Yellowstone Advanced Airway Course Pearls

Thanks to Twitter I was privileged to attend a free advanced airway course hosted by Dr. Richard Levitan a few weeks ago.  This is an incredible 3-day course set in the beautiful Tetons near Yellowstone National Park. The course features lectures, Q&As, and hands-on stations to improve your airway assessment and intubation skills.

Instead of summarizing the entire course, because you really have to experience it yourself to get the full effect, I’m writing down the top 10 pearls I took away from this phenomenal experience.

  1. Intubate one step at a time. Instead of ramming the blade in the airway, take a deep breath and approach the airway in a step-wise fashion. First, find the uvula. Second, perform epiglottoscopy! Track down the uvula until you find the epiglottis. Third, remove the epiglottis off the posterior wall (suction may help remove that sticky film keeping the epiglottis on the posterior wall). Then laryngoscopy, to find a landmark (cords, notch, arytenoids). Finally, place the tube.
  2. Take time to position your patients. Everyone, regardless of age or size, should have ear-to-sternal notch. Want to avoid laundry? Try this.
  3. Learn the airway anatomy. Don’t rely on 2D pictures to understand the airway. Look at the CT imaging of your patients and learn how the turbinates are positioned and where the epiglottis rests in comparison to the hyoid. Understanding positioning and location will improve your skills.
  4. The floor of the nose is flat, when inserting anything into the nose, always stay flat and go straight back.yellowstone2
  5. Levitan has amazing recommendations for performing a cricothyrotomy. He emphasizes making a vertical incision BEFORE going horizontal. This procedure is a bloody mess and very tactile, you want to feel your landmarks before making each cut.
  6. When it comes to a cricothyrotomy, don’t rely on fine motor skills to find the landmarks. You will be too nervous and your hands won’t stay still. Avoid using only one fingertip to palpate and use your entire hand with the laryngeal handshake.
  7. Sedate your patients before invasive procedures to attenuate recall and PTSD.
  8. Learn how to manage yourself, a team, and a patient in a crisis and avoid fixation error. Biggest lesson was his focus on what to do after an unsuccessful intubation attempt; do not try the same method twice. Use bougie, use new blade size, or different operator. But don’t get stuck on stupid.
  9. The DOPE acronym is backwards, if a patient is on a ventilator with signs of hypoxia, you start with (E) equipment first and disconnect the patient from the ventilator and bag them manually.
  10. The Shaka

I recommend everyone try to make it out to the next Yellowstone Advanced Airway Course in 2015. It was honestly a game-changer in how I will now approach the airway.

Edited by Alex Koyfman

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