# Airway Management



## Carlos Danger (May 10, 2015)

My favorite EMS-related topic. Let's talk about it.

Any questions, tips, or tricks?

ETT vs. SGA? VL vs. DL?

Had anything go really bad or really good?

Read any good research or other articles lately? Any good podcasts or videos or classes?

This includes the docs, too. @Nova1300, @medicsb, @JPINFV, @KellyBracket.....and all the others I can't think of off the top of my head. @jwk, too.....he's probably dropped more tubes than many of us here combined.


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## NomadicMedic (May 10, 2015)

"A Bougie on every tube."

I want it on a t-shirt.


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## MonkeyArrow (May 10, 2015)

I have a question for you CRNAs out there. In practice (reality), how much autonomy do you have during an operation? Do you guys have an anesthesiology physician there for every induction and tube? Are you left to yourself unless you have a problem? Do you always have a physician within arms reach?


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## TXmed (May 10, 2015)

DEmedic said:


> "A Bougie on every tube."
> 
> I want it on a t-shirt.




 I 100% agree. It took me a few trys on the airway dummy but once I had it down I feel like there's nothing I can't do with it


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## JPINFV (May 10, 2015)

MonkeyArrow said:


> I have a question for you CRNAs out there. In practice (reality), how much autonomy do you have during an operation? Do you guys have an anesthesiology physician there for every induction and tube? Are you left to yourself unless you have a problem? Do you always have a physician within arms reach?


 At my hospital (I did a month on anesthesiology), the attending is present for all inductions and extubations. Additionally, the plan is discussed between the attending and the CRNA prior to each case. Outside of that, a lot of times the attendings sat in the break room, which includes a monitor showing the vital signs and rhythm for each of rooms. They also carry an in-house portable phone, so they're always able to be reached.


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## SeeNoMore (May 10, 2015)

I think providers should be comfortable with a variety of approaches to airway management. That said I tend to favor Mac 4 /w Bougie (and an assistant if there is someone free which there usually is on flight or dual tier systems) or a VL for my first attempt.

I have been focusing a lot on conducting intubation in a calm planned and orderly manner including verbal checks of steps taken, equipment at hand and plan for failure of first attempt or complications.  I also think it's important to maintain that focus in the post intubation phase so you don't fail to notice low Sp02, hypotension , poor ETT securing, over ventilation etc.

Placing an OG Tube is also good. Often neglected it seems.


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## Carlos Danger (May 10, 2015)

MonkeyArrow said:


> I have a question for you CRNAs out there. In practice (reality), how much autonomy do you have during an operation? Do you guys have an anesthesiology physician there for every induction and tube? Are you left to yourself unless you have a problem? Do you always have a physician within arms reach?



It varies from place to place. Overall, about 40% of CRNA's practice in settings with no anesthesiologist oversight at all - this is mostly in rural areas but not always. The rest of us practice with some degree of oversight......this can be simply on paper and you rarely even see your anesthesiologist, it can be a situation where the MD is there frequently throughout the case, or anywhere in between.

Where I work, the anesthesiologists do the pre-ops and regional blocks, and poke their head in the door during induction. Other than that, I'm completely on my own for all practical purposes. I choose every drug, the induction technique, how to wake up, everything. I'll call for help if I need it for some reason, and there's a good chance that another CRNA will arrive and the problem will be resolved before the anesthesiologist gets there. Our anesthesiologists are great and I learn from them every day, but they are busy, and they know that we know what we are doing.

I did clinical a few places where there were no anesthesiologists within 50 miles. Another place there were anesthesiologists in house, but they did their cases and the CRNA's did all their own cases independently. Another place there were anesthesiologists, but CRNA's did all the OB anesthesia with no oversight (OB is statistically riskiest types of cases). Another place, there were anesthesiologists in house, but only CRNA's on call at night and on the weekends, covering OB, emergency surgeries, floor & ICU tubes, and messes in the ED. The place I did most of my training, there was anesthesiologist supervision in the main and cardiac OR's, but only CRNA's responded to codes and intubations in the ICU and on the floors, and difficult airway cases in the ED. I got some great experience there.


