Cite this post as:
Scott Weingart, MD FCCM. Podcast 141 – A Janu-Airway Case Presented Live. EMCrit Blog. Published on January 10, 2015. Accessed on January 28th 2023. Available at [https://emcrit.org/emcrit/emcrit-live-2015/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: January 10, 2015
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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thanks Scott Sorry to hear Janus General colleagues/admin were not so supportive of the hypothetical case management here. You are correct in that surgical airway is a dying skillset. Levitan said it is now regarded as a sentinel event rather than a part of reality of emergency medicine /emergency airway care. The proliferation of VL and other technologies has further cemented the notion in our collective minds that all airways can be managed non surgically. It is notable as in this case that it cannot prevent all surgical airways I dont think you should change your overall approach and what… Read more »
Thanks Minh. All our SGAs are theoretically capable of blind intubation; I recommend it with none of them. All of them ideally should be used with a fiberoptic bronch or a fiberoptic stylet. I believe Rich and Jim agree.
Thank you for another outstanding talk. What a perfect distillation of the concepts you’ve been teaching that have saved so many lives. Unfortunately, the vast majority of physicians outside the FOAMed community seem to believe that every patient deserves a trial of PEA arrest prior to cricothyrotomy. We know better, and must still do the right thing regardless of the emails that follow.
a trial of PEA arrest, that is perfectly stated, Jordan.
Sadly this also seems to apply to most EMS medical directors…
There are the good ones though.
Trial of PEA arrest … I’m going to remember that one!
Scott, Amazing cast. I’d say if you don’t at least occasionally agonize, you’re not a true Resuscitationist. Leaning towards surgical airway will save many more lives than leaning towards “making sure we’ve tried everything else”. We MUST be confident: mentally, logistically, and physically prepared to perform the Surg Cric from the very beginning of each & every airway we take into our possession and control. Having said that, questions I have for you: Do you have intubating LMA’s @ JJ? If not, do you guys have, and/or is there preparation for:bAintree/LMA/Fiberoptic? Regardless, do you have the Fiberoptic plugged in &… Read more »
First off, great podcast as always. I absolutely love your approach to teaching and have used so much of this to reinforce my own skill set. The case you bring up would make my hair stand up as I have never done a surgical airway despite being in 19 different hospitals over several states as an ICU guy. You ED heros usually take care of this stuff for the patient before I need to get my little paws all dirty. However, there are times when my airways become a real challenge in the unit. The Monday-morning quarterbacks that sit on… Read more »
Craig and Sam. As I mentioned in the case, at Janus General we do not yet have fiberoptic scopes as opposed to my prior job.
Craig, Fiberoptic bronch during emergency airway management is best facilitated with an intubating laryngeal airway. This puts gives you a secretion free path to the glottis and allows continued ventilation during bronch attempts. This was mentioned during the talk.
Roger that..
I must have missed that part…I got two pages while I was listening..
I see your point with the intubating laryngeal airway. I have not used one for that. I think this stuff should be better taught in residency of all branches… Keep up the education Scott.
C
Y
Oops. I do recall now. You mentioned it toward the end
A video sounds like a great idea; will do!
