Adult Airway Day- October 20th, 2009

Station #1: Direct laryngoscopy, jet ventilation, flexible fiberoptic intubation (Hoffman)

ENT direct laryngoscopes

First-line laryngoscopes: Dedo & Lindholm (for Hoffman, Pagedar), Kleinsasser (other staff) click for more information re: Dedo Laryngoscope

Lindholm Adolescent Scope -click here for more information re: Lindholm Laryngoscope

Holinger anterior commissure scope- use for better exposure anteriorly

Jackson sliding laryngoscope- has removable component to facilitate insertion of endotracheal tubes Weerda laryngoscope- useful for supraglottic laryngectomies - click here for more information re: Weerda Laryngoscope

Rudert laryngoscope- triangular shape (used in past by Dr. Trask)

Jet ventilation:

It is important to note that there are 2 different proximal jet cannulas (adaptors that connect the laryngoscope to the jet ventilator), one for the Dedo laryngoscope and one for the Kleinsasser laryngoscope. If the one you are given doesnt seem to fit, ask for the other one! Picture (below, left) shows a Kleinsasser laryngoscope with (A) = light source adaptor and (B) = jet ventilation. Note that the jet ventilation always goes off to the right because it always goes towards the side that anesthesia is on. Picture (below, right) shows the jet ventilation machine (B).

Special intubation techniques 1. Flexible fiberoptic laryngoscope for intubation (need to be at least a __ size ETT) Objectives Recognize the different types of laryngoscopes and their uses.

Be able to set up a direct laryngoscope (Dedo) with light source and jet ventilation Appreciate the relationship of the anterior commissure scope with a cuffed 5-0 MLT ET tube Understand the role of the flexible fiberoptic scope in intubation.

Station #2: Rigid bronchoscopes, telescopes, and foreign body removal (Funk) Rigid bronchoscopes

Storz bronchoscopes (2): adult (6.5 & 7.5 x 43 cm; 8.5 available but in separate location), adolescent (5.0 & 6.0 diameter x 40 cm) If you can, try to use at least a 6.5 bronchoscope, because your optics will be much better (with the corresponding 5.5 mm telescope); if you need to use a 6.0 or smaller bronchoscope, you will unfortunately be forced to use a

2.8 mm telescope. Adult Pilling bronchoscope (7.0 & 8.0 diameter x 40 cm) Mostly used for airway dilatations

Key maneuver: At level of vocal cords, rotate bronchoscope clockwise 90 degrees, so that longer edge of bevel is on the right. Advance scope w/ bevel tip in center of larynx and shorter edge of bevel sliding against left cord, to avoid catching and traumatizing right cord with bevel tip. Two methods to place rigid bronchoscope: 1) Directly. 2) Use Jackson sliding or anesthesia laryngoscopes to guide bronchoscope to level of vocal cords Sample rigid bronchoscope:

Single combo unit with eyepiece, rubber telescope adaptor, and suction port. Dr. Funk does not like this and uses the smaller individual units. A. (Direct view) Bridge adaptor for endoscope vs. glass eyepiece vs. rubber telescope adaptor (for quick transfer b/w endoscope & optical forceps) B. (Top) Prism with connection to light cable

C. (Oblique) Instrument guide for flexible suction catheter vs. jet ventilation cannula (though we usually dont jet through bronchs) D. (Bottom) Adaptor for respirator

Foreign body instrumentation Storz optical forceps (preferred): adult or adolescent Nonoptical forceps- rarely used

If there is concern about the foreign body fitting through bronchoscope, you should brace the foreign body against end of bronchoscope and remove both together as one unit. You do not want to shear the foreign body off the end of the bronchoscope. Objectives

 Be able to put together all the different parts of a bronchoscope and to use optical forceps and rigid endoscope with the bronchoscope.

Station #3: Endotracheal tubes, laryngeal mask airways, anesthesia laryngoscopes (Scamman)

Types of ET tubes: standard, MLT, oral RAE, nasal intubation, lasersafe, EMG laryngeal monitoring, cuffed vs. uncuffed Laryngeal mask airway (LMA) Anesthesia direct laryngoscopes= MacIntosh, Miller, Wisconsin/WisHipple

In kids, the Wisconsin 1.5 blade provides a nice intermediate size blade between the more commonly available Miller 1.0 and Miller 2.0 straight blades.

Glide scope Objectives

Recognize and understand when to use the different types of endotracheal tubes, so that you can appropriately communicate with your anesthesia colleagues Understand the role of the LMA and different anesthesia laryngoscopes in airway management

Station #4: Adult emergency surgical airway (Pagedar)

Slash tracheotomy Needle cricothyroidotomy (see separate handout): 18 gauge needle, end of 3.0 ET tube, extension catheter (prn thick neck), syringe halffilled with saline Extra long Shiley tracheotomy tubes Proximal vs. distal extension Proximal vs. distal location of cuff

Objectives

Understand the role of a slash tracheotomy and needle cricothyroidotomy in emergency adult airway management. Be able to perform these techniques if needed. Understand the different types of extra long Shiley tracheotomy tubes and when use of such a tube may be warranted. click to see: Needle Cricothyroidotomy

1. SUGGESTED READING 1. Benjamin B, Lindholm CE.[Ann Otol Rhinol Laryngol] Systematic direct laryngoscopy: the Lindholm laryngoscopes 2003 Sep;112(9 Pt 1):787-97. 2. Reading 3. Reading

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Miller

Size 00, Premature

nside Length (From Base to Tip) mm 45

Model # 14 - 300FO - MIL - 00

0, Neonate 1, Infant 1.5, Infant Plus 2, Child 3, Medium Adult 4, Adult

55 80 100 130 170 180

14 - 300FO - MIL - 0 14 - 300FO - MIL 1 14 - 300FO - MIL - 1.5 14 - 300FO - MIL - 2 14 - 300FO - MIL - 3 14 - 300FO - MIL - 4