perspectives

Featured on #FOAMED REVIEW 28TH EDITION – Thank you to Michael Macias from emCurious for the shout out! Author: Joe Rogers, MD (Senior EM Resident, Rutgers-NJMS) // Editor: Alex Koyfman, MD & Justin Bright, MD The following is a compilation of helpful tips for managing the airway in the emergency department. **EAR TO STERNAL NOTCH POSITIONING** Why do it? -Position yourself (and your patient) for success! -Universal position for both ventilation and intubation – Facilitates maximal jaw distraction and mouth opening – Independent of age and size, though especially helpful in obese patients Of note: – Contraindicated in context of known or suspected cervical spine pathology Technique: – Horizontally align the sternal notch with the external auditory meatus – The facial plane should be parallel to the ceiling; hyperextending the neck may worsen your view – In adults, the head usually needs to be raised; in infants, the torso may need to be raised **NASAL OXYGEN** Why do it? – Administration of high-flow nasal oxygen during pre-oxygenation and after RSI improves arterial oxygenation during apnea – High-flow nasal oxygen saturates the nasopharynx with oxygen, patients inhale a higher percentage of oxygen, and the oxygen reservoir in the lungs increases prior to apnea – Oxygen saturation can be maintained without respirations if a continuous path of oxygen is supplied from the pharynx to the glottis because alveolar oxygen absorption continues during paralysis (“apneic oxygenation”) – “NO DESAT”: Nasal Oxygen During Efforts Securing A Tube Technique: – During pre-oxygenation apply high-flow nasal oxygen at 15 lpm as well as a face mask at 15 lpm – 3 minutes is an acceptable duration of pre-oxygenation – Leave on high-flow nasal cannula during intubation attempts **BIMANUAL LARYNGOSCOPY** Why do it? -External laryngeal manipulation by the laryngoscopist is the easiest, fastest, and most effective modification to improve view Of note: This is not B.U.R.P or cricoid pressure (both of which are done by an assistant, neither of which are helpful) Technique: – Manipulation is most effective at the thyroid cartilage, where vocal cords attach anteriorly – Once the view is optimized, an assistant can maintain pressure at the right location, freeing the right hand to place the tube **HEAD ELEVATION** Why do it? – Improves visualization by enlarging space beneath tongue and epiglottis – Less force required for full laryngeal exposure – After bimanual laryngoscopy, head elevation is the second easily performed manipulation to improve laryngeal view Of note: – Like ear to sternal notch positioning, head elevation is contraindicated in context of known or suspected cervical spine pathology Technique: – Performed while holding the laryngoscope with the left hand – Lift the patient’s head at the occiput with the right hand, keeping the face parallel to the ceiling – When ideal view is achieved, release the right hand – If possible, briefly suspend the head with the laryngoscope and attempt intubation – If the head is too heavy, have an assistant support the patient’s head and shoulders **STRAIGHT-TO-CUFF STYLET SHAPE** Why do it? – Narrower long-axis dimension allows greater visibility – Better maneuverability within the hypopharynx Technique: – Ideal shape of styletted tracheal tube is straight to the proximal cuff, then ≤ 35 degree angle bend at the proximal cuff (> 35 degrees increases likelihood of mechanical impaction) – Use far right corner of mouth to insert and pivot tube – Tube stays below the line of sight until tracheal insertion – Keep tip visible as it approaches target – If tube catches on tracheal rings after insertion, rotate clockwise and advance tube **EPIGLOTTOSCOPY** Why do it? – The epiglottis is the first reliable anterior landmark at the top of the laryngeal inlet Technique: – Prepare suction to maximize anatomical clarity – Slide blade gently and slowly down tongue – Once the epiglottis is in view, move the tongue to the left and lift epiglottis edge off the posterior pharynx – If the epiglottis is not seen, blade may be too deep: slowly pull back until epiglottis drops into view – Advance blade fully into the vallecula – Create anterior pressure at the hyoepiglottic ligament, causing the ligament to pull the epiglottis forward to expose the glottis – Optimize glottic view with bimanual laryngoscopy and/or head elevation **PREDICTORS OF DIFFICULT AIRWAY IN ED** Most Helpful – Thyroid-to-hyoid less than two fingers Somewhat Helpful – Hyoid-to-mental less than three fingers – Airway obstruction – Poor neck mobility, cervical collars, spinal immobilization – Trauma, facial distortion, secretions, mandibular injury – Obesity – Large tongue, large teeth – Grade 4 Cormack and Lehane score – Correlates to hyoid-mental distance, thyroid-hyoid distance Not Helpful – Mallampati classification not practical in ED setting Bottom line: – Beware the short fat neck – Mallampati not helpful – “LEON” – Look externally – Evaluate 3-3-2 – Obstruction – Neck mobility **PEDIATRIC AIRWAY ANATOMY** The unique features of the pediatric airway persist until about age 8 or 9 years, then become more adult-like: Occiput – The head and occiput in children are proportionally larger than in adults – In supine position may cause neck flexion and airway obstruction – To achieve ear to sternal notch positioning, a blanket may be placed under the shoulders and torso Tongue – Child’s tongue is relatively larger – Lower muscle tone increases risk of passive airway obstruction; MCC airway obstruction in children – Can be managed by better positioning or use of an adjunct device such as oropharyngeal airway or nasopharyngeal airway Larynx – Larynx is more anterior and cephalad in children, C4 vs. C6 in adults – Vocal cords slant anteriorly – Bimanual laryngoscopy more likely necessary to visualize the cords; alternatively, the fifth finger of the left hand can be used to improve glottic visualization – Also may be helpful to lower oneself to below the level of the patient and look up at an angle when intubating Epiglottis – The pediatric epiglottis is floppy, long, and narrow – A straight blade (Miller) can more easily pick up the epiglottis to facilitate intubation in