leisurely laryngoscopy

Click here to load reader

Post on 13-Apr-2017

81 views

Category:

Health & Medicine

0 download

Embed Size (px)

TRANSCRIPT

  • leisurely laryngoscopy

    reuben j. strayer emupdates.com

  • preparationmost important predictor of successwere 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

  • positionignored at your peril

    proper positioning usually ends up saving time (and bad outcomes)

  • do not intubate in this position

    position

  • head at head of bed, or beyond

    position

  • positionear to sternal notch

    Levitan 2003 Akihisa 2015

    the best starting position for laryngoscopy

  • Alexandrou 2011 Ramkumar 2011 Lebowitz 2012 Lee 2015

    head of bed upposition

    improves glottic view for laryngoscopyimproves ventilation and oxygenationreduces likelihood of aspiration

  • head of bed upposition

    improves glottic view for laryngoscopyimproves ventilation and oxygenationreduces likelihood of aspiration

    occiput off

  • head of bed upposition

    improves glottic view for laryngoscopyimproves ventilation and oxygenationreduces likelihood of aspiration

    occiput off

  • head of bed upposition

    improves glottic view for laryngoscopyimproves ventilation and oxygenationreduces likelihood of aspiration

    occiput off

  • de Laveaga 2012 Lee 2014 Dolenska 2015

    patients face at operators xiphoid

    stand up and stand back

    look into the mouth, dont get into it

    position

  • position

    head at head of bed, or beyondear to sternal notchhead of bed upface at operators xiphoidstand up and stand back

  • 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

  • death grip

  • low feather grip

    elbow inZamora 2014

  • start laryngoscopy earlymentation

    respirationairway reflexes

    induction unconsciousness apnea complete paralysis

  • mentationrespiration

    airway reflexes

    induction unconsciousness apnea complete paralysis

    start laryngoscopy early

    thumb twiddling, catecholamines rising

    textbook laryngoscopy

  • mentationrespiration

    airway reflexes

    induction unconsciousness apnea complete paralysistextbook

    laryngoscopyleisurely

    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

  • jaw thrust

    Corda 2012 Weingart 2010

    start when patient becomes unconsciouswhen jaw relaxes, commence laryngoscopy with deliberate slowness

    improves apneic oxygenation

    improves laryngoscopic view

    ideally performed by assistant

  • scissor open mouth barely insert the blade

    get ready for slowness

  • get ready for slowness

  • lead with suctionunderutilized by non-anesthesiologistsimproves view in nearly every patientclarifies anatomy by elucidating tissue planesnine out of ten lungs agree: suction first

  • IGDT incremental goal directed tracheal exposure

    methodical target-to-target progression

  • roll midline down the tongue with deliberate slowness

    suction soft palate

  • identify uvula

  • creep toward uvulasuction posterior wall

  • identify epiglottis

  • optimize head position prnidentify epiglottis

  • head to sky

    ear to sternal notch is the best starting point but may not be the best ending point

    optimize head position prnidentify epiglottis

    atlanto-occipital flex-ex prnyou cant know what the best position is until laryngoscopy

  • creep toward epiglottis

    suction hypopharynxseat blade

  • shift to lifting grip

  • sweep tongue left prnlift mandible expose larynx

  • laryngoscope handle angle less than 45 degrees

    Zamora 2014

  • suction larynx

    interarytenoid notch

  • optimize larynx position prn

    not BURP

    ELM / bimanual laryngoscopy

    not cricoid pressure

  • jaw thrust

  • laryngoscopy optimization

    if you still dont 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

  • use a bougie

    would you rather throw a basketball or a baseball through a basketball-sized hole? coud 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

  • use a bougienot to be reserved for difficult airways

    relax lift for difficult airway practiceself-confirming

  • assistant loads tube over bougielaryngoscope stays in

  • operator advances tube into trachea

  • bougie block

    hqmeded.com

    rotate 180 or withdraw and re-insert using the straight tip

  • tube block

    scancrit.com

    withdraw 1 cm, turn ETT counterclockwise, advance

  • tube delivery: bottom right approach

    No Yespull corner of mouth

  • head of bed up

    standing straight and back

    feather grip

    head optimizationleading with suction

    bougie

    pull corner of mouth

  • Gamble 2014 McKay 2014

    confirm depth - 3 finger tracheal palpation

  • withdraw blade

    inflate cuff.

  • leisurely laryngoscopy head to front of bed occiput off ear to sternal notch incline torso face at operators xiphoid stand up and stand back early laryngoscopy with deliberate slowness

  • assistant operator left handoperator 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 operators xiphoid stand up and stand back early laryngoscopy with deliberate slowness

  • rich levitan jim ducanto minh le cong scott weingart george kovacs tim leeuwenburg andy brainard

    thanks

    emupdates.com

View more