Tag Archive | "direct laryngoscopy"

Airway Finesse

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Visualizing the Airway

Video laryngoscopy uses a camera and a video monitor to visualize the airway and the glottis, enabling faster intubation. Photo James Radcliffe

The ancient Egyptians figured this out when they built the Great Pyramids thousands of years ago. They used tools to work smarter, not harder.

Intubation is the same way; for years I’ve been watching students and experienced providers in labs and in the field do the same exact thing as the guy moving the furniture. The more frustrated they get, the more brute force they apply and the worse the situation gets. It isn’t until they slow down and begin to work smarter that they begin to have success. There are numerous ways that prehospital providers can gain mechanical advantage and optimize our laryngeal view. We have to understand which tools to use for this each patient during each intubation attempt. Choosing the right blade or techniques is important, as is understanding that some patients or situations dictate other options, such as blind-insertion airways or video laryngoscopy. Video laryngoscopy uses a camera and a video monitor to visualize the airway and the glottis, enabling faster intubation when you’re dealing with difficult airways in which you can’t get good line-of-sight visualization.

People have been placing metal sticks in mouths for centuries to examine the oral pharynx, and inventors have been keeping pace by creating a bigger and better device at every turn. But let’s stop and consider what we are really trying to accomplish with direct laryngoscopy.

Four Steps for Direct Laryngoscopy
Step one is to move any obstacles, such as vomit, food or teeth, out of the field of view with good suction. Trying to visualize an airway through all that stuff is like trying to drive 60 mph in a torrential rain storm without windshield wipers. You’re not going to be able to drive in the rain without wipers, and you’re not going to successfully intubate without suction. The suction unit is our best friend when it comes to airway management for EMS (but it seems to be the one piece of equipment that is left in the truck, missing a hose or uncharged, so it often isn’t there when the need arises).Once we clear the airway, then we’re ready to take a look at the airway.

Step two is to get that first look before anything else gets in the airway. The scissor technique allows us to open the mouth of the supine patient so we can get a great look at the posterior oral pharynx. This is where we begin to identify our landmarks and possible obstructions. Looking straight into the mouth, the first thing we see is the tongue. The size of the tongue plays a part in determining which blade we will use for intubation. If we’re able to see past the tongue, we’ll see the uvula lying in the posterior oral pharynx. As we begin looking into the mouth, we consider the proportion of the structures to the overall space. This helps determine the level of difficulty—or as a good friend always says, “how fun” it will be manage the airway. Once we have a good assessment, we’ll have some idea what tools we might want to use.

Which level of difficulty during intubation do you prefer?

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Step three is to choose the right tool for the job. Prior even to opening the airway, the experienced provider has already assessed the patient externally to determine the level of difficulty to anticipate and the equipment to use. Several scoring systems out there assess the level of difficulty of an airway. The most common is the Mallampati score, which ranges from 1 to 4 with 1 being the best view and 4 being the worst. Richard Levitan, MD, came up with a great tool that we will refer to as the “Four Ds” for oral tracheal intubation. The Four Ds include distortion, disproportion, dentitions and dysmobility. A good way for a provider to assess the Four Ds is using the 3-3-2 technique, which includes 3 fingers breath between the incisors, 3 fingers from the hyoid bone to the chin and 2 fingers from the floor of the mouth to the top of the thyroid cartilage. The rule of thumb is the fewer the fingers, the straighter the blade. Imagine trying to get a big fat stick in an opening that’s barely wide enough to get the tongue through. Choosing the correct laryngoscope blade will help ensure that our efforts aren’t impeded by the tool.

Do you use the Mallampati scoring system when assessing the level of difficulty of an airway?

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Step four is selecting an intubation technique. The direct laryngoscope is a lever with a light at the end of it. Unlike a video laryngoscope, which enables users to capitalize on a superior glottic view and access provided by the video image, direct laryngoscopy doesn’t allow us to look around corners. Therefore, we must have a good understanding of the anatomy to correctly place and use it. The first obstacle that we must move with our lever is the tongue. We simply follow the center of the tongue with tip of the blade and gently lift as we advance, and the blade will naturally come to the vallecula at the base of the tongue. Simply pulling the tongue forward and down will displace the tongue and expose the laryngeal structures; veterinarians have been doing that for years to secure airways in large animals. Remember the laws of physics—every action has an equal and opposite reaction. This means that whatever you do with the handle of the blade will move the other end of the blade. Remember you can’t look around corners so trying to play seesaw or rocking back toward the teeth is only going to impede your view.

Anatomy Refresher

EMS Airway Expert Charlie Eisele shows the airway structures on a cross section of a plasticized cadaver head. Photo James Radcliffe

Relax & Recall Your Anatomy Lessons
Remember to work smarter, not harder. When I teach together with my flight medic friend of mine (the one who grades intubation difficulty in levels of fun), he always says, “Relax. Your most important decision in your shift is what’s for lunch. This will pass.”

So relax and take a deep breath. If you’re one of those folks who needs to take a death grip on the handle and your arm shakes when you intubate, try a pediatric handle and hold it with two fingers and your thumb toward the base of the blade. Great. Now imagine those ancient Egyptians again moving large stones with a lever. They didn’t move it by rocking back; they lifted up and forward. so place the laryngoscope blade at the base of the tongue and lift up and out to move it out of the field of view to visualize the laryngeal structures.

I tried every trick and gadget I could find for years, but they never seemed to work and all I did was get frustrated. I was told if you drop the head of the patient off the end of the stretcher or prop up the shoulders, it would make a better view—wrong. It wasn’t until I started to study the anatomy and consider what I was trying to accomplish that I realized that all I was doing was moving all the structures into my field of view, requiring me to move them even farther to get that good look at the larynx. However, if the patient’s condition will allow, then raise the head to bring the ears even with the chest, thus aligning the axes to allow for a better view.

Success Is As Easy As…
Finding your success is as easy as following this simple rule: Don’t block your view. Keep the blade at an angle to maximize the field of view by sweeping the tongue to the left and slightly turning the handle toward the left. Make sure when inserting the tube to keep the tube to the right side of the mouth, and watch the tip advance through the glottic opening. One technique for advancing the tube is the hook method, simply sliding the tube into the oral cavity from the right corner of the mouth.

If you understand the anatomy and the mechanics of direct laryngoscopy, your success rate will greatly improve. Remember that intubation is a finesse skill, not brute force, so relax and work smarter, not harder.

Be Safe,
Jim Radcliffe, MBA, BS, EMT-P

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The Five Ws of Intubation

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Ask yourself “w” questions (i.e., who, what, when, where and why) when starting an intubation. Photo iStockPhoto.com

We learned that airway comes first in the very first class all of us took in EMS. Up until the recent changes in the American Heart Association guidelines, we had the following mantra stuck in our heads: “Annie, Annie, are you OK?” We were to open the airway, then look, listen and feel. So when it comes to managing the airway in the field, this is the first priority and often the most overwhelming to EMS providers.

Airways can be simple or complex depending on the particular patient, the environment and the experience of the provider. The gold standard for a secure airway, however, the ultimate goal is oxygenation with successful first-time insertion of the endotracheal tube (ETT).We reserve the ETT for a particular patient population in the EMS community. Let’s call them the “who.”

Who & When
The “who or “when” would be those patients who are unable to protect their own airways, who are apneic or who require ventilator support—either manually or by ventilator.

