Leisurely Laryngoscopy

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



occiput off



occiput off



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



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


start laryngoscopy early

thumb twiddling, catecholamines rising

textbook laryngoscopy

mentationrespiration

airway reflexes


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

Health & Medicine

Leisurely Laryngoscopy