Own the Airway!

Reviewed and revised: 05 July 2014

This is a collection of my favourite online video resources to help even the greenest emergentologist ‘own the airway’. This post contains some truly awesome educational resources. Enjoy!

As well as the resources provided in this post, further great resources include:

Also, don’t miss the new LITFL podcast series featuring RFDS’s very own airway Kung Fu master, Minh Le Cong: Own the Airway Audio. For the novice there is also the great EMBasic Airway Episode podcast by Steve Carroll.

Preoxygenation

First, buy yourself some time by adequately preoxygenating the patient.

Open and clear the airway

I’ll start off with the basics. Make sure you can use simple airway adjuncts, including the oropharyngeal and nasopharyngeal airways.

Suction if you need to.

Ventilation

Open the airway and ventilate via a bag-valve-mask using high-flow oxygen.

Reuben Strayer’s take on bag-valve-mask ventilation is essential viewing:

Emergency Ventilation in 11 Minutes from reuben strayer on Vimeo.

If the patient is edentulous, then you might want to adjust the position of the mask like so:

From EM Updates (click image for source)

Racine SX, et al (2010). Face mask ventilation in edentulous patients: a comparison of mandibular groove and lower lip placement. Anesthesiology, 112 (5), 1190-3 PMID: 20395823

Don’t forget you don’t need to hand ventilate if you’ve got a ventilator handy… EMCrit‘s Scott Weingart shows how:

Vent as a Better BVM from Scott from EMCrit on Vimeo.

Laryngoscopy

Now let’s get Scott to talk us through the steps of laryngoscopy. Optimise the position of the patient before you start — this step is often overlooked in the emergency setting. Take Scott’s advice on making the patient’s earhole the same height as the jugular notch to heart.

Remember to use bimanual laryngoscopy.

Make sure you can tell the difference between the larynx and the esophagus!

Stylets and bougies

Bend your stylet to the correct shape. This video shows why it is easier if the stylet is ‘straight-to-the-cuff’, with a hockey stick bend near the cuff. Remember to insert the endotracheal tube from the right side of the patient’s mouth to maximise your view and provide optimal control of the position of the tip of the endotracheal tube:

If you can’t get the tube in first time you might want to recheck the patient’s positioning and consider reaching for a bougie. The bougie should be your best friend in the emergency department!
httpvh://vimeo.com/1085978
The new video takes bougie trouble shooting to a whole new dimension of sophistication:

Also check out Ernest Wang’s video demonstration of bougie-assisted intubation.

LMA

Still can’t get the tube in? Reach for an LMA:

You can also use an LMA as part of a “Rapid Sequence Airway” (RSA) approach to improve peri-intubation oxygenation before laryngoscopy like Darren Braude does:

You can intubate through a standard LMA, but it is usually easier to use a dedicated intubating LMA as shown by the HQMedEd team:

Needle cricothrotomy

OK… you’ve tried an LMA but the chest ain’t rising and the patient looks a little blue… Great, now you can’t intubate and can’t ventilate. While you wait for help to arrive, your options include percutaneous needle cricothrotomy as demonstrated by Andrew Heard:

This is why he uses the cannula that he uses:

This how to convert the cannula into a definitive airway using the Melker kit:

Surgical cricothrotomy

Instead of the needle you might want to use a knife. Here is an open cricothyroidotomy a la Scott Weingart:

Or the bougie-assisted approach shown by the HQMedEd team:

Darren Braude also does bougie-assisted crics:

Or you might like this scalpel-bougie-tube only approach from Andy Heard at Royal Perth Hospital (I know I do!):

Scott Weingart and Minh Le Cong have a great discussion of the merits of the needle cric vs an open bougie-assisted approach in EMCrit’s Podcast 053 — Needle vs Knife: Part 1. There is also this video of Ernest Wang’s approach to the emergency cricothyrotomy.

Some cric kits are so quick and easy they don’t even need commentary!

Laryngoscope doesn’t work!

But, what if all the laryngoscopes in the hospital aren’t working?  You could resort to the old spoon and torch technique I’ve described previously, or my personal favourite ‘blind digital intubation’:

Rich JM. Successful blind digital intubation with a bougie introducer in a patient with an unexpected difficult airway. Proc (Bayl Univ Med Cent). 2008 Oct;21(4):397-9. PMCID: PMC2566913

Here is how Rich describes the technique:

PMC2566913 Bougie-assisted digital intubation. (a) After the epiglottis is identified by palpating it with the long finger of the left hand, the bougie is threaded through the glottis and advanced into the trachea. Tracheal clicking elicits tactile vibrations, which confirm tracheal placement of the bougie. (b) The bougie is withdrawn slightly so that the 25-cm mark is at the corner of the lip. The endotracheal tube is threaded over the bougie while the bougie is stabilized in place. (c) With the bougie held in place, the endotracheal tube is turned a quarter turn to the left and then advanced to an appropriate depth. (d) The tube is held in place while the bougie is withdrawn. Tracheal intubation is then confirmed using capnography or an esophageal detector device.

Pentax video laryngoscope

Or why not just cheat and use the Pentax video laryngoscope they’ve got in my old department:

Awake intubation

There is a way to avoid all this ‘can’t intubate, can’t ventilate’ messiness of course. If the patient isn’t crashing, but needs intubation and you think it might be difficult, then awake intubation of the a spontaneously breathing patient is the way to go. First up is Scott Weingart’s demonstration (check out the accompanying podcast here):

And don’t forget Dr Michael Baillin’s entertaining demonstration of “auto” awake fiberoptic intubation:

Reuben Strayer puts it all together!

To finish, Reuben Strayer, from Emergency Medicine Updates, brings it all together in his screencast lecture on Advanced Airway Management for the Emergency Physician. Also, check out his Emergency Department Intubation Checklist.

Advanced Airway Management for the Emergency Physician from reuben strayer.

But wait, there’s an encore — Reuben also has a great 12 minute screencast on pediatric intubation:

12 minute screencast: pediatric airway for emergency physicians who are not also pediatricians from reuben strayer on Vimeo.

Additional Airway Management Resources:

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Comments

  1. says

    This is an excellent resource. Thanks for your effort to present such a good, thorough post. I’m actually going to run most of this by our residents for a good airway review.

    Have a good day.

    • says

      Cheers Jim -- thanks for the feedback -- hope it all helps! The educational resources available for free on the web are unbelievable these days. Sometimes it’s nice just to tie a few things together.
      Chris
      PS. Not sure who to cheer for in your battle with bongi in the med blog awards -- good luck to you both!

  2. James says

    That is awesome Chris. What a great post. Makes me feel a bit silly trying to teach you something today. Hope you enjoyed the session.

  3. Sa'ad Lahri says

    Hi!
    Thank you for a great resource!
    Will be sharing with my registrar’s and medical officers

    Sa’ad
    Cape Town
    South Africa

  4. Rebecca Weir says

    Thank you once again for sourcing excellent resources for educators such as myself to utilise for teaching. My Rural Critical Care post grad students don’t often get to see a lot of this stuff in real life but they need to at least have the foundational knowledge “just in case” something comes through the doors. Therefore being able to show them videos and practice on mannequins is invaluable.

    Greatly appreciated LITFL and well done “FOAMed”

  5. says

    This was the site that inspired it all. Love the content. We’ve taken most of these concepts and given it a little different structure at our place by dividing the tasks into 8 discrete tasks. I’ve finally gotten around to turning it into a video series and online class titled: Essentials of Emergency Airway Care. It would be awesome if you could check it out and give us some feedback. http://www.thesharpend.org/eeacc

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