Tag Archive | "epiglottis"

Scary Airways

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Overcoming fear is the first step to slaying the dragon of a difficult airway. The next is choosing your tools to face the monster. Photo Chris Swabb

By Jim Radcliffe, BS, MBA, EMT-P

I hope everyone is having a great year. I know the economy is tight and there’s all this political stuff going on in and out of our industry, but that’s not why we got into this business in the first place. Somewhere in our lives, we were bitten by the EMS bug. Some of us really came down with it and we have spent most of our lives serving other people. Believe it or not, I’ve had the honor and privilege of knowing some paramedics and EMT’s in their 80s still serving and teaching, running circles around their younger counterparts.

However, it doesn’t matter how old or young, new to medicine or experienced you are, we all have to understand the anatomy and physiology (A&P). Few have the luxury of going through programs with excellent science programs that mirror what medical school students must learn, so A&P becomes scary. One particularly scary and disorienting area of A&P is the airway. The A&P of the airway is scary for a couple reasons, I know it was to me and still is today—but for different reasons. I would like us to take a few minutes to take a look at the A&P from a couple perspectives and talk about how we might make it a little less scary for everyone.

Bring on the Nightmares
Do you remember when you were a student or a new paramedic and going into the operating room for an airway rotation? How about that first field intubation you did? It was probably in front of your preceptor or field training officer (FTO). Wow, I know it was a couple decades ago for me, but I still remember that my hands were shaking and I was sweating while trying to verbally walk myself through the steps and reviewing the A&P in my head.

I did all this as I attempted to impress the anesthesiologist behind me, whom I had met only an hour before. Then I remember noticing that he was right behind me, and his chin was almost on my shoulder as he was trying to look down my laryngoscope blade to see what I was seeing. I know it sounds like a Steve Berry cartoon, but it’s true. It took me several years and my turn as a preceptor and instructor to understand that intubation is not just scary for the student but also for the preceptors and FTOs.

Over the past several years I’ve learned a couple things I think could really help us conquer this fear of the airway A&P and help us all to be better providers and paramedics. So the first thing we have to do is what my good friend Charlie used to say, “Take a deep breath and relax and think about what’s for lunch.” To be a good provider, you have to know the A&P upside down and backwards (and I like to say so well that you have nightmares about the epiglottis.)

Monsters, Dragons & Beasts—Oh My!
So let’s start at the top and review some basic A&P that we all must know. Air comes into our patient through the nose and the mouth as they breathe or we breathe for them. The air going in through the nose is warm filtered and humidified as it goes over the turbinates lined with cilia to filter out the dust and things floating in the air to keep it out of our airways. That air then proceeds down through the nasal pharynx, connects with the posterior oral airway and goes down to the larynx.

Remember that the oral and nasal passages are separated by the hard and soft pallet. The air going in through the mouth must pass by the teeth and proceed the first monster of the airway, the tongue. Yes it seems like and looks like a monster the first time you attempt to slay the dragon of an airway and you are staring down a laryngoscope blade at that beast. No wonder it’s the largest and most common airway obstruction. After getting passed the tongue there is this strange character that you meet called the uvala. He is just hanging there off of the soft pallet pointing you south toward the darkness of the airway. When the patient is breathing this is like a wind tunnel but when you are marching through here with a little metal stick with a light on the end of it the air is still, stagnate and full of foul odors. As you begin to round the corner to head down to the larynx the uvula reminds you, “watch out for the epiglottis just around the corner.

Oh yes the epiglottis, not quite as large as the tongue but still a monster that’s slippery and illusive. For years, I would intubate by looking for the vocal cords Then one day, I realized that everyone has an epiglottis and it’s always in the same place. Think about it for a minute; pull up that old A&P picture from the recesses of your brain and look at the side view. Yep that’s it. Follow the center of the tongue, the forough, to the base of the tongue. At the base of every tongue is an epiglottis. The landmark between the tongue and the epiglottis is called the vallecula. The epiglottis comes in many sizes depending on the size of the patient and how many Whoppers they consume daily.

Which landmark do you look for most when beginning an intubation?

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If you’re intubating, then you most likely have laid the patient flat on their back. (I’m not sure who ever thought to do that, because all the stomach content is now running toward the posterior oral airway and we have to lift all of the structures out of the way.) If you can, place the patient in a low Fowler’s position, it will make your life so much easier and help fix that crook in your neck as well.

Weapons of Choice
If your patient is large, you’ll most likely find a large, floppy epiglottis lying in a pool of slime at the bottom of the posterior oral airway, just waiting to jump up and ruin your day. You’ll need one other weapon in your arsenal to slay this monster, which would be your suction, never leave home without it. It seems that this monster is a lot easier to defeat when you take away his hiding places. Also when you put the patient in a low fowler’s position and put about two inches of padding behind the patient’s head you straighten out the airway and take away the corner’s for the epiglottis to hide. Choosing the correct light stick (laryngyscope blade) is important here, depending on the size of this epiglottis you may need a thin, wide or curved stick to defeat the monster. We will save the choice of weapon for another discussion. Once you defeat these two monsters, entering the cave of the airway dragon is pretty easy from there.

Over the past several years, numerous additions to the EMS airway resources have improved prehospital airway management. One simple change has been the introduction of fiberoptic and LED lighting systems on laryngoscope blades, which has made illuminating the airway much easier.