Happy New Year! Very nice case and analysis. A few thoughts: -Preparation is key. In the OR, when I work with ENT (see NAP4 data) I verbalize a plan A, B, C, and sometimes a D. This drops the energy level in the room and facilitates smoother care. -To reiterate what a previous contributor asked, did this ‘patient’ have a known potentially difficult airway? If so, then awake FOI is the standard of care. Otherwise your algorithm was ok. I’m not sure I would have gone for the 3d look w/ the Miller if the pt was de-satting and I… Read more »
Erik, great comments. Not sure how you convert the crics to oral. Way I have done is fiberoptic from above, deflate the cuff of the cric for a moment and drop the bronch to the carina. Put a bougie through the cric. Pull the cric back on the bougie and sink the tube mounted on the bronch. If there are any problems, repass the cric over the bougie. If you can get a DL/VL view (usually after the gi bleed/airway bleed/vomiting has been controlled) you can do the same thing with a 2nd bougie. Cric to trach conversion is no… Read more »
Thanks for the kind words 🙂 Yes, cric conversion as you described: FOI, deflate cric balloon so I don’t pop it and snake past w/ scope. At this point I’m over 26 cm in with the scope. Ideally I’d pull the scope back past the cric and make sure I was infraglottic with the ETT but sometimes ‘better is the enemy of good enough’ and we give test breaths to ensure ventilation before removing the cric. I don’t use a bougie because I don’t want to pop my ETT cuff but it would be nice to have some sort of… Read more »
Hey Scott, I’ve recently become a huge fan of the fiberoptic LMA technique (fiberoptic/aintree/LMA if no intubating LMA). Through conversations with my colleague & good friend Andy(Sloas), and through practice, I’ve come to realize the true power & potential of the technique. As you know Andy would prefer to intubate all comers in this fashion (directly to RSA and fiberoptic from there), and although I don’t think we should necessarily be doing this for every single intubation (for various reasons), I do think it may be the wisest approach in select cases. Even if not directly to RSA on first… Read more »
Sam, Hopefully I have convinced Andy to abandon the aintree approach. Ideal is AirQ—>reox—>place ETT in until sits just above mask outlet and inflate balloon—>put on bronch port and keep bagging—->bronch at your leisure—>when at carina, deflate ETT and advance, reinflate—->confirm depth with bronch
Scott, I agree, as does Andy, the aintree is an extra step– would prefer to skip this step. But when you don’t have I-LMAs, it’s the only way to accomplish intubation through the Fiberoptic Bronch with a regular (non-intubating LMA). Also agree that AirQ is prob most ideal intubating LMA, esp given the more shallow & direct angle on the tube, and love Dr. Cook’s technique as you describe above. Either way–when it comes to difficult/failed airway algorithm, I think the Fiberoptic/LMA approach should probably be much higher up. While I do think there are clear cases that this approach… Read more »
Not sure that would be how I would see this algorithm change. A few things you may want to put into the mix. In academic centers, the 1st attempt is almost always a resident attempt, so to not have an attending attempt doesn’t make much sense. In stable intubations, the first two attempts may be resident driven. The LMA/bronch approach is not cheap. Either you are killing an ambuscope or you are dealing with the cost of bronch reprocessing in the non-disposable version. Both are fairly expensive. If the pt has kept their sats throughout the laryngoscopy stage, there is… Read more »
Scott, I have searched on youtube today to find some vids of the intubation with the LMA. I saw a few vids. Have you done a video on this…sorry if you have and I am just not finding it. The videos I saw show that the ET tube can only be placed at a certain level past the intubating LMA unless using the exchange catheter like device preloaded over the bronch. I know that I should be able to wrap my head around the sequence you noted above….forgive me. But if you could do a quick vid on this or… Read more »
Great case grippingly presented. We all could have been there. Ironically, had an anesthesia or emergency resident given a bolus of propofol and the patient arrested on induction, then in all the hospitals I’ve worked he would have been pronounced dead with the cause attributed to his illness and no further investigation or criticism would have been likely. However, in your hypothetical case at JGH, your meticulous preparation, resuscitation, and pre-emption resulted in a surgical airway being a viable option and he made it to ICU alive with a good airway, and as always the downstream providers made fundamental attribution… Read more »
Cliff–such wonderful comments. Agree with all.
Where do you fit a trach in the bag. Everything else seems to fit perfectly, but I can’t find a spot for that.
Love the shift in terminology, bet Levitan will love it too.
We have a 6.0 cuffed adult tube rather than a trache.
See http://youtu.be/GfB1PLn9zIY?t=1m
Cliff
Yeah, we had plenty of those and that’s what we put in; but a trach is quite nice to place if possible. Of course being written up for using an ETT doesn’t make much sense either as that is the recommendation of every textbook out there.
I’m not sure why a cuffed ETT in the neck would be considered an unstable airway. Seems no more precarious than a fresh trach as long as some basic efforts were made to secure the tube. Do you have a preferred securing method by the way? (sutures, tape, trach ties, anchorfast device on the neck?)
Great case… hopefully your colleagues in real life aren’t as douchy as the ones sending emails at Janus.
Like Minh, I also wondered about blind intubation via LMA. Published success rates are decent.