In some cases, selecting this group is obvious. If they can’t breathe on their own, then someone or something needs to do it for them. In other patients, it’s a little harder to determine whether we need to intervene with the airway. This is where we providers need to read the signs or look at tea leaves for guidance. We find signs in our assessment with things like rate and quality of respiration, end-tidal CO2, skin color, work of breathing and pulse oximetry. And sometimes, you’ve gotta ask yourself, “What are the voices telling me?”

Sometimes we providers become a bit anxious, regardless of our level of certifications, licensure or experience, about placing an ETT and controlling a patient’s ability to breathe spontaneously. A good example of this is the provider that doesn’t have the correct medications or the experience to perform a rapid sequence intubation (RSI) on a patient, so they attempt to “snow” the patient with narcotics or try to muscle past the patient’s gag reflex. We’re all guilty of this in some form or fashion at some point in our careers. I sometimes hear providers (including physicians) say, “I did the best with what I had.” Is this really our best? Maybe looking at other options and supportive care that is more time consuming, less glorious and in the best interest of the patient would be the better choice.

What
“What” are we really attempting to do when we intubate using direct laryngoscopy? The simple explanation would be to place a tube into the patient’s trachea to allow for ventilation. This is easier said than done. It’s simple enough in concept but requires us to displace the anatomy that stands between the oral opening and the trachea. Part of this challenge is m the largest obstacle in the airway—the tongue. We need to move it out of the visual field to be able to see the laryngeal structures. Usually when you encounter that huge floppy tongue, there’s a big floppy epiglottis attached to the base of it. If you don’t see it right away, look in the pool of pizza, beans and beer oozing out of the airway, lying in the back of the posterior oral pharynx.

What's the structure at the base of the tongue that prevents aspiration?

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Complicating the patient’s own anatomy is the fact that we’re trying to place a large metal stick in this small space and make enough room to guide the ETT through it to the trachea without inadvertently placing it in the esophagus. If we understand the anatomical structures and how they move, we can use that to successfully manipulate the airway.

One of the most common mistakes I see is when providers attempt to pry with the laryngoyscope blade as opposed to lifting the structures. Remember that the structures we’re attempting to displace are still attached to the patient by a large hinge joint known as the jaw, or mandible. If we displace the jaw, the soft structures attached will follow. This holds true for correct manipulation as well as incorrect ones. If we pry back toward the patient’s head, then all the structures we’re attempting to move out of our way are simply coming up in our face. You may hear this referred to as rocking or prying. It’s often associated with contact with the teeth and pulling the oral opening closed.

The most common cause of that is holding high on the laryngoscope handle and using the 90-degree angle of the handle and blade as the fulcrum and rocking back. Remember basic physics from high school? “Every action has an equal and opposite reaction.” If you’re pulling back on the stick, the other end of the stick is going to react as well and pull the structures right into your view. If we lift the stick up and away, say toward the corner of the ceiling, the jaw will lift and the tongue and epiglottis will follow.

Where
“Where” makes a difference—whether it’s on the cot, in the door, on the floor, in the dark on a train and in the rain. (This is starting to sound like a Dr. Seuss book, but it really is true.) We should make our first attempt our best attempt, so we should try to pick a place or modify the conditions to create our best attempt. If we can get the patient to the stretcher and an elevation and position that enhances our ability to obtain direct visualization of the airway, we’re setting ourselves up for success.

One bad habit I see providers have in the field is to slide the patient to the end of the cot and allow their head to hang back or attempting to intubate with the cervical collar in place. Again, think about the anatomy, have you ever tried to talk with a cervical collar on or hang your head over the back of the chair you’re sitting in? Did you notice that your chin was pointing one direction and your airway was going the other? Provide the patient has no cervical injury the ideal position would be to lift the patients head so to bring their ears even with their chest, you may hear this referred to as ear-to-sternal notch or a wedge technique.

Another great trick you might want to think about is a concept that Dr. Richard Levitan introduced in his book, “The Airway Cam Guide to Intubation and Practical Emergency Airway Management”, ELM or bimanual laryngoscopy, where the intubator actually will manipulate the trachea to bring the glottis opening into view. If the patient has a suspected cervical spine injury, hold inline stabilization while another provider secures the airway, allowing the jaw to be manipulated without restriction. We can’t always relocate the patient when we need to control the airway, so try to use gravity and the patient’s own anatomy to assist in locating and securing the airway.

Why & How
That would leave us with two final questions: why and how. The “why” is pretty simple, to oxygenate my patient. However, that is easier said than done because many of the airway adjuncts we use and the oxygen delivery system are subject to human error, failure or misuse result in injury to the patient, hyper- or hypo-oxygenation, so we must constantly reassess to ensure we are providing adequate oxygenation in a safe manner.

Finally comes the “how?” The simple answer is to do things with the easiest, safest and most efficient means possible. Every situation is different; some patients may require a simple oropharyngeal airway (OPA), a few breaths and transport. Another may need RSI, a definitive airway and the use of video laryngoscopy, which uses a camera and a video monitor to visualize the airway and the glottis, enabling faster intubation. A few may even need a surgical airway.

What benefit might video laryngoscope have that traditional direct laryngoscope does not?

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Conclusion
The patient, the situation, the patient’s illness or injury, the provider’s experience, and the resources available will determine the tools and means of airway control. Ultimately you have to have an airway plan tattooed on your brain so it’s right there every time you need to manage an airway. We’ll save that discussion for another day.

I hope the next time you pick up a laryngoscope or an endotracheal tube you ask yourself these simple questions: who, what, where, when, why and how. Hope to see you soon.

Stay safe,
Jim Radcliffe, BS, MBA, EMT-P

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Intubation Up in the Air

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Intubation takes about twice as long in-flight due to the confined space, quick and reliable means to intubate while in the air. Photo Mark C. Ide

By Lars P. Bjoernsen, MD, & M. Bruce Lindsay, MD

In the prehospital setting, emerg­en­cy care providers must anticipate difficult airways. Air medical crews in particular are routinely tasked with managing the most difficult airways—those complicated by concomitant head injuries, multisystem trauma or presumed cervical spine injury.

Ideally, an airway should be efficiently secured with the method that offers the greatest safety and the least morbidity. The standard advanced prehospital method in trauma patients has been rapid sequence induction (RSI) oral intubation with direct laryngoscopy, which has been shown to be a safe air medical practice.1

In-flight airway management decision-making and practice are significantly influenced by practice setting and aircraft type, but the success rate of intubation in the air medical service is equal to the prehospital setting overall, with air medical personnel routinely contributing to the prehospital care of injured patients by establishing definitive airways.2 We believe innovative technologies, such as video laryngoscopy, will improve the success rates and decrease the morbidity of prehospital intubation, as it is in our aeromedical practice at the University of Wisconsin Hospitals and Clinics.


In-Flight Challenges

Difficult intubation is encountered in approximately 7–10% of patients requiring prehospital emergency endotracheal intubation.3 Stabilization of the cervical spine makes it more difficult to visualize the vocal cords using conventional direct laryngoscopy because optimal alignment of the airway axis requires neck extension.4 Further, cervical collars significantly reduce the ability to open a patient’s mouth, contributing to poor views on direct laryngoscopy.5 In addition, conventional laryngoscopy routinely causes movement of the unprotected cervical spine.6

The prehospital setting itself, particularly in limited workspaces (like that of a helicopter), further increases the difficulty of intubation. And yet, a 1998 study showed that air medical intubations, both pre-flight and en route, for scene calls and interhospital transports, are accomplished with a very high success rate.7

However, in-flight intubation takes approximately twice as long as intubation in a ground setting. This prolongation of intubation is primarily due to problems with positioning of the air medical crew and patient.8 Because a greater success rate is reported when intubation is performed before takeoff, there have been many documented cases in which the crew decided to perform an emergency landing and RSI rather than attempt in-flight intubation.9

Promising New Technology
Studies have proven the video laryngoscope as an effective device for tracheal intubation and shown it provides an improved view of the vocal cords compared with traditional laryngoscopy, even in difficult intubations.10 Although not yet extensively tested in the prehospital setting, case reports show that the video laryngoscope is a promising device for emergency intubation, leading experts to predict that video laryngoscopy will dominate the field of emergency airway management in the future.11

The goal of the video laryngoscope is to facilitate the visualization and recognition of anatomical structures and to facilitate manipulation of airway devices. With its low weight, high-resolution screen and compact size, the portable video laryngoscope has the potential to be a useful device for air medical crews.