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## MonkeyArrow (May 10, 2015)

As a followup, is there any real way of determining who gets which cases? I know you said at one of your practices, CRNAs did all OB anesthesia, the riskiest, so I was wondering is that atypical? Would you say as a general rule, the docs get the bigger or riskier cases (cardiac, peds, etc.)?


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## Carlos Danger (May 10, 2015)

MonkeyArrow said:


> As a followup, is there any real way of determining who gets which cases? I know you said at one of your practices, CRNAs did all OB anesthesia, the riskiest, so I was wondering is that atypical? Would you say as a general rule, the docs get the bigger or riskier cases (cardiac, peds, etc.)?



Just depends on how things are set up.

Like I said, about 40% of CRNA's work totally independently. This is mostly in smaller, rural hospitals and the CRNA's in those places do everything.....scheduled cases, emergency cases, OB, floor tubes, everything. But hospitals like that don't usually do cardiac/thoracic or big trauma or big neuro cases. Still, things can get real interesting with unscheduled cases and OB crapstorms in the middle of the night.

In the bigger hospitals where you have bigger surgeries there is generally much more supervision.....but again, it depends. At my program's home hospital, the CRNA's didn't do any adult cardiac or thoracic anesthesia; the residents got all those cases. But the CRNA's did do neonatal and pediatric cardiac cases, with anesthesiologist oversight. The place I did most of my training, the CRNA's did all the cardiac and thoracic cases, with only loose anesthesiologist oversight. The places where there were CRNA's and anesthesiologists doing their own cases, it was kind of "who is good at / wants to do what". "Joe the MD likes doing peds and mask inductions, so he's gonna do the tonsillectomies and ear tubes. Frank the CRNA is good at placing and managing epidurals, so he's gonna do the big bowel resection". It had nothing to do with which cases were bigger than others. But some places, it might.


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## Nova1300 (May 11, 2015)

Yes, you can pretty much seek out whatever practice environment you wish, so long as you are geographically flexible. 

And hopefully you will get a chance to experience all of those environments while in school so you can make that decision.

I have never supervised, though I imagine with an experienced anesthetist there is little work involved.  Some of my favorite tricks in the OR came from 60+ y/o anesthetists, many of whom didn't even have a BSN.  

I, personally, would never want to practice anesthesia alone.  I have been in enough disasters in my career to always appreciate another set of hands nearby, no matter what the certification behind the person's name.  

But, I don't provide anesthesia anymore. Thus my opinion is really moot compared with those who do it everyday.


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## SeeNoMore (May 11, 2015)

Good info. I am on the 10 year plan to get into crna school. If I'm lucky. But its intereting to note so many folks here have done it. Because the topic is brought up : did you know people who went as late as their late 30s or early 40s? Thanks


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## Carlos Danger (May 11, 2015)

SeeNoMore said:


> Good info. I am on the 10 year plan to get into crna school. If I'm lucky. But its intereting to note so many folks here have done it. Because the topic is brought up : did you know people who went as late as their late 30s or early 40s? Thanks



I passed boards just a few days before my 40th birthday, and there were a few in my class older than me. Also I have a good friend who joined the Navy in his mid-30's specifically to go to CRNA school; he was like 44 when he finished.


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## Carlos Danger (May 11, 2015)

SeeNoMore said:


> I think providers should be comfortable with a variety of approaches to airway management. That said I tend to favor Mac 4 /w Bougie (and an assistant if there is someone free which there usually is on flight or dual tier systems) or a VL for my first attempt.
> 
> I have been focusing a lot on conducting intubation in a calm planned and orderly manner including verbal checks of steps taken, equipment at hand and plan for failure of first attempt or complications.  I also think it's important to maintain that focus in the post intubation phase so you don't fail to notice low Sp02, hypotension , poor ETT securing, over ventilation etc.
> 
> Placing an OG Tube is also good. Often neglected it seems.



I'm a size 2 or 3 straight blade in most cases. Only use the bougie when I need it, but I like to have it within reach of course.

Being slow and methodical and paying close attention to position is probably the most important factor, I think, along with good laryngoscopy technique and experience.

I was taught that OG tubes actually increased the incidence of aspiration. Not sure how strong the evidence (if any) is to back that up, but it does make sense to me that in someone with a full stomach, one of the last things you want to do is disrupt the esophageal sphincter. Would be something worth reading about when I get a chance.


