway management is more akin to organised tournament fighitng with rules, referee and time limits. You know when your fight is and its matched to a similar skilled or weighted opponent. there is an umpire to ensure your safety. If you want to concede the match, you can throw in the towel. critical care airways are like an armed robber who has broken into your house, unexpected and you need to act or you die. Suction outsourcing and ELM outsourcing is akin to having a group of friends with you to beat the heck out of the robber and gain control of the situation…rather than you trying to do it solo! However as Sean says, you have to train to be able to survive and succeed, if you are by yourself.

    • says


      Great comments as always. It’s funny all of my work around airway is an attempt to take the chaos of the critical care airway and evolve it till it feels nice and quiet like an OR. I’ll know I can retire when I can be an old geezer watching some of the juniors progressing through an airway paradigm all the way to cric without ever raising their voices or any of the patients in the next bay even realizing something is going on.

  3. says

    Nice Wee Scott. I find myself being the hench person (man-woman) most of the time nowdays. Did this a couple of times last week in fact – once doing a ketamine DSI on young chap with bad pneumonia who developed trismus post ketamine that took 200 mg of sux and some propofol to break – fairly hairy and glad of the bougie/vid laryngoscope. Interestingly, the high-flow nasal prongs we used during the DSI were a real hindrance to proper bagging as we couldn’t get a good seal until we got rid of them.

    Keep up the good work!


    • says

      It is interesting; are you folks using the EC technique or thumbs forward? I am beginning to think that folks that are having seal problems are using EC; which is why I have never had a problem.

      For folks that don’t know him, Oli runs an AMAZING criticial care podcast which you can find on the Intensive Care Network Site.

  4. Viking One_alias Per says

    Friends and Colleagues

    I am a happy follower of this blog.
    However, after following the airway management debate I felt it was time to contribute… despite NOT being an Anglo-Saxon emergency physician.. With a training background as dual specialist in Scandinavia in anesthesia and intensive care which includes being the resuscitator (since there are no emergency physicians here) in ED as well as working a large proportion of my time in the pre hospital arena. I feel an urge to comment on this debate…
    First, outsourcing suction is NO new thing, we do that all the time in theatre and ED with bleedings – whatever it is from facial injuries or bleeding from tumors in the airway.
    DSI is something that we do on the pre hospital arena, in ICU, in ED all the time… facilitating the controlled induction of anesthesia and avoiding any battle with the patient.
    External manipulation of the larynx should ALWAYS be performed by the laryngoscopist (no matter whether it is VL or conventional methods) – that person is the only one who can place larynx in an appropriate position – a good way to do this is by placing the laryngoscopist fingers on top of the fingers to an assistant who then can keep larynx in selected place.

    Don’t misunderstand me, I have a great respect for airway management, which should be done by the one most skilled there and then, no matter of rank and speciality…. however, I often feel that the airway debate around emergency medicine (a speciality in which I have also worked in the UK with great pleasure) is focused TO MUCH on gadgets, bougies, VL, various fancy nemes and “so called” new inventions… The essentials in intubations are a deep knowledge of involved drugs, a thorough training program for all involved, respect for air ways – and GOOD LARYNGOSCOPI SKILLS… which is sometimes forgotten and gets less attention…. !!! go and practise practice practice,,,

    BUT – my main point is around organization of the team – there are NO reasons for doing RSI’s, DSI’s ect different in the ED than in theatre or in the pre hospital arena !
    It can all be planned, it can all be trained, it can all be simulated !!!!

    Good luck – I love following these blogs and learns loads from following….

    • says

      thanks so much for commenting.
      a few points of clarification:
      DSI is not a controlled induction, which is absolutely standard practice. It is a crash dissociation in a critically ill patient.

      Actually despite the all-caps as proof, if you are both looking at the same video screen there is absolutely no advantage to the intubator performing the ext. larygneal manipulation.

      I am glad we share a fundamental respect for the basics of airway management: good laryngoscopy skills, peri-intubation knowledge of drugs and sequencing, etc. However, what you dismiss as gadgetry and fancy names is what needs to be done when those basics have failed.

      I would state definitively that this discussion is not a product of emergency medicine, but by all of those concerned about the management of the difficult airway. For proof of this, I would suggest perusing the Society of Airway Management’s list-serv and newsletters. This is an international group whose members are predominantly anesthesiologists. There you will find intense discussion and debate on the exact subject matters you mention.

      One of mentors from the anesthesia world, when asked what is his difficult airway plan, would consistently answer, “My difficult airway plan is that I am really good at laryngoscopy.” That is swell in the operative anesthesia world, where CICO situation is 1 in 10,000. Not so great in the ICUs and the EDs. I can’t agree at all that airway management is the same in the OR as ED/ICU.

      I am glad to have you as a reader to lend both an anesthesia and international perspective. Please take my comments warmly as they are intended.

  5. Viking One_alias Per says

    This is great – blogs, debate, exchange of experiences, attitudes…
    Many good points in your answer.
    One thing that I find important to emphasize, is around location.
    YES, I agree, that it is different to intubate/anesthesize+intubate outside OR. However, one need to think that it is a similar procedure. The absolute SAME things NEED need to happen!
    Positioning, potentially preoxygenation, drugs, airway handling.. all the same.. same sequence as well. What differs is the location, supporting staff around you, knowledge of the patient… BUT when preparing for intubation, one need to think the same… one can easily, be training, simulation, mental preparation ect create a working environment with the same level of security as in OR.. I do that for every intubationo/airway handling I do.. no matter whether it is in ED, on ICU or in a pre hospital sick patient.
    There are NO “crash” situations.. not for DSI, not for RSI, not for any intubation… the leader needs to be very focused on the whole procedure, placement of staff and equipment ect…
    So YES, it differs, but that can be controlled and handled – with a mindset of creating an equal optimal worksetting as in OR !

    • says

      “Crash” is a description of the patient condition not a resuscitator mindset, but I chalk this up to different uses in different countries. With the way we use the word, of course there are crash situations.

      Now as to bringing the same preparation and sequencing to both venues we agree. Where we differ is which venue needs to be emulated.

      Here is the preparation and sequencing we do at our institutions:
      Sinai Intubation Checklist. If you do the same level of preparation in all of your operative cases then I commend you; if you want to tell me that all ORs in Scandanavia prepare this way for every intubation, then I want to move there; but if you tell me that ANESTHESIA as a field across the world prepares this way on every intubation, then I know this to be untrue.

      At least in the US, anesthesia decides preop that the airway is potentially difficult and goes awake, or they don’t. In the latter case, very little is done to prepare for difficult airways. Maybe there is a cart floating around somewhere in the central OR core, maybe not.

      You should talk to Jim DuCanto, a frequent contributor to this blog and a full-time anesthesiologist. He will tell you how hard he needs to work to get these concepts understood in the anesthesia world.

  6. DocXology says

    I think Viking’s comments are directed at aspiring primary responder clinicians (reading this blog) who may have an unhealthy focus on advanced airway tools but lack the fundamental knowledge and skills to perform an intubation meticulously and correctly in conventional manner. By all means have your bag of tricks at the ready but don’t rummage around in them simply because you are unpractised or possess poor technique.

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