jim du canto - the airway toolbox
Post on 15-Apr-2017
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TheAirwayToolbox
JamesDuCanto,M.D.AnesthesiologistandQualityOfficer
DirectorofSimulationLabAuroraSt.Luke’sMedicalCenterMilwaukee,Wisconsin,USA
NoCOI’stoDeclare
• …ButIdoregularlyreceivequiteabitofequipmentforevaluation
• Noproductendorsementsperse—butIdohavemyownpreferences,ofcourse.
TherewasStuff.Butnotalotofstuff.
TheworldofMedicinewaslimitedtowhatcouldbefoundintheForestortheSwamp
“FinestCricothyrotomyToolDevisedbyNature”—M.LeCong
BrownKiwi(Apteryxaustralis),ChicagoFieldMuseum
• …Andtherewasaproliferationofstuff,beginningwithtoolstointubateandventilate
Draeger Pulmotor,1907-1940’s
Batteryoperatedlaryngoscope
So,WhereDoesThatLeaveUsToday?
• Multitudeofdevices,techniquesandchoices• Choiceofsmall-purposebasedkitsinadditionto
thelargerbundles
InthewordsofWilliamGibson,
• “TheFutureHasArrived— It’sJustNotEvenlyDistributedYet”
http://quoteinvestigator.com/2012/01/24/future-has-arrived/
FrenchVideoconferencingconcept
Inotherwords…
• Off-the-shelftechniquesandequipmentexiststotakeairwaymanagementtothenextlevel
Soherearethefirstrelevantquestions…
• #1-WhereAreWewithEmergencyAirwayManagementwithrespecttoequipmentandtechniques?
• 2-Whydoweneednewdevicesandprocedurestoaugmentanalready“crowded”disciplinelikeairwaymanagement
• #3-Howarewegoingtoimplementthesetoolsandmethodsinourpractice?
Question1:WhereareWe?
• WeareatSteps1-2-3!– Step1isDL,VL,Bougie,etc...• Wecallit“PlanA”
– Step3isCricothyrotomy.• Mostofuscallthis“PlanC”
• Step2isaknown butlargely“MissingLink”– Step2isSupraglotticairwaybasedtechniques• Shouldbe“PlanB”,butisstillabitsketchytoEmergencyAirwayManagement
Question2:Whyallthisnewstuff?
• Because…EveryNowandThen,YouStepinIt,andthebackupplantoamissed“Step1”issorelylacking.
OK,Whatjusthappened?CICV.Briefly,untilIwenttoPlanB
• Unsuccessful“Step1”– Marginalpreoxygenation withplanforRSIwithAirtraq
– Attachedheadframepreventsfacemaskventilation
– Larynxvisualizedbutunabletobecannulated• Successful“Step2”– RescueVentilationestablishedwithSGA– VideoStyletintubationthroughSGA
HowshouldweproceedwhenStep1(akaPlanA)doesnotsucceed?
• Weneedtoplanforfailure.There,Isaidit.
XXXXXXXXXXXX
Step3Readiness:TheKitIDon’tLeavetheLockerRoomWithout
Carrying
--IntubatingCatheter(Bougie)--6.0mmETT--Scalpel(#10BladeRetractableor#11)--Syringe--34fr NasalAirway(SplitLongitudinal)
• Thekityouwouldalways carrywhenonclinicalduty
• SupportsreadinessforSurgicalAirway
• Componentsalsosupportwidevarietyoftechniques– (DL/VL,blindnasal,blindoral,Trans-SGA,Maskventilation)
ExperiencewithSurgicalAirwayMarch2015
• “ITHAPPENEDSOFASTTHAT…–NopausetoactivateoverheadlightsintheOperatingRoom!–Scrambletofindthebougie and6.0ETT!
Doesthissoundlogical?
Analysis,Mr.Spock….
Now..for theSecond SmallKit
Kit#2:AincA VideoStyletKit#1:Cric-Kit
VideoDrivenEndoscopeDesignedtofitWithintheTrachealTube
--AincA VideoStyletà$500USDà100Uses
VideoStyletVisualizationSystems…Simplifiedfiberoptic
intubationsystemstosupportStep2(andStep1)
• Similarhandlingskillstorigidstylets usedw/VLandDL– Functionsasastylet,scopeorlightwand– Visualizationthroughtipoftrachealtube
• Easyandquicktosetup,integrallightsource
• WorkinacomplementaryfashionwithDL,VLandSGA
Clarus VideoStylet
-Semi-Malleablevideodrivenstyletendoscope-Currentprice$8000USD
UEMedicalStylet-RigidVideoStylet(UEMedical),-CurvedforSGAIntubation
-CurvesettofunctionthroughtheAir-QSGA;alsow/Glidescope-Currentprice$3000USD
VideoStyletSimplicity--72yo Malew/RecognizedDifficultAirway,electivesurgery--H/oFusionSkullBasetoT12--Intubationperformedwithlightsedation
JenningsMouthGag
-FirstmentionmedicalLiterature1914forCleftLipandPalaterepair
-ModificationoftheWhiteheadMouthGag1877
-CurrentlyusedinENTandOralSurgery
SimpleDevicetoSupportStep2(aswellasStep1)—JenningsMouthGag
JenningsMouthGagSolvesProblemofIntraoralSpace
• Carefullyappliesforcetoopenoralcavitywithsmallmovementsofthelockingratchet
• Intuitivelyeasytouse• MiddleopeningopensmidlineforstylettedETTdelivery
VideoStyletAssistStep1
• Morbidobesitywithseveresleepapnea–Grade3to2Bvisualization
• Navigationofstyletendoscopetooffercompletevisualizationduringintubation–Visualizationbecomesgrade1
OneMoreShiftfromStep1/PlanA
Lasttopic—Devicetoassistventilation
• IntroducingtheOxylator Resuscitator– AlternativetoBag-Valve– Fixedminuteventilation(10-12litersperminute)– Suitableforadultandpediatricuse(patientsgreaterthan10kg)
– Fixedflowrate30litersperminute
TheOxylator SolvesSeveralImportantProblems
• Thoroughpreoxygenation priortoRSI• TheProblemofInconsistenciesofVentilationwithBVM’s– Controlsflowratetopreventhighinspiratoryflowrates• Leadtogastricinsufflationandcentralvenouscollapse
• PermitsTwo-HandedMaskVentilationTechnique
InClosing,OneLastQuestionaboutStep3—
Whatareyougoingtodowhenit’sTimetoCuttheWatermelon?
-Stepinandcut!”–M.Ueshiba
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