The introduction of video laryngoscope, which enables users to capitalize on a superior glottic view and access provided by the video image, has significantly changed first attempt success rates When you’re dealing with difficult airways in which you can’t get good line-of-sight visualization, video laryngoscopy uses a camera and a video monitor to visualize the airway and the glottis, enabling faster intubation. It has also given us a huge educational advantage. In teaching settings, the video laryngoscope allows the preceptor or instructor to see what the student or new provider is observing. For the classroom or lab setting, video trainers allow the instructor to walk the student through the airway and discuss issues that are encountered. I have found the use of video laryngoscope in cadaver labs has been extremely helpful to the students. Many video laryngoscopes have a “video out” feature that allows you to push the image to a larger screen for a group to be able to see what the intubator—whether the instructor or another student—is observing.

No More Fear
Over the years teaching in cadaver and airway classes, students will ask why they were never told these things in their initial training. I have found that understanding the A&P, the use of landmarks and the introduction of video laryngoscope has helped to take the scariness out of prehospital airway management. Hope this helps your practice.

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

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Roadmap to the Glottis

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When we intubate a patient, all we really want to do is place the endotracheal tube in the glottis. Let’s face it, the glottic opening can be a tough feature to locate on a good day, let alone wh

To get two the epiglottis and the posterior cartilages, your two new best intubation buddies, you have to get past the tongue first. Illustration JEMS/Wainwright Media

en things just aren’t going well. Blood, vomit, laryngospasms, edema; you know the drill. If you want to find the glottis, stop looking for the glottis. What? Read on, friends, I’ll show you.

Anatomy of the Larynx
The larynx is made up of three single cartilages and three pairs of cartilages.

The thyroid is the largest of the laryngeal cartilages. It’s within this cartilage that the glottis is located. The anterior ends of the vocal cords are attached to the thyroid cartilage. This feature gives us the ability to directly move the glottis to improve our view. Known by different names, external laryngeal manipulation (ELM), backward upward rightward pressure (BURP), digital physical laryngeal manipulation; the procedure of manipulating the thyroid cartilage to optimize the glottic view has been described for many years.(1–3)

The cricoid cartilage, the most inferior of the laryngeal cartilages, is the only laryngeal cartilage that’s a complete ring. In pediatric airway, the cricoid cartilage is the narrowest part of the airway. Non-cuffed tubes fit snuggly into the ring to prevent air leak. Cricoid pressure has been used to improve glottic view during laryngoscopy, but I think you will find that laryngeal manipulation does a better job of optimizing the glottic view. One of the very best studies I’ve read on the use of cricoid pressure was published in 2007. The authors concluded, “We recommend that the removal of cricoid pressure be an immediate consideration if there is any difficulty either intubating or ventilating the ED patient.”(4) As an airway professional, you owe it to yourself to read the entire study.

Let me now introduce to you, straight from the back of the tongue—the most important airway landmark, the intubator’s very best airway friend, the gateway to the glottis—THE EPIGLOTTIS!

Remember when I told you to stop looking for the glottis? I want you to start looking for the epiglottis. Remember from our last lesson that the inferior (extrinsic) tongue muscles are connected to the mandible, hyoid and epiglottis. We can use that connection to locate the epiglottis. I’ve found the epiglottis to be easier to locate on a more reliable basis for both novice and experienced providers. Sounds like a study in the making.

Try this: Insert the laryngoscope blade into the patient’s mouth and just follow the tongue posteriorly until you locate the epiglottis. Lift the epiglottis and there’s the glottic opening. Most of the time, it’s just that easy.

Posterior Cartilages
The second best friend of the intubator is the group of three pairs of cartilages, which lie along the posterior border of the glottic opening; the corniculate, cunneiform and aryetnoid cartilages. The arytenoids sit on top of the posterior portion of the cricoid cartilage. The posterior end of each vocal cord is attached to an arytenoid cartilage. The length and medial-lateral positioning of the vocal cords are accomplished by movements of the arytenoids. The arytenoids can’t be seen in the standard laryngospic view because they’re buried in tissue.

The corniculates sit on top of the arytenoids and are seen during laryngoscopy immediately lateral to the interarytenoid notch. The cureiform are embedded in the aryepiglottic folds. They give support to these membranes, which connect the arytenoids to the epiglottis. In the standard laryngoscopic view, the cuneiform can be seen immediately lateral to each of the corniculates.

Collectively these cartilages go by a variety of names: the arytenoids, posterior cartilages, nodes. Regardless of which term you use, know that they are the posterior border of the opening to the glottis and are identified by a notch in the middle and two pairs of bumps on either side.

So there you are. Your new best intubation buddy is the epiglottis, and your second best buddy, the posterior cartilages. I find it ironic that these most helpful features lay right behind our nemesis, the tongue. A good knowledge of the airway anatomy is really a roadmap to success. Bust open that A&P book that you’ve got shoved up there on the shelf. It will make you a better provider.

Take care and be safe.

1. Benumof JL & Cooper SD. Qualitative improvement in laryngoscopic view by optimal external laryngeal manipulation. J Clin Anesth. 1996;8(2):136–140.
2. Knill RL. Difficult laryngoscopy made easy with a “BURP.” Can J Anaesth.1993;40(3):279–282.
3. Levitan RM, Mickler & Hollander JE. Bimanual laryngoscopy: A videographic study of external laryngeal manipulation by novice intubators. Ann Emerg Med. 2002;40(1):30–37.
4. Ellis DY, Harris T & Zideman D. Cricoid pressure in emergency department rapid sequence tracheal intubations: a risk-benefit analysis. Ann of Emer Med. 2007;50(6): 653–665

Watch a video of Charlie explaining how to visualize the glottis.

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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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