Scott, you are incapable of doing a ‘cast and not teaching me something. As I scanned the show notes before listening, I thought to myself: HOP killers, difficult airways, crics: now HERE’s a ‘cast in my wheelhouse. And then I listened, and I learned. I’ve never done inline waveform capnography when doing bag mask ventilation. For some reason, I’ve had a mental block whereby I’ve always reserved the inline capnography for post-placement of either ETT, SGA, or cric. But as you rightly point out, when doing BMV, it’s tough to tell by just feel and watching chest rise how successful… Read more »
thanks, Bill
Dr. Weingaert, As usual, I enjoyed you podcast. The sweat on my palms made me realize that I could place myself easily in this situation. I work as a PA in a remote environment where emergency airway management is a very rare thing to deal with. But, as anything can happen, and with a population of patients with many severe and potentially severe co-morbidities, I still have to be prepared. I have found much inspiration in your talks to look critically at my set up and, more importantly, my mind-set. Thought experiments like this have pushed me to better prepare… Read more »
that is great, Jose!
I think it can not be said enough that preparation is the key in these situations. The method of getting the airway can be up for debate to some degree as you all have noted above. In the end getting the airway by whatever means saves the patient. I learned the hard way one time when I asked the RT for a bougie and they looked at me kinda funny. I am a full time locums so every new hospital brings new challenges and variance with practice comfort by the teams in work with. Preparation for such things is paramount.… Read more »
To my mind retrograde is only useful in an awake intubation setting where you cannot see cords. Then you have all the time in the world to make this work. Long wire through the bronch channel is probably the best way to pull off retrograde.
well…if folks are bringing up all sorts of airway techniques like retrograde, FOI via LMA..I think its prudent to remind ourselves of KISS principle. Blind intubation is , like surgical airway skills, a dying art. It was de rigeur in the past for ENT lists, Dental lists to do blind nasal tubes daily, with bottles of CO2 to induce hyperventilation to assist the procedure. But that is in spont breathing patients..so maybe not so suitable for this hypothetical case! Blind nasal as a rescue technique is terrible. patient is usually apnoeic so no guidance as to if in right direction!… Read more »
Great case that gave me flashbacks to my most recent cric. A couple comments, 1. Fortunately, not all hospitals look at a surgical airway as a Sentinel Event. In fact at my facilities I have never been criticized for my airway choices or performance. Even my most recent “cric”. Which turned out to be a supraglottic or sublingual airway, which was necessitated by comlete calcification of the cartilaginous and membranous structures of the neck. 2. Not all EMS medical directors consider a surgical airway a failure. Howeve, many medical directors are familiar with the “hero” mentality of some ems providers… Read more »
Can’t wait to see you at SMACC, Mike
Wow… great podcast! I can’t agree with you more.. it’s a dying skillset that scares the heck out of most providers. The only way to be ready is learning from situations like you described, mental preparedness, and hands on practice whether that be simulation or by cadaver. The latter is hard to obtain for the average provider. While I’m genuinely heartbroken that I probably won’t be able to attend SMACC; however, I was able to attend CCTMC this past year and participated in the anatomy lab, in which Bill Hinckley (who’s comment I saw above) lectured on Cricothyrotomy. Forgive me… Read more »
thanks for those kind words, Rory.
RE: 141 (airway at Janus General w/ 45 y/o male w/ sarcoid).
Extremely nicely done.
I was sorta on the fence about re-upping for CME membership until I heard this one. Got on it today.
Jim Carroll, CRNA
Wisconsin
: )
Good job on this Scott. Great case with great teaching. Also good discussion on the professional fallout of doing a surgical airway, i.e., the harassment that can occur in their aftermath. Let me add this encouragement to your lecture–always do the right thing. You may need to “justify” the cric after the fact, but if you were doing the “right thing,” it will be easy to explain–just tell the truth, just tell it like it is. I provided anesthesia recently for a patient in severe liver failure in an outside procedural area (a portosystemic shunt). Going through your case reminded… Read more »
Wonderful talk Scott. These points are so important and under appreciated. They must be more widely disseminated. Also excellent solid physiology basis. I agree with using the devices with which one has the most experience. Intubation over a broncoscope through either the nose or mouth is my preferred method. While learning intubation through the nose over a bronch in a large patient is very easy (but may limit tube size). Intubation through the mouth over a bronch takes very much practice esp with patients with large tongue and limited velo pharyngeal space. I have a few questions. First what is… Read more »
Fantastic points! As to the Low bicarb intubation–see Podcast 3