Airway Cases and Clinical/Cadaveric images and videos

Emergency advanced airway management with intubation, supraglottic airway or front of neck access is usually a high-stress time-sensitive high-acuity low-frequency situation in a critically ill patient that may rapidly deteriorate to arrest at any time. It is a difficult to practice and train however being able to train your brain and eye to recognize anatomy, landmarks and situations as well as think of possible solutions may be part of the answer. Collected here is a library of clinical and cadaveric cases to try to help me in this journey.

isolating right left lung bougie cma cadav lab 2017-11-10

Head and Neck Positioning

Dynamic head elevation may be important for optimal laryngeal exposure for tube delivery.

Intubation Positioning: start with ear to sternal notch sniffing as best as you can, then during laryngoscopy if need to improve laryngeal exposure then consider dynamic head elevation (may be up or down with more/less base of neck flexion and AO extension

Head elevation effect in cadaver lab case with Rich Levitan @airwaycam. Note that all you need to deliver the tube reliably is to identify the posterior cartilages and interarytenoid notch.

Ramping may also help improve laryngeal view (but it is not always about the view).

Use dynamic head and neck positioning during laryngoscopy if required.

Vomitology and Fluids in the Airway

Case of Hematemesis arrest, limited mouth opening, first attempt with CMac Mac 3 blade

Same case with the previous failed DL/VL standard geometry blade attempt, 2nd intubator with CMac D-blade

Suction Assisted Laryngoscopic Airway Decontamination techniques (SALAD 2017) – Cadaver model and airway case

Progressive Landmark Identification with Epiglottoscopy Followed by Laryngeal Identification and Exposure

Airway On Demand: “Good example of a glidescope blade initially placed too deeply. This is common with VL beginners. Practicing Epiglotoscopy (ala Levitan) would have helped. It might be argued that the operator was using too large a blade, but still, with careful placement, this can be avoided. What is the danger? The Eso can give the appearance of the larynx with appropriate stretch. This could lead to an eso intubation.”

Avoid Plunge and Pray Laryngoscopy

The Vocal Cords Con: Glottic impersonation

 

Spontaneous breathing and air bubbles to find the airway

Air bubbles from the airway or moving cord with spontaneous respiration may be able to help identify pathologic airways where there is little recognizeable anatomy due to distortion, damage, drenching (fluids) or debris

Tongue control and creating space and alignment for tube delivery

Optimal VL View and Tube Delivery

Cadaver lab (?) VL tube delivery. Stay back and stay high. Aim for a 50/50 view at the most (HT @kovacsgj): no more than 50% of the glottic at the top of the screen leaving lots of tube delivery space at the bottom of the screen and not more than 50% of the cords seen.

<50/50 VL view in this case: less is more

Grade 2 view on hyperangulated VL (looks like CMAC Dblade) with view of esophagus, improves to Grade 1 with ELM. No tube delivery issue, styletted.

Omega shaped epiglottis VL styletted tube delivery …. into the esophagus!

Styletted tube delivery

Normal delivery of endotracheal tube loaded with stylet

Bougie Tube Delivery

Inability to railroad tube delivery over a bougie during traumatic arrest with a bloody airway

Tube delivery over bougie with no issues in this case

Blade choice

Airway Trauma and Pathology

Stab wound to the neck

Ludwig’s angina

Foreign body

Combo Techniques

Combination of VL plus flexible endscopy is a complimentary technique where VL provides the space to get to just above the glottis and then flex can navigate perilaryngeal pathology and confirm navigation into the trachea.

Awake intubation

Awake intubation cases by flexible endoscope

Example of cadaver lab(?), flexible endoscope (aScope) through an endotracheal tube loaded into a channeled king vision  and navigating the endoscope into trachea

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