Additionally, it provides significant benefit in situations where access to the patient’s head is limited, such as during automobile extrication or in air medical settings when the intubator may be placed adjacent to the patient instead of in line with the patient’s head. The intubator is not required to be “in line” with the patient and therefore can be easily applied in-flight and in other settings with limited space.12

Case Report
No scientific studies have yet looked at intubation success rates in the air medical setting with video laryngoscopy or evaluated the benefit of intubation in-flight with video versus direct laryngoscopy on the ground. Until those studies have been conducted, we must look to case studies for anecdotal reports of this device’s impact on prehospital airway management, including a case report we have submitted to a peer-reviewed journal.13

Our air medical service was called to the scene of a high-speed motor vehicle crash, where the flight crew intubated a 26-year-old male driver pre-flight (in the ground ambulance). On first contact with the air medical crew, the immobilized patient had a Glasgow Coma Scale of three, with rapid, snoring respirations, a blood pressure of 106/60 and a heart rate of 118. Because of trauma to the head and possible cervical spine injuries, it was anticipated to be a difficult airway case.

While in the ambulance, the air medical crew secured the patient’s airway using RSI and oral-tracheal intubation with a GlideScope® Ranger video laryngoscope. In-line immobilization of the neck was provided by one of the paramedics and cricothyroid pressure held by the other. The GlideScope Ranger video laryngoscope provided an excellent, unobstructed view of the vocal cords and an endotracheal tube was easily passed. The patient was transported by helicopter to the regional Level 1 trauma center, where evaluation revealed extensive multisystem injuries.

We have utilized the video laryngoscope for simulated patients (manikins) in the patient care compartment of both an EC-135 and Agusta 109 Power aircraft. Intubation position varied, both from the head of the patient and next to the patient, during daylight and limited light settings. We found the device easy to use when standard direct laryngoscopy would have been difficult or impossible.

Conclusion
No single airway device offers a solution to all scenarios, but we consider the video laryngoscope a useful addition to the range of devices available to the air medical crew. The use of these devices has been suggested in recent guidelines as an alternative technique in difficult intubations, and case reports have suggested that it can be beneficial when managing a patient with cervical immobilization.13-14

However, no studies yet compare prehospital use of video laryngoscopy and direct laryngoscopy by ground EMS or air medical crews. One randomized, single-blinded study that compares different types of video laryngoscopes and traditional direct laryngoscopy with Macintosh laryngoscope was recently started.15 This study will hopefully provide guidance toward implementation of a video laryngoscope for prehospital difficult airway management.

References

1. Vilke GM, Hoyt DB, Epperson M: “Intubation techniques in the helicopter.” Journal of Emergency Medicine. 12(2):217–224, 1994.
2. Thomas SH, Harrison T, Wedel SK: “Flight crew airway management in four settings: a six-year review.” Prehospital Emergency Care. 3(4):310–315, 1999.
3. Adnet F, Jouriles NJ, Le Toumelin P, et al: “Survey of out-of-hospital emergency intubations in the French prehospital medical system: A multicenter study.” Annals of Emergency Medicine. 32(4):454–460, 1998.
4. Hastings RH, Wood PR: “Head extension and laryngeal view during laryngoscopy with cervical spine stabilization maneuvers.” Anesthesiology. 80(4):825–831, 1994.
5. Heath KJ: “The effect of laryngoscopy of different cervical spine immobilisation techniques.” Anaesthesia. 49(10):843–845, 1994.
6. Hastings RH, Marks JD: “Airway management for trauma patients with potential cervical spine injuries.” Anesthesia & Analgesia. 73(4):471–482, 1991.
7. Slater EA, Weiss SJ, Ernst AA, et al: “Preflight versus en route success and complications of rapid sequence intubation in an air medical service.” Journal of Trauma. 45(3):588–592, 1998.
8. Stone CK, Thomas SH: “Is oral endotracheal intubation efficacy impaired in the helicopter environment?” Air Medical Journal. 13(8):319–321, 1994.
9. Braude D, Boling S: “Case report of unrecognized akathisia resulting in an emergency landing 10. Rai MR, Dering A, Verghese C: “The GlideScope system: a clinical assessment of performance.” Anaesthesia. 60(1):60–64, 2005.
11. Sakles JC, Rodgers R, Keim SM: “Optical and video laryngoscopes for emergency airway management.” Internal and Emergency Medicine. 3(2):139–143, 2008.
12. Braude D, Richards M: “Rapid Sequence Airway (RSA): A novel approach to prehospital airway management.” Prehospital Emergency Care. 11(2):250–252, 2007.
13. Bjoernsen LP, Parquett B, Lindsay B: “Prehospital use of video laryngoscope by an air medical crew.” Air Medical Journal. In Press (scheduled September/October 2008).
14. Henderson J, Popat M, Latto P, et al: “Difficult Airway Society guidelines.” Anaesthesia. 59(12): 242–1243; author reply 1247, 2004.
15. Samuels J, Brody R: “Comparison study in adult surgical patients of five airway devices.” (Prospective, randomized comparison of intubating conditions with Airtraq Optical, Storz DCI Video, McGRATH Video, GlideScope Video, and Macintosh Laryngoscope in randomly selected elective adult surgical patients.) Weill Medical College of Cornell University: ClinicalTrials.gov identifier: NCT00602979. (Planned start April 2008.)

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Direct Laryngoscopy Improves Choking Child’s Outcome

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From left: Jersey City (N.J.) Firefighter Pedro Reyes, Jersey City Medical Center EMT Dispatcher Jennifer Pedone, EMS Supervisor William Bayer and EMT Joseph Biggy, Fire Captain Albert Bauer, 5-year-old Priscilla Pereira, paramedics Brian Moriarty and James High, and firefighter Nelson Justino. Photo James Woods

Editor’s Note: Below are two pediatric choking cases. Read about each and then read JEMS Editor-in-Chief A.J. Heightman’s comments and suggestions on why they had different outcomes and how EMS providers can keep their pediatric airway skills sharp.

Grape Obstructs 5-Year-Old’s Airway
By Steven A. Cohen, BS, NREMT-P
JERSEY CITY, N.J. — At a backyard barbeque on July 10, 5-year-old Priscilla Pereira was buzzing around, singing songs and eating grapes when she began to choke. Priscilla’s mother, Ivelisse, saw her child turn purple and go limp. The mother told CBS news, “Honestly she was already gone. She was like gone…she was gone”.

A family friend, who is a nurse, was at the barbeque and tried to do the Heimlich maneuver to no avail. Another friend called 9-1-1 for assistance. The 9-1-1 call was received in the HUDCEN (Hudson County Emergency Network), Jersey City Medical Center’s EMS Dispatch Center. EMT Dispatcher Jennifer Pedone screened and prioritized the call while ensuring that the Heimlich Maneuver was being performed.