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## SeeNoMore (May 11, 2015)

Remi said:


> I'm a size 2 or 3 straight blade in most cases. Only use the bougie when I need it, but I like to have it within reach of course.
> 
> Being slow and methodical and paying close attention to position is probably the most important factor, I think, along with good laryngoscopy technique and experience.
> 
> I was taught that OG tubes actually increased the incidence of aspiration. Not sure how strong the evidence (if any) is to back that up, but it does make sense to me that in someone with a full stomach, one of the last things you want to do is disrupt the esophageal sphincter. Would be something worth reading about when I get a chance.



Huh. OG tubes increasing aspiration has never occurred to me. I will also look into that , especially because I typically place them on all intubations. My thinking was that I would then be prepared to better manage the patient. Very interesting.


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## Carlos Danger (May 12, 2015)

SeeNoMore said:


> Huh. OG tubes increasing aspiration has never occurred to me. I will also look into that , especially because I typically place them on all intubations. My thinking was that I would then be prepared to better manage the patient. Very interesting.


Well now that I think of it, I think the increased risk with OGT was in the context of strategies to use PRE-intubation in patients who are judged to be at high risk for aspiration. Once the ETT cuff is inflated, you are pretty safe no matter what, of course.


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## NomadicMedic (May 12, 2015)

OG/NG tubes were always last on the list for me, and I always seemed to forget about them unless I was working a submersion incident or a code with HUGE gastric insufflation. 

(And honestly, I'm still not very good at NG tubes. They always seemed to get caught up in the back of the oropharynx and refuse to be placed. Practice more?)


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## Nova1300 (May 12, 2015)

sometimes an oral airway works wonders for passing a gastric tube.


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## medicsb (May 12, 2015)

Align ear to sternal notch, ramp them up if need be (at least sniffing position, if possible), and bimanual manipulation of the larynx PRN.  Those have helped me more than anything else and you will get far more milage from those than a bougie.  My favorite airway book is the out-of-print "Airway Cam Guide to Intubation and Practical Emergency Airway Management" by Rich Levitan.  Short, succinct, and truly practical.


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## SeeNoMore (May 12, 2015)

DEmedic said:


> OG/NG tubes were always last on the list for me, and I always seemed to forget about them unless I was working a submersion incident or a code with HUGE gastric insufflation.
> 
> (And honestly, I'm still not very good at NG tubes. They always seemed to get caught up in the back of the oropharynx and refuse to be placed. Practice more?)



This still happens to me on occasion.


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## medicsb (May 12, 2015)

Actual need for a gastric tube in the prehospital setting is rare.  Anyhow, the gastric tube should be placed orally (nasal route is a risk factor for VAP).  To help you can have someone perform a jaw thrust or you can use your nondominant hand to grab the mandible and distract it anteriorly while inserting the tube.  Still having trouble?  Just stick you finger in the back of the throat to help guide it.  Be care not to force it if you're getting a lot of resistance.  (In the past year where I'm working, a medicine resident caused a pneumo while placing a dobhoff tube, which managed to make its way past the cuff of the ETT and into a lung.  OOPS!)


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## SeeNoMore (May 13, 2015)

medicsb said:


> Actual need for a gastric tube in the prehospital setting is rare.  Anyhow, the gastric tube should be placed orally (nasal route is a risk factor for VAP).  To help you can have someone perform a jaw thrust or you can use your nondominant hand to grab the mandible and distract it anteriorly while inserting the tube.  Still having trouble?  Just stick you finger in the back of the throat to help guide it.  Be care not to force it if you're getting a lot of resistance.  (In the past year where I'm working, a medicine resident caused a pneumo while placing a dobhoff tube, which managed to make its way past the cuff of the ETT and into a lung.  OOPS!)



How do you recover from a mistake like that? Don't get me wrong, I'm not trying to say I could not have made the same mistake but I think I'd have to quit.


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## NomadicMedic (May 13, 2015)

SeeNoMore said:


> How do you recover from a mistake like that? Don't get me wrong, I'm not trying to say I could not have made the same mistake but I think I'd have to quit.



that's why they call it practicing medicine


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## Nova1300 (May 13, 2015)

SeeNoMore said:


> How do you recover from a mistake like that? Don't get me wrong, I'm not trying to say I could not have made the same mistake but I think I'd have to quit.



