|
|||||
 |
Contents:
Confirmation of ETT Position
Difficult Airway & Failed Intubation
Double Lumen Tubes
This is my personal insertion technique: I prefer not to put my hands in the mouth! After getting the LMA into the the mouth (with the cuff softly inflated), I move it to the right side and rotate it 90 dig left, then use it like a spoon to scoop the tongue up and to the left, sometimes with a 'jiggling' motion. As the tongue moves forward, the LMA will slide easily into the hypopharynx, especially if directed downwards (caudad) from the side of the mouth. If getting into the hypopharynx is difficult, put the LMA in backwards and rotate 180 degrees once far enough in. Make sure the LMA is well lubricated, including the shaft. Persisting if the patient starts to gag or bite is not a good idea! I use the same technique for the ProSeal (i.e. I don't use the introducer). See also Fastrach ETT, the full instruction manual (large!)
Fibreoptics in Airway Management
My personal approach is to stand facing the patient with them sitting bolt upright in the sniffing position and put the TV stack immediately to their left. Bolt upright is the best position for a patient with significant respiratory compromise. I set up TCI propofol and remifentanil infusions to provide conscious sedation - ensuring they remain awake at all times is important! I topicalise the nose using using 5% lignocaine/phenylephrine mixture (three sprays each nostril repeated three times at 5 minute intervals), and do the same for the pharynx and larynx with 3-4 repeated sprays of 5% or 10% lignocaine at 5 minute intervals. With a suitable malleable spray nozzle it is possible to direct the spray directly onto the larynx. Adequate local anaesthesia of the larynx is indicated by a change in the voice. After softening the tip of the ETT in hot water I then put it into the hypopharynx via the nose. Keeping the 'point' of the ETT medial and inferior minimises the risk of damaging the turbinates, and the vasoconstriction from phenylephrine reduces the risk of bleeding to near-zero. Nasal intubation should not, however, be performed in patients with high cervical fractures! Then I run the well-lubricated scope down the ETT and into the trachea, gently railroading the ETT over the scope once it's in. Sometimes the point of the tube can catch on the larynx, so be ready to rotate it as you go in. I typically give a small bolus of remifentanil before passage of the ETT into the nose and into the tracheal. Coughing if any is brief. There are a lot of other ways to topicalise the airway, but this technique is simple, safe and reliable. ENT Technologies can provide the sprays and malleable nozzles. The ADAIR site has an airway equipment museum with examples of many devices, and the Austrian Difficult Airway equipment list is quite comprehensive. Here are some historical laryngoscopes. Suppliers of intubation equipment include:
Airway Societies & Newsletters
|
||
|
|