The first unit on the scene was a first responder engine from the Jersey City Fire Department, led by Capt. Albert Bauer; this first-in crew also found the child cyanotic and unresponsive. Using a bag-valve mask (BVM), firefighters Pedro Reyes and Nelson Justino were able to get a minimal amount of air into the small patient. It was just enough to keep her oxygenated and improve her color.

Shortly after the fire first responders arrived, a Jersey City Medical Center (JCMC) BLS unit manned by EMS Supervisor William Bayer and EMT Joseph Biggy arrived. They inserted an oral airway and continued BVM ventilations. They too were able to maintain the patient’s color and pulse.

JCMC’s ALS unit, staffed by paramedics Brian Moriarty and James High, then arrived on the scene. During direct laryngoscopy, paramedic Moriarty was able to visualize a grape lodged in Priscilla’s trachea and dislodged it with a pediatric Magill forceps. High was then able clear the grape from the airway with a finger sweep.

Paramedics Brian Moriarty and James High demonstrate how they removed a grape from a pediatric patient’s blocked airway.

Once the airway was cleared, and after a short round of BVM ventilations, Priscilla began to arouse and cry for her mother. This was the best sound that the paramedics said they had ever heard. In order to comfort Priscilla, the EMS crew gave her a teddy bear that’s kept on the ambulances for such occasions. She clutched it close to her throughout the short trip to JCMC. On arrival at the hospital, the child was given a thorough examination, mother and daughter were reunited, and Priscilla was discharged to the care and follow-up observation of her mother.

On Aug.10, 30 days after her choking incident, Priscilla got a chance to meet the team of rescuers that saved her life during a press conference at JCMC. The survivor showed no residual signs of the trauma she endured a month earlier, singing for the camera crews and high fiving her rescuers.
This is a story where all of the links of the chain of survival working as planned. There was early access with bystander intervention, rapid fire first response and intervention, solid BLS care and advanced care by a well-trained team of paramedics.

Related Link
Channel 2 WCBS News Story

Steven A. Cohen, BS, NREMT-P, is assistant director of EMS for the Jersey City (N.J.) Medical Center Department of Emergency Medical Services Office.

In many cases, a lodged foreign body such as a pushpin, can completely occlude a pediatric airway. Photo A.J. Heightman

Pushpin Obstructs 3-Year-Old’s Airway
OCEANSIDE, Calif. — A 3-year-old preschool student choked to death after swallowing a pushpin at the Montessori School of Oceanside, county officials said. Tyler Howell of Oceanside died Monday afternoon of asphyxiation due to airway obstruction, according to the San Diego County Medical Examiner’s Office.

His teacher told authorities that shortly before 1 p.m., the boy made a gasping sound, grabbed his neck and passed out, becoming unresponsive.

A bystander performed cardiopulmonary resuscitation while paramedics were summoned to the preschool at 3525 Cannon Road, the medical examiner’s Office reported. Paramedics took the boy to Tri-City Medical Center, where he died at 1:50 p.m.

Related Link
Fox 5 News Story

Editor A.J. Heightman comments: These two pediatric choking cases had completely opposite outcomes but a common genesis. Small children, particularly those under the age of five, have a habit of putting small objects in their mouth. In the Jersey City case, the fire first responders and EMT crew were both able to ventilate the 5-year-old child until the ALS crew arrived and used direct laryngoscopy and a pediatric Magill forceps to dislodged the grape which had “plugged” the airway like a rubber stopper in a sink.

A McGill forceps with a grape clasped in it simulates the obstacle that was removed from Priscilla’s blocked airway. Photo JEMS

In the Oceanside case, the object that caused the 3-year-old to choke to death was a pushpin, a common item in schools throughout the world. A pushpin is extremely dangerous if inhaled or ingested because it has a needle-like tip on one end that is a hazard in and of itself. If inhaled into the tiny airway of a young child, it can anchor itself in an unusual position, making it extremely difficult or impossible to dislodge. This is particularly true if it advances past the vocal cord region where it can no longer be visualized. In many cases, a lodged foreign body such as a push pin, can completely occlude the airway.

Both of these cases point out why EMS personnel need to stay current in their airway skills, carry adult and pediatric Magill forceps in their first-in airway bags and bring suction in with them on all airway calls.

In addition, crews need to understand, for their own emotional wellbeing, that there are often young children that get into impossible circumstances and can’t be resuscitated. It’s the nature of our work and a part of EMS that we all hate. But it’s critical that crews understand and accept the fact that, despite their best efforts, young patients are going to die.

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An Introduction to Video Laryngoscopy

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The GlideScope Ranger in use by Dr. David Cannell, during a medical mission in the Philippines. Photo Verathon

“…video laryngoscope provided excellent laryngeal exposure in a patient whom multiple experienced anesthesiologists had repeatedly found to be difficult or impossible to intubate using direct laryngoscopy.”(1)

Let me put my view of video laryngoscopy right up front. Video laryngoscopy is better than direct laryngoscopy. It reliably provides a better view and requires less force than direct laryngoscopy. There’s less trauma to the patient. First-pass intubation success rates are higher and require less time than direct laryngoscopy. Video laryngoscopy is better for our patients and should be the standard of care for oral tracheal intubation.

Wow, Charlie, those are pretty bold statements! I make these statements based on five years of experience with a variety of video laryngoscopes in the field, the operating room (OR) and cadaver labs. I have these views based on the scores of journal articles and studies I’ve reviewed. I have these beliefs from conversations EMS, anesthesia and emergency medicine professionals from the U.S., Canada, Europe, Australia and Asia. Ask anyone who has ever used a video laryngoscope and you’ll find very few who don’t agree with most of my statements. Yep, I’m pretty comfortable with my point of view, but this wasn’t always my position.

I’m a tightwad. Just ask my wife and anyone I’ve worked with. I hate spending money, especially my own. Also, I am a skeptic. I look at new technology with a suspicious eye. I see no reason to change for the sake of change. Imagine my thoughts back in 2006 when I first saw a video laryngoscope. Wow! That’s a lot of money for a camera and some lights. I’ve done just fine intubating patients for over twenty years with my metal sticks, why should I change? It took me at least a year of working with the instrument before I started to believe there was a better way to intubate my patients.

Direct laryngoscopy has changed very little since its implementation in medicine over a century ago. The early ’90s saw several developments in the anesthesia world. In operating rooms, flexible and rigid fiber optic devices were used to place endotracheal tubes in patients with difficult airways. Even seasoned professionals needed extensive practice with these devices.(2) It was incredibly rare for these instruments to find their way to an emergency department, let alone in the hands of EMS providers.

I’d like to tell you that anesthesiologists used fiber optic instruments as the springboard to video laryngoscopy, but I can’t do that. Video laryngoscopy truly had its birth in the profession of surgery; specifically laparoscopic surgery. The earliest patent I could find for a video laryngoscope was issued to Dr. Jonathan Berall in 1998.(3) The first commercially available video laryngoscope was designed by Canadian surgeon, Dr. John Allen Pacey and introduced in 2001.

I have to make a disclosure here. Dr. Pacey is one of my EMS heroes. He’s a soft-spoken man, but vigorously passionate in caring for his patients and developing new technologies. I’ve known Dr. Pacey for years and I’m honored and humbled to call him my friend. Earlier this year, I was privileged to interview him for this website. During the interview, he told the story of how he developed the GlideScope. I’ve heard the story countless times, but each time it’s told, I listen with wonder. Watch the video interview and see what I mean.
It took me a while to understand that video laryngoscopes are not traditional laryngoscopes. I was routinely frustrated and typically unsuccessful because I tried to apply direct laryngoscopy skills. My epiphany came when I finally realized it isn’t a laryngoscope, it’s a camera! With that paradigm shift, I became proficient. It’s the function of every video laryngoscope to place a miniature camera and light in the supraglottic region and transmit the image to a monitor.

