This is part 2 of a 2 part series called “how we make easy airways harder”. In this episode I focus on improving endotracheal intubation and avoiding common errors that make airway interventions less likely to be successful.

Airway Checklist Examples

<figure class="wp-block-image"></figure>



<figure class="wp-block-image"></figure>



<figure class="wp-block-image"></figure>



<figure class="wp-block-image"><figcaption>Anything worse than grade 2a is ideally managed using a bougie. Image: nurse-anesthesia.com</figcaption></figure>



<figure class="wp-block-image"><figcaption>Grade 3a should be optimized if possible but can usually be managed using a bougie. Grade 3b cannot be intubated and must be optimized.</figcaption></figure>

Reference:

EMCrit Checklist page

SALAD Airway

Rich Levitan on epiglottoscopy

Video discussion proper steps of laryngoscopy (Credit: EMCrit)

Video demonstrating the value of head elevation in grade 3a view (Credit: AIME Airway/EMCrit)

Bougie and Positioning

PART Trial Effect of a Strategy of Initial Laryngeal Tube Insertion vs Endotracheal Intubation on 72-Hour Survival in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. Wang HE, Schmicker RH, Daya MR, Stephens SW, Idris AH, Carlson JN, Colella MR, Herren H, Hansen M, Richmond NJ, Puyana JCJ, Aufderheide TP, Gray RE, Gray PC, Verkest M, Owens PC, Brienza AM, Sternig KJ, May SJ, Sopko GR, Weisfeldt ML, Nichol G. JAMA. 2018 Aug 28;320(8):769-778. doi: 10.1001/jama.2018.7044.

Effect of a Strategy of a Supraglottic Airway Device vs Tracheal Intubation During Out-of-Hospital Cardiac Arrest on Functional Outcome: The AIRWAYS-2 Randomized Clinical Trial. Benger JR, Kirby K, Black S, Brett SJ, Clout M, Lazaroo MJ, Nolan JP, Reeves BC, Robinson M, Scott LJ, Smartt H, South A, Stokes EA, Taylor J, Thomas M, Voss S, Wordsworth S, Rogers CA. JAMA. 2018 Aug 28;320(8):779-791. doi: 10.1001/jama.2018.11597.

Head-Elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Khandelwal N, Khorsand S, Mitchell SH, Joffe AM. Anesth Analg. 2016 Apr;122(4):1101-7. doi: 10.1213/ANE.0000000000001184.

Feasibility of upright patient positioning and intubation success rates At two academic EDs. Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Sembroski EG, Eddy CS, Perkins AJ, Cooper DD. Am J Emerg Med. 2017 Jul;35(7):986-992. doi: 10.1016/j.ajem.2017.02.011. Epub 2017 Feb 5.

Cross-over study of novice intubators performing endotracheal intubation in an upright versus supine position. Turner JS, Ellender TJ, Okonkwo ER, Stepsis TM, Stevens AC, Eddy CS, Sembroski EG, Perkins AJ, Cooper DD. Intern Emerg Med. 2017 Jun;12(4):513-518. doi: 10.1007/s11739-016-1481-z. Epub 2016 Jun 14.

Cricoid Pressure is Dead

Laryngeal view during laryngoscopy: a randomized trial comparing cricoid pressure, backward-upward-rightward pressure, and bimanual laryngoscopy. Levitan RM, Kinkle WC, Levin WJ, Everett WW. Ann Emerg Med. 2006 Jun;47(6):548-55. Epub 2006 Mar 14.

Cricoid pressure: indications and complications. Landsman I. Paediatr Anaesth. 2004 Jan;14(1):43-7. Review.

Ideal Cricoid Pressure Is Biomechanically Impossible During Laryngoscopy. Trethewy CE, Doherty SR, Burrows JM Clausen D. Acad Emerg Med. 2018 Jan;25(1):94-98. doi: 10.1111/acem.13326. Epub 2017 Nov 3.

Life-saving or ineffective? An observational study of the use of cricoid pressure and maternal outcome in an African setting. Fenton PM, Reynolds F. Int J Obstet Anesth. 2009 Apr;18(2):106-10. doi: 10.1016/j.ijoa.2008.07.006. Epub 2009 Jan 13.

The Bougie and First-Pass Success in the Emergency Department. Driver B, Dodd K, Klein LR, Buckley R, Robinson A, McGill JW, Reardon RF, Prekker ME. Ann Emerg Med. 2017 Oct;70(4):473-478.e1. doi: 10.1016/j.annemergmed.2017.04.033.

Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. JAMA. 2018 Jun 5;319(21):2179-2189. doi: 10.1001/jama.2018.6496.

<figure class="wp-block-image"></figure>