It's too late at that point.  You have too much debt.  Even if you're bad at it, you gotta do it.


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## Accelerator (May 13, 2015)

A trick I learned from a senior medic who is also a respiratory therapist is to have your partner(or your friendly neighborhood firefighter) hook the patient's right cheek out of the way. Such a simple trick but it helps so much.


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## FiremanMike (May 16, 2015)

I got really good with the bougie, then decided to start using the king vision.. Man, that thing is like cheating..


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## Accelerator (May 16, 2015)

FiremanMike said:


> I got really good with the bougie, then decided to start using the king vision.. Man, that thing is like cheating..



We've started using vividtracs at our system. I'm not a fan because you have to hook into a laptop. Something like the king vision seems like it would be a better alternative.


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## Aprz (Jun 3, 2015)

A friend and I on Facebook were talking about using a bougie. I was trying to describe to him how I use the bougie. I had bookmarked a website that demonstrated this. Here it is.

http://prehospitalmed.com/2012/10/24/bougie-with-kiwi-and-pistol-grip-cool-stuff/

Since this is EMTLife's Airway Megathread, I should also share a link to our rapid sequence induction thread.

http://emtlife.com/threads/rapid-sequence-induction-howto.32185/


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## JPINFV (Jun 3, 2015)

SeeNoMore said:


> How do you recover from a mistake like that? Don't get me wrong, I'm not trying to say I could not have made the same mistake but I think I'd have to quit.




Mistake? The resident just scored an extra chest tube (I kid...).


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## Aprz (Jun 29, 2015)




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## Nova1300 (Jun 29, 2015)

Aprz said:


>




This thing can be a lifesaver for an airway misadventure.


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## Carlos Danger (Jun 30, 2015)

The Fastrach is a good device, but there are newer LMA's that you can intubate though with a normal ETT.

I know there are a few out there, but the Air-Q is the one I've used quite a bit. It's a great LMA on it's own, and intubating through it is easier than the Fastrach.


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## VFlutter (Jun 30, 2015)

SeeNoMore said:


> How do you recover from a mistake like that? Don't get me wrong, I'm not trying to say I could not have made the same mistake but I think I'd have to quit.



Better than the NG tube in the brain....

We use non-weighted dobhoffs. Supposedly, injuries where much more common with the old weighted ones. OGs in the lung happen every now and then.

There is really no reason to place an NG on an intubated patient. It will likely be pulled and replaced with an OG in the ICU. Except those patients you know will need it after extubation, ie belly surgeries, but not really a concern for most.

Also a yankauer works well to help guide it where it needs to go.


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## Aprz (Jun 30, 2015)

@Chase i-gel






We recently had a separate discussion on it here.

Air q LMA






Looks like an LMA with a big inner diameter.


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## NYBLS (Jul 5, 2015)

Mac 3 or miller 2 for all standard adult intubations. Bougie is opened and shoved under the pts shoulder so all I have to do is grab it and pull it. First pass success should be the name of the game with something changing between attempts.


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## MonkeyArrow (Jul 5, 2015)

The size of the laryngoscope used is also a factor. I'm not quite sure where I read this but some anesthesiologists prefer to almost exclusively use a smaller laryngoscope for most patents (size 2). They "choke up" on the handle to where their pinky and/or ring finger are physically on the blade. Too large of the blade just gets in the way, making it more worrisome to lift having to use a lever and there being too much blade deeper into the oropharynx and obstructing anatomical landmarks.


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## Carlos Danger (Jul 5, 2015)

MonkeyArrow said:


> The size of the laryngoscope used is also a factor. I'm not quite sure where I read this but some anesthesiologists prefer to almost exclusively use a smaller laryngoscope for most patents (size 2). They "choke up" on the handle to where their pinky and/or ring finger are physically on the blade. Too large of the blade just gets in the way, making it more worrisome to lift having to use a lever and there being too much blade deeper into the oropharynx and obstructing anatomical landmarks.


That is exactly what I do. Miller 2 for almost everyone. I hold the scope in my left hand with only my thumb, index, and middle finger on the handle so that I can use my left pinky finger to flick open the lips and push the tongue forward as I slide the blade into the mouth. My right hand is available to lift the head, grab the bougie, manipulate the glottis, whatever.


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