Airway Management Research Update: NewTube

Have I told you I once did five intubations in one day? Modesty dictates I remain stoic and not terribly forthcoming about the details, so I’ll just say I’m thankful for my training, my experience and the fact that each of my patients had names beginning with “Resusci.”

Even those of us who get most of our practice on polyurethane people can learn a lot from Airway World’s quarterly research webinars. Although the hour-long sessions target hospital practitioners, the pace and level of complexity are appropriate for paramedics, too.

September’s podcast featured a case concerning a very unlucky 38-year-old who was shot in the abdomen, then struck by a car. The presenter, Dr. Calvin Brown III of Boston’s Brigham and Women’s Hospital, added that the morbidly obese male was intubated prehospitally on the third attempt, but became difficult to ventilate due to a suspected endotracheal tube (ETT) cuff tear.

Replacing a faulty ETT is essential but far from routine, says Brown. The process involves insertion of a bougie or catheter through the damaged ETT to serve as a guide for the new tube. Research shows that maintaining a view of the glottis during the procedure, with video laryngoscopy (VL) instead of direct laryngoscopy (DL), improves the odds of first-attempt success while lowering the risk of hypoxia.

VL was both the medium and the message highlighted during the two quarterly updates I’ve watched. For those of us accustomed to DL only, switching to VL feels a little like transitioning from three-lead to twelve-lead EKGs. It’s difficult to abandon something familiar that works, even when confronted with superior technology.

Still, the most flexible among us will keep an open mind when trying to imagine holding a laryngoscope in someone’s vallecula while withdrawing an ETT over a bougie. I’ve never done that, but I think I’d need either a helper or one more appendage with an opposable thumb. After the webinar, I watched an independent video of that procedure, during which the bougie had to be anchored by a finger deep in the oropharynx while the tube was withdrawn.

The finger-in-the-oropharynx part scares me; I’m wondering if pediatric Magill forceps would be a better choice.

Brown continued his scenario by introducing an ED attending who elected to use VL for direct visualization of ETT removal and ended up pulling the bougie out with the tube. What a silly clinician.

The lesson is, choose the right tool. Attempting direct visualization of the glottis with a hyper-curved VL blade is like trying to fry an egg in a microwave. No, I’m not speaking from personal experience.

Brown’s case study concluded with the attending physician unable to re-intubate, then calling for a cric kit before wondering if a laryngeal mask airway (LMA) might be a better choice. The answer is most definitely yes according to a study that found the probability of effective ventilation through an LMA was greater than 99%.

The message to prehospital providers is that LMAs or other supraglottic airways are viable, temporary alternatives when the gods of airway management are busy giving some other medic an easy intubation.

You can view Airway World’s quarterly research updates at https://www.airwayworld.com/webinars/.

Mike Rubin is a paramedic in Nashville, Tennessee and a member of EMS World’s editorial advisory board. Contact him at mgr22@prodigy.net.