How to convert a cookgas to an ETT

Tips from Cookgas.com

A. Selecting the Proper Size and Pre-Insertion Suggestions

• Sizing the air-Q® Blocker correctly is very important. Typically, LMA Supreme size 2.5 cross-references to air-Q size 2.5, LMA 3.0 to air-Q Blocker 3.5, and LMA 4 & 5 to air-Q Blocker 4.5).
• Look at the patient’s Ideal Body Weight (IBW), not the patient’s actual weight. If, for instance, a 5’2”, 125 lb. woman has an IBW of 50 – 60 kg, the appropriate size would be 3.5.
• Visualize the patient, especially the facial structures and laryngeal area. Small structures should guide you to smaller air-Q Blocker sizes, etc.

B. Insertion Suggestions

• Elevate the tongue
• If insertion is forced the epiglottis may down-fold or become lodged into the keyhole opening.
• The patient will still be able to breathe without difficulty, but intubation is more difficult. Jaw Lift is the best way to do this and is very easy to do. Performing a jaw lift also makes sliding the air-Q Blocker into the pharynx much easier as well.
• Doing a jaw lift during insertion is important with all Supraglottic airways, not just the air-Q Blocker.
• Prior to insertion, lubricate both the front and back of the air-Q Blocker.
• Be sure to lubricate the ridges within the mask cavity also.
• If the patient’s mouth is dry the air-Q Blocker ridges can get hung up on the back of the tongue during placement.
• Proper lubrication only takes a few seconds.
• When using the Blocker tube or NG tube through the guide channel, make certain that you lubricate the top of the guide channel and the Blocker tube or NG tube thoroughly.
• Place the Air-Q Blocker with the red tab on the pilot balloon in place.
• Once placed, remove the red tab and inflate with 2 – 5 cc of air or just until you get a nice, firm bounce on the pilot balloon.
• Keeping the red tab in place during insertion keeps the valve open allowing the mask to adjust easily and conform to the pharyngeal space.

C. Minimizing Leaks

• If the clinician hyper-extends the head during placement, put the head in the neutral position after placement. This is better for the patient overall and helps minimize leaks.
• With the air-Q® Blocker inflated, pull the air-Q Blocker back 1/4 – 1/2 inch. This can help to correctly place it.
• Again, it is important to use a jaw lift during insertion. If not done during the original insertion, ask the clinician to remove air from the mask, back the air-Q Blocker out about 3 – 4”, then re-insert using a jaw lift.
• Try a different size of air-Q Blocker. If you use a 3.5, and the patient looks a little big, go up to a size 4.5. If you use a 4.5, and the patient looks a little small, go down to a 3.5.

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D. Intubation Tips: Lubrication

• Prior to intubation, lubricate the OETT generously and lubricate the inner portion of the air-Q Blocker airway tube by sliding the OETT up and down within the air-Q Blocker airway tube several times.
• If it is still a little sticky, then remove the OETT and place a little more lubricant near the end of the OETT and replace the OETT into the air-Q Blocker airway tube.
• This will really lubricate the tube well which is the secret to easy passage within the air-Q Blocker. Again, all this just takes a few moments, but is very important. If the tubes are not lubricated well, the clinician will find it harder to tell when he/she enters the trachea or hits an obstruction.

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E. Intubation Tips: Difficult Visualization

• If use of Fiber Optics does not immediately allow a view of the opening to the trachea and cords, the epiglottis is most likely down-folded (partially shut) or sitting within the air-Q Blocker’s keyhole opening into the mask. This usually happens when a jaw lift has not been done during insertion.
• The epiglottis can then get caught by the keyhole tunnel structure. This can partially close the epiglottis (obstructs the view entirely), or entrap the epiglottis within the keyhole opening.
• Alternatively, a bi-manual external jaw lift will usually expose the glottis for visualization. This can usually be alleviated by performing the “Klein Maneuver.” Deflate the air-Q Blocker, and pull the air-Q Blocker back about 2 – 3 inches. Next, reinsert the air-Q Blocker using a lower jaw lift. This will generally lift the epiglottis up and into the proper position.

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F. Intubation Tips: Bougie Insertion

• It is important to lubricate the bougie so it slides easier, giving the clinician better tactile feedback while passing the bougie.
• First place the ET tube through the air-Q Blocker airway tube approximately 12 – 15 cm, but not completely into the patient. This is called pre-loading the ET tube.
• The ET tube is much smaller than the air-Q Blocker airway tube and will help to keep the bougie centered and help to guide it toward the glottic opening.
• If the clinician passes the bougie alone through the air-Q Blocker before the ET tube is inserted, it is much more likely that the bougie will spin off center during placement.
• The air-Q Blocker airway tube is much larger than the ET tube and also is oval- shaped, giving the bougie much more room to move off center.
• Next, insert the bougie through the ET tube with the tip pointing anterior, and gently pass the bougie forward feeling for obstruction to further passage.
• Do Not Force the bougie. If it goes into the trachea, it will go quite easily.
• If it does not, it is probably off to one side or the other, or hitting the epiglottis as described above. (Remember this is very delicate tissue!)
• Feel over the cricoid area of the neck during passage, a nurse or medic can do this for you.
• A scraping sensation will usually be felt as the bougie passes over the cricoid ring. It takes a little practice to get the feel of this.
• Once the bougie passes into the trachea, advance the ET tube into the trachea using the bougie as a guide.
• Note: Sometimes the bougie, or any type of stylet for that matter, can be properly placed within the trachea, but one is unable to pass the ET tube. In this case, the ET tube is probably hung up on the lower aspect of the inlet.
• If this happens it usually helps to deflate the air-Q Blocker cuff and apply cricoid pressure while passing the ET tube. Also turning the ET tube ¼ turn to the left (counterclockwise) will help by placing the bevel of the ET tube facing down.
• If this does not help, try a smaller ET tube.
• This obstruction to passing the ET tube is not a specific problem to the air-Q Blocker; this happens occasionally with all stylet intubations and intubation devices.
• If the bougie does not go into the trachea easily, it usually misses to one side or the other.
• It usually misses to the right. Pull the bougie back a few centimeters, twist the bougie slightly to the left if you believe it missed to the right, and try to pass again.
• With a little practice, one can usually “walk” the bougie slowly over to the midline and into the trachea.
• This does take some practice. Remember, the bougie will advance quite easily when you enter the trachea, DO NOT FORCE the bougie.
• Hint: A helper feeling over the cricoid area of the neck can often feel the bougie if it misses to one side or the other. Remember if the epiglottis is causing an obstruction, this can lead to unsuccessful attempts with the bougie as well.