A number of instruments are on the market, and they differ in the location of the viewing monitor, shape of the blade and method of inserting the endotracheal tube. Monitors are either attached directly to the laryngoscope handle or at the end of a cable that is connected to the handle. Attached monitors are compact and typically take up less room in gear bags. When you adjust the handle with an attached monitor, you also have to move your head to stay in front of the screen. Detached monitors provide a larger viewing screen and don’t require you to move your head when you adjust the handle.

I’ve seen three blade shapes; a modified Macintosh, an L shape and the proprietary angle of the GlideScope. Remember, the blade is the vehicle used to place the camera and lights in the supraglottic area using the least amount of force. I’ve found the greatest success by using my thumb and two fingers to manipulate the blade; it just doesn’t take much pressure to obtain a view. If you have to apply significant force to obtain a video view, you need to perfect your technique or try different shaped blade.

Two of the L shaped instruments I’ve used with monitors attached to the handles have an endotracheal tube channel on the right side of the blade. Once you have a clear view of the glottis, advance the tube through the channel into the glottis. The other method of placing a tube is manually placing the tube with your right hand. Some of my European friends prefer to place the tube without a stylette, but I’ve had much greater success using one.

Each device offers other features such as video and still recordings, disposable or reusable blades, battery type, air worthiness certificates, ruggedness, size and monitor size. The best way to determine which video laryngoscope is best for you is to put one in your hand. Try as many as possible. Start with manikins, and then move to the cadaver lab and patients. I’ve used pretty much everyone out there, so let me know if you have any questions.

Let’s talk about the elephant in the room; cost. I’ve met very few folks who weren’t impressed with the view, ease of use, and superiority of video laryngoscopes over direct laryngoscopy. I’ve met very few folks who didn’t hesitate when they saw the price tags and I was one of them. While I am still a card carrying tightwad, I do believe you get what you pay for.

How many of you old timers remember using a Porta-Power and Come-Along for vehicle extrication? When Ed Curtrell showed us a new fangled hydraulic tool, a Model 32 spreader, he wanted $5,000 for the system. Show me a rescue unit today without a high pressure hydraulic tool; it’s the industry standard. Last year, the State of Maryland required every ALS unit to have cardiac monitors with 12-lead ECG capabilities. How much did you pay for your most recent monitor? It’s the standard of care.

With all of the recent literature, articles, and editorials questioning EMS providers’ competency to provide endotracheal intubation, I just don’t understand why folks aren’t running to this proven technology. End-tidal carbon dioxide capnography isn’t cheap, but we embraced it and made it a standard of care. Because of adverse court settlements involving direct laryngoscopy, the attorney for a community based emergency physicians group proactively recommended the group drop direct laryngoscopy by its emergency physicians. The group now either intubates in the emergency department via video laryngoscopy or places a supraglottic airway.

The two operational medical directors who have had the greatest impact on my EMS career are Frank M. Yeiser, Jr., MD and Douglas Floccare, MD. Both of these men taught me that same thing; just do what’s best for your patient. Friends, video laryngoscopy is what’s best for your patients.

Take care and be safe.
Charlie

References
1. Richard M. Cooper, Can J Anesth. 2003;50:6, 611-613.
2. Clifford Boehm, MD Assistant Professor of Trauma Anesthesiology, R Adams Cowley Shock Trauma Center. Personal communication, 2008.
3. Jonathan Berall, US Patent 5,827,178, www.uspto.gov.

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic.

For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police.

Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization.

Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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‘Grounded’ Care

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Visualizing the airway in a burn patient

By Marvin Wayne, MD, FACEP, FAAEM

Airway management is a basic and essential skill of anyone caring for an injured or a seriously ill patient. Although many patients can be managed with a non-invasive airway, many benefit from endotracheal intubation.

Much has been written about the hazards of endotracheal intubation, even in this latter patient group. Paralytics have been suggested, and utilized, by some ground and air EMS systems, but concern has arisen over the ability of crews to achieve effective intubation even with paralytics.

One study, for example, showed esophageal intubation rates for all patients as high as 25%.(1) The challenge for prehospital advanced life support (ALS) providers, then, is achieving a balance between the need for intubation and safely achieving that intubation.

Even in the most controlled circumstances, endotracheal intubation can be challenging. Although the addition of routine end-tidal CO2 (EtCO2) monitoring has reduced the incidence of esophageal intubation, it does not reduce the difficulty of the prehospital intubation process. In the field, poor lighting conditions, bad weather, the physical location of the patient, injuries to the neck and spine, and variations in skill levels of the operators contribute to that difficulty. But new technology may be able to provide some, if not all, of the solution to that dichotomy.(2)

The goal of any new airway technology should be to reduce multiple attempts at intubation, as well as prevent dental, mouth and airway trauma, desaturation, intracranial hypertension, pneumothorax, pulmonary aspiration and even iatrogenic death from an unrecognized esophageal placement.(2)

The Advent of Video Laryngoscopy
For many years, direct laryngoscopy (DL) has been the gold standard by which to achieve intubation, performed with either curved or straight laryngoscope blades. However, DL often yields surprisingly poor laryngeal views. Alternatives have been explored, but most have proved to be difficult to master, time consuming, unreliable and costly. Even rigid fiber-optic laryngoscopes—the technology on which “modern” DL is based—hasn’t been widely used, despite its advantages. What has been needed is a device that provides a full view of the glottic airway during laryngoscopy and is easy to learn and master by medical personnel who may or may not frequently perform intubations.

A significant advance took place in this realm when the video laryngoscope (VL) was developed for use in the surgical suite. These devices have a camera lens incorporated into the handle or blade, allowing the image of the larynx/glottis to be displayed on a monitor that’s either directly attached to, or separate from, the blade/camera system. The ability to see the larynx while intubating, even in the most difficult patients, as well as being able to use the monitor as a teaching tool, are recognized as important advancements in airway management.

Although many of these devices (i.e., McGrath Series 5 from LMA North America, TruView from Truphatek, Storz DCI, AWS-S100 from PENTAX Medical Co., Video Macintosh Intubating Laryngoscope System from Volpi AG and GlideScope® from Verathon Medical®) have proved their worth in the hospital setting, a new design was necessary for use in the prehospital environment. This new device would have to be rugged, small and easy to manipulate when working in difficult field conditions.

Currently, the only product on the market that we believe meets all of the criteria for
use in the prehospital environment is the compact GlideScope Ranger.

The Ranger has a digital camera lens incorporated into the center (versus the tip) of its specialized blade, which allows a wider view of the vocal cords on its monitor. A unique anti-fogging technology provides an unobstructed view of the larynx throughout the entire process of tube placement, a feature that’s especially valuable during emergency intubation. It weighs less than 2 lbs. and is engineered to be dependable in a variety of challenging field conditions, including very high or low temperatures, high humidity, and high altitude.

The Ranger is powered by a rechargeable lithium battery, which provides a minimum of 90 minutes of continuous use. A rigid stylet aids in the control of the endotracheal tube (ETT) as it enters the larynx. The blade has a 60º curvature in the midline to match anatomical alignment, so it doesn’t require a “line of sight” for a good view. The high-resolution color display monitor provides a clear picture of the larynx and vocal cords even in bright light, which, again, transforms it into a valuable teaching tool.

