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leisurely laryngoscopy
reuben j. strayer emupdates.com
preparationmost important predictor of successwe’re not going to talk about it
mindset optimizing physiology preoxygenation airway pharmacology paralysis vs. breathing
supraglottic device/LMA esophageal occlusion device rigid optical stylet flexible endoscope/fiberoptic retrograde cricothyrotomy/tracheostomy transilluminating lighted stylet blind nasal midline submental digital intubation
airway modality
positionignored at your peril
proper positioning usually ends up saving time (and bad outcomes)
do not intubate in this position
position
head at head of bed, or beyond
position
positionear to sternal notch
Levitan 2003 Akihisa 2015
the best starting position for laryngoscopy
Alexandrou 2011 Ramkumar 2011 Lebowitz 2012 Lee 2015
head of bed upposition
improves glottic view for laryngoscopyimproves ventilation and oxygenationreduces likelihood of aspiration
head of bed upposition
improves glottic view for laryngoscopyimproves ventilation and oxygenationreduces likelihood of aspiration
occiput off
head of bed upposition
improves glottic view for laryngoscopyimproves ventilation and oxygenationreduces likelihood of aspiration
occiput off
head of bed upposition
improves glottic view for laryngoscopyimproves ventilation and oxygenationreduces likelihood of aspiration
occiput off
de Laveaga 2012 Lee 2014 Dolenska 2015
patient’s face at operator’s xiphoid
stand up and stand back
look into the mouth, don’t get into it
position
position
head at head of bed, or beyondear to sternal notchhead of bed upface at operator’s xiphoidstand up and stand back
operator catecholamine management
patient HR
95% 90%92% 85% 75% 65% 50%
laryngoscopy attempt #1
laryngoscopy attempt #2
laryngoscopy attempt #3
BVM Cricothyrotomy
30%
LMA
140
130
120
110
100
90
80
70
60
50
40
30
20
10
operator HR
Aspiration ACLS
SpO2
death grip
low feather grip
elbow inZamora 2014
start laryngoscopy earlymentation
respirationairway reflexes
induction unconsciousness apnea complete paralysis
mentationrespiration
airway reflexes
induction unconsciousness apnea complete paralysis
start laryngoscopy early
thumb twiddling, catecholamines rising
textbook laryngoscopy
mentationrespiration
airway reflexes
induction unconsciousness apnea complete paralysis
textbook laryngoscopy
leisurely laryngoscopy
with deliberate slowness
Sluga 2005
start laryngoscopy early
goal: one millimeter per second
optimal conditions not at the start, but at the end of laryngoscopy
jaw thrust
Corda 2012 Weingart 2010
start when patient becomes unconsciouswhen jaw relaxes, commence laryngoscopy with deliberate slowness
improves apneic oxygenation
improves laryngoscopic view
ideally performed by assistant
scissor open mouth barely insert the blade
get ready for slowness
get ready for slowness
lead with suctionunderutilized by non-anesthesiologistsimproves view in nearly every patientclarifies anatomy by elucidating tissue planesnine out of ten lungs agree: suction first
IGDT incremental goal directed tracheal exposure
methodical target-to-target progression
roll midline down the tongue with deliberate slowness
suction soft palate
identify uvula
creep toward uvulasuction posterior wall
identify epiglottis
optimize head position prnidentify epiglottis
head to sky
ear to sternal notch is the best starting point but may not be the best ending point
optimize head position prnidentify epiglottis
atlanto-occipital flex-ex prnyou can’t know what the best position is until laryngoscopy
creep toward epiglottis
suction hypopharynxseat blade
shift to lifting grip
sweep tongue left prnlift mandible expose larynx
laryngoscope handle angle less than 45 degrees
Zamora 2014
suction larynx
interarytenoid notch
optimize larynx position prn
not BURP
ELM / bimanual laryngoscopy
not cricoid pressure
jaw thrust
laryngoscopy optimization
if you still don’t have an intubatable view, come out and ventilate
patient positioning early laryngoscopy lead with suction IGDT head repositioning bimanual laryngoscopy jaw thrust
with deliberate slowness
use a bougie
would you rather throw a basketball or a baseball through a basketball-sized hole? coudé tip
it is easier to intubate with a bougie than with an endotracheal tube
Shah 2011 Nolan 1993 Gatuare 1996 Noguchi 2003 Martin 2011 Jabre 2005 Detave 2008
use a bougienot to be reserved for difficult airways
relax lift for difficult airway practiceself-confirming
assistant loads tube over bougielaryngoscope stays in
operator advances tube into trachea
bougie block
hqmeded.com
rotate 180º or withdraw and re-insert using the straight tip
tube block
scancrit.com
withdraw 1 cm, turn ETT counterclockwise, advance
tube delivery: bottom right approach
No Yespull corner of mouth
head of bed up
standing straight and back
feather grip
head optimizationleading with suction
bougie
pull corner of mouth
Gamble 2014 McKay 2014
confirm depth - 3 finger tracheal palpation
withdraw blade
inflate cuff.
leisurely laryngoscopy head to front of bed occiput off ear to sternal notch incline torso face at operator’s xiphoid stand up and stand back early laryngoscopy with deliberate slowness
assistant operator left hand
operator right hand
push drugs jaw thrust
additional jaw thrust prn provide bougie pull right corner of mouth load tube over bougie
3 fingers for ETT depth
low feather grip
blade into mouth creep blade down midline
identify uvula creep toward uvula
identify epiglottis creep toward epiglottis
shift to lifting grip sweep tongue left prn
lift mandible, expose larynx
withdraw blade
open mouth
suction soft palate
suction posterior wall optimize head prn
suction hypopharynx
suction larynx optimize larynx prn
deliver bougie
advance tube into trachea
inflate cuff @emupdates
leisurely laryngoscopy head to front of bed occiput off ear to sternal notch incline torso face at operator’s xiphoid stand up and stand back early laryngoscopy with deliberate slowness
rich levitan jim ducanto minh le cong scott weingart george kovacs tim leeuwenburg andy brainard
thanks
emupdates.com
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