Airway Management

[Carlos Danger]

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.

 

[NomadicMedic]

"A Bougie on every tube."

I want it on a t-shirt.

 

[MonkeyArrow]

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?

 

[TXmed]

"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

 

[JPINFV]

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.

 

[SeeNoMore]

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.

 

[Carlos Danger]

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.

 

[MonkeyArrow]

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.)?

 

[Carlos Danger]

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.

 

[Nova1300]

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.

 

[SeeNoMore]

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

 

[Carlos Danger]

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.

 

[Carlos Danger]

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.

 

[SeeNoMore]

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.

 

[Carlos Danger]

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.

 

[NomadicMedic]

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?)

 

[Nova1300]

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

 

[medicsb]

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.

 

[SeeNoMore]

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.

 

[medicsb]

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!)