What are you're "go to" primary and secondary airway methods?

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FiremanMike

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Just curious what it's like in other parts of the country/world. When I speak of primary and secondary airway methods, I'm referring to what tools you grab first and then where do you go if your first method fails?

For me, my primary as of last year has been an intubrite MAC 3 with a bougie. I used to grab the MAC 4 first, but I've found that most airways can be visualized at least partially with a mac 3, and this allows me to choke up and hook my pinky around the jaw (of course pediatric patients would get smaller blades..). I've also made an effort to elevate the cot 30 degrees if possible before intubating, I find using gravity to help is wondrous. Some of you might wonder why I grab the bougie right away, and my answer is "why not". The bougie is about $6 more expensive than the stylet, but offers much more flexibility when encountering poor airway visibility.

My secondary airway method would be the king vision with a channeled blade (we also carry the unchannelled blade as an option, but it would be my third choice with no other mitigating factors). We were fortunate to purchase the king airway and an endless supply of blades and it really does do a supurb job, especially on obese patients. It is, of course, not an "end all, be all", and sometimes patient anatomy simply doesn't work right with the king/channeled, but it is definitely a great tool to have.

So, what says the masses?

**ETA - I use the bougie as a stylet, holding the tube back about 10" from the tip and pinching the bougie through the tube for manipulation.
 
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FiremanMike said:
When I speak of primary and secondary airway methods, I'm referring to what tools you grab first and then where do you go if your first method fails?
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Miller 2 or 3 --> +/- bougie --> intubating LMA


FiremanMike said:
most airways can be visualized at least partially with a mac 3, and this allows me to choke up and hook my pinky around the jaw
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That is interesting. What do you gain by hooking your pinky around the jaw? How do you keep the blade off the lower incisors?


FiremanMike said:
*ETA - I use the bougie as a stylet, holding the tube back about 10" from the tip and pinching the bougie through the tube for manipulation.
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I've heard of this, but it sounds rather clumsy and I can't visualize how it would make intubating easier. Do you mean you hold the bougie against the distal tip of the ETT?
 
Halothane said:
That is interesting. What do you gain by hooking your pinky around the jaw? How do you keep the blade off the lower incisors?
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Maybe nothing, but it feels good. As for keeping the blade off the teeth I go with the method of placing the blade in along the tongue until I can see the uvula, then I slide it caudally until it slides into the vallecula, then I just give it a slight rotate to lift the epiglottis where I want it. Should visibility not be what I want it yet, I'll lift up and away with the jaw slightly and usually I can now see at least the bottom of the cords.


I've heard of this, but it sounds rather clumsy and I can't visualize how it would make intubating easier. Do you mean you hold the bougie against the distal tip of the ETT?
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I tried to find a picture of what I'm talking about but was unable. Picture the bougie with no tube on it, picture the point about 10" up where you are holding it for manipulation. The distal end of my tube will rest there, usually I'll actually pinch it a bit but really it can just rest against my fingers while I manipulate the bougie into place. This allows for one fluid motion after bougie placement to put the tube in, and saves you the step of grabbing the tube and placing it over the bougie.
 
King Vision, video largyn

First and if needed second, then LMA
 
1) Direct laryngoscopy, typically with a Mac 4 and a bougie.

2) King tube

We have the Pentax available. I've used it a handful of times, and hated it more with each use. I'm not opposed to indirect laryngoscopy, but I'd prefer something other than the Pentax. I was a pretty big fan of the McGraths when we trialled them.

ETA: I'll also have the tube already on the bougie, sitting above my fingertips.
 
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I'd go with a King followed by an LMA. If need be I'd use a CombiTube but I prefer a King.

Note: My state does not allow EMT-I's or AEMT's to intubate as we are considered BLS.
 
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Don't yell but ours is King then ETT + bougie if the King fails.... :wacko: we're required to use a bougie on every ETT attempt.

As of October first though it's paramedics discretion including the use of the bougie and type of airway.
 
Robb said:
Don't yell but ours is King then ETT + bougie if the King fails.... :wacko: we're required to use a bougie on every ETT attempt.

As of October first though it's paramedics discretion including the use of the bougie and type of airway.
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Wtf not even LA county haha
 
Mac 3 and bougie, bougie used as a stylet on every attempt.
Backup is the LMA Supreme.
 
Mac-3 and bougie (kiwi grip as well); King LTS-D as "rescue", but often is first line; adding KingVision soon at one service and GlideScopes at the other; if intubating a non-arrest patient an NC is on the patient @ 15L/min.

FiremanMike said:
I tried to find a picture of what I'm talking about but was unable. Picture the bougie with no tube on it, picture the point about 10" up where you are holding it for manipulation. The distal end of my tube will rest there, usually I'll actually pinch it a bit but really it can just rest against my fingers while I manipulate the bougie into place. This allows for one fluid motion after bougie placement to put the tube in, and saves you the step of grabbing the tube and placing it over the bougie.
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Kiwi grip! I enjoy this method. There are also some other related forms, "pistol grip," etc. Basically you don't need a friend to load your tube and are less likely to take your eyes off the prize. Here is a video of it in action.

Robb said:
Don't yell but ours is King then ETT + bougie if the King fails.... :wacko: we're required to use a bougie on every ETT attempt.

As of October first though it's paramedics discretion including the use of the bougie and type of airway.
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I'm not sure what's so bad about that. If your next step after an initial attempt is to reach for a bougie...why not have it available on the first attempt?

I bougie every time.

TRSpeed said:
Wtf not even LA county haha
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Nothing bizarre about bougie's, unless you're in the US I guess.
 
I also bougie every time, and we're adding VL (intubrite, it looks like...) and that'll be the first choice, per the medical directors.
 
Intubrite isn't actually video larangoscoppy, it's just a fancy handle with an extra lightbulb on the blade. The second bulb is a black light and supposed to make the cords glow, but that has not been my experience.
 
FiremanMike said:
Ah nice!

Have you guys tried the king vision? How does it compare to the king and the glide scope?
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Yes. We've trialed them all. I do like the KingVision, but the intubrite is nice because the techniques it's the video scope is the same as DL. Very little retraining and there should be no technique loss when moving between the VL and DL. The Glidescope is similar to the King Vision. I was also impressed with the Pentax, but the basic model hasn't been updated in years and they were just bought by a competitor.
 
DEmedic said:
Yes. We've trialed them all. I do like the KingVision, but the intubrite is nice because the techniques it's the video scope is the same as DL. Very little retraining and there should be no technique loss when moving between the VL and DL. The Glidescope is similar to the King Vision. I was also impressed with the Pentax, but the basic model hasn't been updated in years and they were just bought by a competitor.
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How much is the Intubrite? Does it compare to the McGrath?
 
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