There appear to be special benefits to the GlideScope Ranger for trauma patients with limited mouth opening or in cervical immobilization.(3) Very little force is required to expose the glottic opening with the blade so manipulation of the head and neck is reduced. It also functions well in situations where blood or other fluids are present, in mildly obese patients, and because direct visualization of the glottis is unnecessary during intubation, the GlideScope Ranger is less stimulating, an advantage for use in semi-awake patients.

A New Technique
The manner in which tracheal intubation is performed with the GlideScope is unique to its design. The handle is held in the left hand in the same way that one would hold a standard laryngoscope, while the blade is inserted between the teeth under direct vision. It’s important to start out in the midline of the tongue and to stay on the midline. (There’s no need to sweep the tongue out of the way, as is usually the practice with conventional laryngoscopes.)

When the uniquely curved blade passes the teeth, the clinician can now follow the landmarks on the video monitor proceed to the larynx. Identifying the glottis is generally easy. The only technical difficulty with the GlideScope may be guiding the ETT toward the image of the glottis seen on the screen. This difficulty is encountered because the camera is directed (by design) at a 60º angle.

The manufacturer recommends bending the ET tube to conform to the shape of the blade for a gentle curve of 60º. Still, the angle by which one inserts the tube is quite steep. A special stylet developed to lessen the difficulty of passing the tube into the trachea is available, but if advancing the tube presents a problem, withdrawing the GlideScope 1–2 cm will allow the larynx to drop down and reduce the angle required to insert it correctly.

The main limitation of the GlideScope is that there may be a physical resistance in the advancement of the ET tube; with a little practice this limitation is easily overcome. But once familiar with the steep angle of approach, the device is extremely easy to handle.

Case Reports
The following are examples from Whatcom (Wash.) Medic One of the type of cases in which the GlideScope Ranger may be extremely useful.

Case 1: EMS responded to a conscious 57-year-old female, a victim of a fire that started in her home. She had second-degree burns on her legs, buttocks and thighs greater than 30% of her body. She had redness of her face, but no obvious singeing of nares. There were questionable particulates in her oral cavity, but no voice change. Pulse oximetry was 93% on room air, rising to 95% on oxygen given by non-rebreather (NRB) mask. The patient had a history of smoking one pack per day. Respiratory rate was 30 but appeared unlabored. Blood pressure was 130/90, heart rate was 110. She was awake and talking.

Because she was 25 miles from a community hospital and 100 miles from a burn center, and although a major airway burn was not expected, it was elected to provide rapid sequence intubation (RSI) as a precaution prior to helicopter transport to the burn center. RSI was conducted, and the GlideScope Ranger was used to visualize the airway.

Surprisingly, the crew found she had soot in her pyriform sinuses, edema of her glottic opening and significant erythema of the entire region. The GlideScope made possible a quick (18 seconds) and easy intubation, and the video monitor provided an excellent teaching opportunity the prehospital personnel involved. In addition to direct visualization, EtCO2 further confirmed correct tube placement.

Case 2: EMS responded to a 60-year-old male in severe respiratory distress. He was in the bedroom of a manufactured home. He suffered from severe Pickwickian syndrome related to morbid obesity, and had a body mass index (BMI) of 43. (His weight was approximately 656 lbs).

He was obtundent and had a pulse ox of 85%. Blood pressure could not be obtained in the patient’s current position, and moving the patient would require assistance that was not available at the time. His respiratory rate was 40, shallow and labored. Oxygen by NRB mask did not improve his condition.

In light of further deterioration, intubation was the only alternative. However, his BMI and body habitus were going to make it a difficult intubation. He was sedated with midazolam and, using the Ranger, was intubated within 26 seconds. Despite limited mouth opening and a difficult position, tube passage was assured via excellent visualization of his vocal chords.

Case 3: EMS responded to a 67-year-old male in cardiac arrest found in an alley behind a tavern. It was 2 a.m. and raining, and he was difficult to get to because vehicle access was blocked by construction in the area. The first responding basic life support (BLS) unit started CPR with bag-mask ventilation (BMV) performed with extreme difficulty.

The patient had vomited copious amounts of stomach contents. The AED showed that no shock was indicated. After suctioning the oral cavity, intubation was performed with the Ranger in 33 seconds. Tube placement was confirmed by direct visualization on the GlideScope monitor and EtCO2. The patient, who had probably sustained a primary respiratory arrest, was successfully resuscitated.

Case 4: EMS responded to a car struck by a semitruck at high speed. The driver of the car was trapped in the vehicle and had significant craniofacial trauma. His airway was compromised, and he had agonal respiration. To extricate him, extensive rescue operations were required.

A paramedic was able to intubate the patient from the open windshield using a Ranger with the blade of the laryngoscope reversed. It took two attempts and 42 seconds to place the tube, with suctioning required after the first attempt. Confirmation of tube placement was done via direct visualization on the GlideScope monitor and EtCO2.

These case reports demonstrate the capabilities of a video laryngoscope, now available to EMS personnel, in performing emergency intubation. In the first case, without video visualization it would have been difficult to diagnose the glottic swelling that was unsuspected on initial examination. In the second case, this high-BMI patient with complex anatomy might not have been able to have any airway achieved. In the third, a dark night, aspiration and other factors made any airway extremely difficult. And in the fourth, it’s unlikely the intubation could have taken place at all until the patient was extricated from the vehicle.

The ability to successfully intubate critical patients in the field, especially those who present with difficult airways for a variety of reasons, is an important advancement in emergency airway management.

The Impact on Prehospital Care
The potential impact of video laryngoscopy on prehospital medicine may be significant, especially for ground services that are often faced with difficult airways and air medical personnel who must work in tight quarters while airborne.

As previously mentioned, field intubations are by definition fraught with potential complications, such as esophageal intubation, pneumothorax, reduced ventilation and oxygenation, and pulmonary aspiration.(2) Because of the ability to visualize the airway without distortion from fogging to, in effect, “see around the corner,” many of these complications can be avoided.

One study looked at Cormack-Lehane ratings (Grades 1–1V) of those obtained with the GlideScope in 15 patients with cervical collars.(4) The Cormack grading in 14 of the 15 patients (93%) was reduced by one when using the GlideScope. Five Grade I1 patients became Grade 1 using the GlideScope. The average time of intubation with the GlideScope was 38 seconds without complications, including any damage to the teeth. This improvement in visualization of the glottis during intubation is a major factor in the conclusion of some that direct laryngoscopy for emergency intubation will become a relic.(2,3)

The GlideScope has also become the method of choice for many in training of airway management.(5) Currently, Whatcom Medic One is conducting a crossover study of video camera-assisted intubation versus traditional laryngoscopy. Although preliminary data is encouraging, many questions remain to be answered. These include cost versus benefit and skill maintenance of the traditional technique when a camera system isn’t available. Time and the marketplace, we believe, will help answer those questions. However, a new era of airway management may soon be on all of our horizons.

References
1. Katz SJ, Falk JL: “Misplaced endotracheal tubes by paramedics in an urban emergency medical services system.” Annals of Emergency Medicine. 37(1):32–37, 2001.
2. Rao BK, Singh VK, Ray Sumit, et al: “Airway management in trauma.” Indian Journal of Critical Care Medicine. 8(2): 98–105, 2004.
3. Rose DK, Cohen MM: “The airway: Problems and predictions in 18,500 patients.” Canadian Journal of Anaesthesia. 41(5 pt 1):372–383, 1994.
4. Sakles J: “The GlideScope Video Laryngoscope: A practical guide to the future of airway management.” Emergency Medicine and Critical Care Review. 2(1):34–35, 2006.
5. Agrò F, Barzoi G, Montecchia F: “Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization.” British Journal of Anaesthesia. 90(5):705–706, 2003.
6. Rai MR, Dering A, Verghese C: “The GlideScope System: A clinical assessment of performance.” Anaesthesia 60(1):60–64, 2005.

