Author: Jonathan St. George (EMBER Project)
FIVE THINGS YOU CAN DO ON YOUR NEXT SHIFT TO IMPROVE YOUR LARYNGEAL VIEW
Your next patient requiring a definitive airway has just arrived, and you’re having trouble visualizing where to place your endotracheal tube. The number of tools available to you has multiplied significantly over the years, but tools are nothing without good technique. Here are FIVE simple maneuvers you can add now to your airway skills to improve your laryngeal view and successfully intubate your patient.
THINK VALLECULOSCOPY ENGAGING THE HYOEPIGLOTTIC LIGAMENT
Want a clear view of of the vocal cords? Remember that your path to getting there is finding the epiglottis and seating your blade into the valleculum. Anterior movement of the blade will then engage the hyoepiglottic ligament and will lift the epiglottis and bring the cords into view. Watch this beautiful video and you’ll get the idea. As the hyoepiglottic ligament is engaged, the cords will blossom into view.
Your goal may be to get a clear view of the vocal cords and the larynx but your path to getting that clear view is finding the epiglottis and engaging your blade into the valleculum, NOT searching for the vocal cords.
DON’T LEAN FORWARD…
In moments of stress during a difficult intubation it may seem that moving closer is better, but aside from increasing the chances of getting blood, vomit or other secretions on your face it does nothing to improve your view.
Instead, lean back. bend your legs slightly and align your sight along the laryngeal axis to get the best view.
THE LARYNGEAL AXIS LEAN BACK TO OPTIMIZE THIS AXIS
Remember you want your line of sight to look directly along the laryngeal axis. Once your patient is in a sniffing position, eaning forward into the mouth just makes this harder. So LEAN BACK! Thanks RCEM for the image.
DITCH CRICOID PRESSURE
The original intention of cricoid pressure was to prevent aspiration during intubation. This has since been debunked as another medical myth.
USE BIMANUAL LARYNGOSCOPY DITCH CRICOID PRESSURE AND BURP
This doesn’t mean a more thoughtful use of posterior pressure on the larynx can’t improve your view. Bimanual laryngoscopy will improve your view along the laryngeal axis. https://www.youtube.com/watch?v=LgSrtspeONg
MANDIBULAR ADVANCEMENT THE ADVANCED OPERATOR’S JAW THRUST
The simple jaw thrust can clear an occluded airway, it makes sense that advancement of the mandible can also improve a physician’s view during intubation. Watch how a simple jaw thrust can improve your view in this video. https://www.youtube.com/watch?v=p_QM7vjvRYk Here is airway master Ron Walls take on this technique. Watch here
MAKE A SALAD (SUCTION ASSISTED LARYNGOSCOPY AND DECONTAMINATION)
In the emergency airway, blood, food, vomit and other secretions are always a hazard. Picking up and putting down the suction when badness is welling up from the esophagus can quickly become an exercise in futility. Welcome to the SALAD technique. Suction as much as you can and then just leave it in the esophagus. Wow, what a great idea! Demonstration of the technique doesn’t come until minute 11 in case you just want to see it… https://vimeo.com/123169076
Photo by NatalieMaynor
MAY THE AIRWAY BE EVER IN YOUR FAVOR
In the zombie apocalypse, airway management will be more straight forward… Until then, mastery of these five techniques will give you a better chance of surviving your next intubation.
Five Things (to Master the Airway) – Created with Haiku Deck, presentation software that inspires