Leisurely Laryngoscopy

In the past two decades, airway management has been revolutionized by the development of video laryngoscopy, hyperangulated blade geometry, optical stylets, laryngeal masks, and a host of advances in airway pharmacology and technique. The core skill of airway management, however, remains laryngoscopy, whether or not the operator uses a blade with a camera at the end. In this presentation, we break down laryngoscopy into its discrete components and describe best practice technique at each step. We will start by describing common mistakes made in patient positioning; proposing a set of parameters the provider can use to guide positioning that is optimal for laryngoscopy, including the configuration of the patient in the bed, the bed height and head elevation, as well as provider stance. We then move into the effect of laryngoscope grip on operator catecholamine management and describe the optimal laryngoscope grip for emergency airway management. We next confront one of the core principles of RSI, the delay between medication administration and commencement of laryngoscopy, and propose an alternative approach that emphasizes early laryngoscopy with deliberate slowness. We turn our attention to the value of the jaw thrust–as performed by an assistant–during airway management, and then move into a step by step analysis of laryngoscopy as the blade moves into the mouth, down the tongue and ultimately to the glottis. We espouse suction as an underutilized device by emergency providers, and describe the two most important intra-laryngoscopy optimization maneuvers: optimization of the position of the head, and optimization of the position of the larynx. We discuss the value of using the gum elastic bougie for both difficult and routine intubations and describe pitfalls encountered when using the bougie (and how to manage them). We conclude by describing the 3-finger tracheal palpation method of endotracheal tube depth confirmation.

1. leisurely laryngoscopy
reuben j. strayer
emupdates.com

2. preparation
most important predictor of success
we’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

4. position
ignored at your peril
proper positioning usually
ends up saving time (and bad
outcomes)

5. do not intubate in this position
position

6. head at head of bed, or beyond
position

7. position
ear to sternal notch
Levitan 2003
Akihisa 2015
the best starting position for laryngoscopy

8. Alexandrou 2011
Ramkumar 2011
Lebowitz 2012
Lee 2015
head of bed up
position
improves glottic view for laryngoscopy
improves ventilation and oxygenation
reduces likelihood of aspiration

9. head of bed up
position
improves glottic view for laryngoscopy
improves ventilation and oxygenation
reduces likelihood of aspiration
occiput off

10. head of bed up
position
improves glottic view for laryngoscopy
improves ventilation and oxygenation
reduces likelihood of aspiration
occiput off

11. head of bed up
position
improves glottic view for laryngoscopy
improves ventilation and oxygenation
reduces likelihood of aspiration
occiput off

12. 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

13. position
head at head of bed, or beyond
ear to sternal notch
head of bed up
face at operator’s xiphoid
stand up and stand back

14. 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

15. death grip

16. low feather grip
elbow in
Zamora 2014

17. start laryngoscopy early
mentation
respiration
airway reflexes
induction unconsciousness apnea
complete
paralysis

18. mentation
respiration
airway reflexes
induction unconsciousness apnea
complete
paralysis
start laryngoscopy early
thumb twiddling, catecholamines rising
textbook
laryngoscopy

19. mentation
respiration
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

20. jaw thrust
Corda 2012
Weingart 2010
start when
patient becomes
unconscious
when jaw relaxes,
commence laryngoscopy
with deliberate slowness
improves apneic oxygenation
improves laryngoscopic view
ideally performed
by assistant

21. scissor open mouth
barely insert the blade
get ready for slowness

22. get ready for slowness

23. lead with suction
underutilized by non-
anesthesiologists
improves view in nearly
every patient
clarifies anatomy by
elucidating tissue planes
nine out of ten lungs agree:
suction first

24. IGDT
incremental goal directed
tracheal exposure
methodical target-to-target
progression

25. roll midline down the
tongue with deliberate
slowness
suction soft palate

26. identify uvula

27. creep toward uvula
suction posterior wall

28. identify epiglottis

29. optimize head position prn
identify epiglottis

30. head to sky
ear to sternal notch is the best starting point but
may not be the best ending point
optimize head position prn
identify epiglottis
atlanto-occipital flex-ex prn
you can’t know what
the best position is
until laryngoscopy

31. creep toward epiglottis
suction hypopharynx
seat blade

32. shift to lifting grip

33. sweep tongue left prn
lift mandible expose larynx

34. laryngoscope handle
angle less than 45
degrees
Zamora 2014

35. suction larynx
interarytenoid notch

36. optimize larynx position prn
not BURP
ELM / bimanual laryngoscopy
not cricoid pressure

38. jaw thrust

39. 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

40. 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

41. use a bougie
not to be reserved for difficult airways
relax lift for difficult airway practice
self-confirming

42. assistant loads tube over bougie
laryngoscope stays in

43. operator advances tube into trachea

44. bougie block
hqmeded.com
rotate 180º
or withdraw and re-insert using
the straight tip

45. tube block
scancrit.com
withdraw 1 cm, turn ETT
counterclockwise, advance

46. tube delivery:
bottom right approach
No Yes
pull corner of mouth

47. head of bed up
standing straight and back
feather grip
head optimization
leading with suction
bougie
pull corner of mouth

48. Gamble 2014
McKay 2014
confirm depth - 3 finger
tracheal palpation

49. withdraw blade
inflate cuff.

50. 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

51. 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

52. rich levitan
jim ducanto
minh le cong
scott weingart
george kovacs
tim leeuwenburg
andy brainard
thanks
emupdates.com