Disclosure: The author has received no monetary support from Verathon Inc. His EMS system, Bellingham/Whatcom County, Wash., has received support from Verathon in the form of four video laryngoscopes for evaluation and research purposes.

This article was originally published in The Perfect View.

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How to View the Supraglottic Structures

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Gustav Killian, who created suspension laryngoscopy, prepares a bronchoscopy in this historic photo. Photo Repro, Universität Freiburg, Germany.

My wife really doesn’t enjoy going to historical sites with me. I’m one of those guys who reads every word and looks at every artifact. I could spend an hour at just one display. Combine my interest in history with my passion for airway management and writing this article was inevitable.

I’ve heard it said that tradition is the reason we use to explain a technique when we’ve forgotten the original rationale. History gives a view of our origins and an explanation of why we do the things we do. In regard to laryngoscopy, I’ve found that little has changed in centuries.

Indirect Laryngoscopy: Sun & Mirrors
Indirect viewing of the supraglottic structures has been described since the mid 18th century. And while it isn’t specifically documented, laryngoscopy with mirrors has likely existed since the first century A.D. The use of dental mirrors to examine the oral cavity was mentioned by Celsus at the end of the first century B.C., and such instruments were found in the remains of Pompeii, which was destroyed in 79 A.D.(1,2) In 1743, French obstetrician Andre Levret described using a variety of oral inspection devices.(3) Philipp Bozzini invented an endoscope of sorts, a series of tubes connected to a small candle lantern. He developed the device in 1804 and used it to inspect bodily openings. In 1807, he published a description of his device and his works, but the Vienna Faculty of Medicine effectively quashed his work by saying, “Only very small and unimportant parts of the body could be examined.”(4)

Benjamin G. Babington, a physician and epidemiologist, is generally regarded as the inventor of the laryngoscope because a description of the device was published in March 1829.(5,6) With the patient’s back to the sun, a hand mirror directed sunlight on to a modified dental mirror, which reflected light onto the supraglottic structures. A down-turned metal tongue depressor was attached to the dental mirror with a spring to displace the tongue and help create a larger viewing area.(7)

Over the next 25 years, a number of European physicians experimented with a variety of mirror devices to observe the supraglottic area, but it took a Spanish singer to truly exploit indirect laryngoscopy. Intrigued by the singing voice, Manual Garcia made extensive records on his observations of the laryngeal structures and their movements to produce sound. He presented Physiological Observations on the Human Voice to the Royal Society of London in 1854 and was eventually awarded an honorary degree in medicine.(8)

If you accept that early Romans used dental mirrors, practitioners used indirect laryngoscopy to look around the tongue for more than 1,800 years. Although advancements were made in technique, the basics never changed. Today’s video laryngoscopy uses a similar technique to view around the anatomy with a camera, monitor and lights rather than mirrors and sunlight.

The Next Step: Direct Laryngoscopy
Indirect laryngoscopy provided reasonable observation, but substantial diagnostic and surgical constraints remained. With advances in anesthesia, patients better tolerated instruments placed in their hypopharynx, and this paved the way for exploitation of direct laryngoscopy.

Adelbert von Tobold is credited with the first direct visualization of the larynx in 1864 using a tongue depressor and mirror for illumination.(9) His technique was repeated by various practitioners who all sought to improve the view. Just as today, airway pioneers were beset with the problems of displacing the anatomy and adequate illumination.(10,11) To this day, almost every development in direct laryngoscopy equipment and technique has been directed at overcoming these two adversities.

Early techniques consisted of using a tongue spatula (depressor) to displace the tongue and a handheld mirror to focus light into the patient’s mouth. Head-mounted mirrors soon replaced the handheld mirrors, and light sources ranged from sunlight to gas or electric lights. In some cases, physicians used carbide miners lamps to provide illumination. This open-flame light source was short-lived due to several untoward incidents involving newly developed, highly flammable inhaled anesthetic agents.

At the turn of the 20th century, a viewing tube replaced the flattened spoon-shaped tongue depressors. Imagine a hollow wooden or metal tube with an L-shaped handle at the proximal end. In most cases, the patient sat facing the physician. The practitioner inserted the tube into the patient’s mouth and pulled the handle to displace the tongue and mandible. I found a picture from 1910 that showed an attachment that applied pressure on the thyroid cartilage and displaced the larynx posteriorly as the mandible was drawn forward.(12) Hmmm, maybe external laryngeal manipulation isn’t such a new technique?

Have you ever heard of suspension laryngoscopy? I hadn’t either until I read the story about Gustav Killian’s tired arm. As the story goes, Killian took a medical artist to a cadaver lab to get drawings of the larynx in 1909. Killian inserted a laryngoscope and exposed the supraglottic anatomy for the artist. Apparently the artist was slow and Killian’s arm got tired. Being a resourceful inventor, Killian screwed metal rods to the dissection table and attached the rods to the laryngoscope suspending the cadaver’s head and maintaining a view for the artist.(13)

The next two great steps were light bulbs and batteries. These eliminated the need for mirrors and the inevitable negative interaction between open flames and flammable anesthetic agents. Bulbs on the distal tip of the laryngoscope blade enhanced illumination of the structures.

I’d like to tell you about the next great leap forward in direct laryngoscopy, but I really didn’t find any.(14,15) I offer my apologies to doctors Magill, Miller and MacIntosh. I ran a search on the U.S. Patent and Trademark Office website for “laryngoscope” and found 225 patent numbers issued for devices since 1925.(16) The vast majority of these patents had to do with blade shape or illumination; all trying to resolve the two issues that Tobold spoke of in 1864. EMS exhibit halls are filled with the new and improved. Some devices truly help; others not so much.

Look at what’s in your airway bag today. Is it really that much different than Babington’s tools? Let’s face it; we’re still using a metal stick and a light. Perhaps that’s our lot in life … or is it?

Check out a video with Charlie and Dr. Jack Pacey, the inventor of the GlideScope video laryngoscope system. They talk about how Pacey came up with the idea for the video laryngoscope and how he turned that idea into today’s GlideScope devices.

References
1. Celsus: Lib. vii, cap. xii, 1.
2. Manning WH: Review of ‘Roman Surgical Instruments and Other Minor Objects in the National Archaeological Museum of Naples,’ Greece & Rome (Second Series). 1996;43(2):222–223.
3. Garrison FH: An Introduction to the History of Medicine. W.B. Saunders: Philadelphia, 459, 1922.
4. Mackenzie M: Use of the Laryngoscope in Diseases of the Throat. Longmans, Green & Co.: London, 12–18, 1865.
5. Mackenzie M: Use of the Laryngoscope in Diseases of the Throat. Longmans, Green & Co.: London, 20–24, 1871.
6. Harrison D: Benjamin Guy Babington and his mirror. J Laryngol Otol. 1998;112(3):235–242.
7. Proceedings of Societies. London Medical Gazette 1829; 3: 555.
8. Jahn A & Blitzer A: A short history of laryngoscopy. Log Phon Vocol. 1996; 21:181–185.
9. Jahn A & Blitzer A: A short history of laryngoscopy. Log Phon Vocol. 1996; 21:183.
10. Tobold A. Chronic Diseases of the Larynx. W. Wood & Co: New York, 5, 1868.
11. The Practitioner: A Journal of Practical Medicine. 1896; 337:89.
12. Jahn A & Blitzer A: A short history of laryngoscopy. Log Phon Vocol. 1996; 21:184.
13. Jahn A & Blitzer A: A short history of laryngoscopy. Log Phon Vocol. 1996; 21:184.
14. Burkle CM, Zepeda FA, Bacon DR, et al: A historical perspective on the advances in laryngoscopy as a tool for the anesthesiologist. Anesthesiology. 2004;100(4):1003–1005.
15. Macintosh RR: A new laryngoscope. Lancet . 1:205, 1943.
16. United States Patent and Trademark Office. http://patft.uspto.gov/

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic.

For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police.

Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization.

Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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Should EMS Intubate?

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The Intubation Debate

Intubation is one of many tools in the EMS provider’s airway management toolbox. (Photo A.J. Heightman)

Did you make it to the 2011 EMS Today Conference & Exposition? What a great experience! I had the honor to moderate a panel discussion titled “Should We Intubate?” Four great panelists and about 200 folks in the audience resulted in lively debates and a challenge to be great EMS providers. As the moderator, I really didn’t get the chance to stand on my soapbox, so I’ll take that opportunity now.

Why does the thought of taking endotracheal intubation out of the hands of paramedics invoke such a visceral response? I didn’t whine when the EOA left. No heartburn when I put MAST back on the shelf. What is it about an ET tube? Because for decades, it’s all we had.

Endotracheal intubation via direct laryngoscopy has been used since the late 1800s.1 Numerous BLS airways were developed during World War II. Extraglottic airways appeared in our airway kits in the early 1980s.2 Flexible and rigid fiber optic laryngoscopes made their way into operating rooms in the early 1990s. It wasn’t until the turn of the century that laryngoscopy changed for EMS with the development of video laryngoscopes.

For about 110 years, direct laryngoscopy has been THE method to place an endotracheal tube. In EMS, we’ve relied on this method for about 40 years (depending on how you write the timeline). We reinforce the dogma that the endotracheal tube is the airway of choice by referring to all other devices as “rescue airways.”

Should we intubate?

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So I ask the question: Should we intubate? When it’s appropriate, absolutely. The endotracheal tube is a wonderful tool that has been successfully placed and managed for decades outside of the operating room. It continues to be used successfully by EMS professionals on a daily basis.

I’ve read a ream of studies professing the evils of prehospital endotracheal intubation. While there are descriptions of hypoxemia and trauma during endotracheal tube placement, the vast majority of the described evils come from what is done after the tube is placed; hyperventilation, hypocarbia, unrecognized misplaced tubes and reduction of blood return to central circulation.

Wait a minute; can’t those same evils occur with extraglottic airway devices or even a bag-valve mask? Why yes, they can. You can also add gastric distention, vomiting and reduced tidal volume to the BVM list. We have to do a great job managing any airway device.

As technology has progressed, we’ve been given fantastic new tools to help us do a better job. We’ve all seen studies that show the effectiveness of end-tidal carbon dioxide monitoring to verify tube placement and appropriately ventilate. Since 2003, studies from hospital and EMS settings have published results of the use of video laryngoscopy; shorter intubation times than direct laryngoscopy, high first pass success rates, and Grade I–II views with poor neck mobility.3-5 The gum elastic bougie, (and its plastic alternatives) is such a simple and incredibly effective tool, it should be mandatory in every airway kit. I’m quite sure you can list several other items. Proven technology must be embraced as the standard of care for our patients.

Are you allowed to intubate?

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So, I ask: Should you intubate? It’s entirely up to you. Are you willing to use the tool that best fits the patient, the conditions and your abilities? Are you willing to do what it takes to be a professional airway manager?

I’ll leave you with the challenge leveled at the end of the panel discussion. All of us must drive to excel as medical professionals, to refuse to accept mediocrity as a level of care and to simply do the very best for our patients.

I’m excited and humbled at the opportunity to provide information that will help all of us become better airway managers. I look forward to hearing from you.

Until next time, take care and be safe.

Charlie


References

  1. Bailey B (1996). “Laryngoscopy and laryngoscopes–who’s first?: The forefathers/four fathers of laryngology.” The Laryngoscope. 106(8):939–943, 1996.
  2. Donmichael TA. US Patent 4497318, Feb. 5, 1985.
  3. Agro F, Barzoi G, Montecchia F. “Tracheal intubation using a Macintosh laryngoscope or a GlideScope in 15 patients with cervical spine immobilization.” Br J Anaesth. 90(5):705–706, 2003.
  4. Nouruzi-Sedeh P, Schumann M, Groeben H. “Laryngoscopy via Macintosh blade versus GlideScope: success rate and time for endotracheal intubation in untrained medical personnel.” Anesthesiology. 110(1):32–37, 2009.
  5. Cormack RS & Lehane J. “Difficult tracheal intubation in obstetrics.” Anaesthesia 39(11):1105–1111, 1984.

Glossary

EOA = Esophageal obturator airway

MAST = medical anti-shock trousers

BVM = bag-valve mask

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Charlie Eisele, BS, NREMT-P

Charlie Eisele, BS, NREMT-P has been active in EMS since 1975. After 22 years of service, he recently retired from the Maryland State Police, Aviation Command where he served as a State Trooper, flight paramedic, instructor, flight operations supervisor, director of training, and tactical paramedic.

For over 25 years, Charlie has been a collegiate level educator and curriculum developer. He has served numerous programs including the University of Maryland, and its R Adams Cowley Shock Trauma Center, College of Southern Maryland, Grand Canyon National Park, Marine Corps Base Quantico, Virginia Department of Fire Programs, and Maryland State Police.

Charlie is the co-developer of the internationally delivered advanced airway program at the R Adams Cowley Shock Trauma Center. He is the Airway and Cadaver Lab Course manager for the University of Maryland critical care emergency medical transport program. He’s the co-developer of the EMS Today airway and cadaver lab program. Charlie has been recruited nationally to provide airway management curriculum and education for a variety of private, federal, state and local organization.

Charlie is an Eagle Scout and a published author. He serves on the Journal of Emergency Medical Services Editorial Board and is a member of the program board for the EMS Today Conference & Exposition.

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EMS Airway Clinic is a new site offering best practices in airway management and education for EMS professionals and educators, featuring:
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    Featured Airway Products

    Providing emergency patient care on the ground or in the air is complex and challenging. That's why the tools used by paramedics and EMTs must be adaptable in a constantly changing clinical situation — quickly operational, rugged and easy to use. Learn more about EMS airway management.

    GlideScope Ranger

    The GlideScope Ranger video laryngoscope delivers consistently clear airway views enabling faster intubations in EMS settings. Available in reusable or single-use configurations.

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    GlideScope Cobalt AVL

    GlideScope Cobalt AVL

    The GlideScope Cobalt AVL video laryngoscope offers airway views in DVD-clarity, along with real-time recording. On its own or when combined with the GlideScope Direct intubation trainer, the Cobalt AVL is an ideal tool to facilitate instruction of laryngoscopy.

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    GlideScope AVL Reusable

    GlideScope Cobalt AVL

    The GlideScope AVL Reusable video laryngoscope offers airway views in DVD-clarity, along with real-time recording. On its own or when combined with the GlideScope Direct intubation trainer, the AVL is an ideal tool to facilitate instruction of laryngoscopy.

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