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intubation@intubation-sgalambro.info

Unexpected Difficult Intubation. Things to do? An unusual approach Combined Use of the MacIntosh Laryngoscope and a Flexible Bronchoscope in Cormak- L ehane III-IV laryngoscopies .

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The difficult ventilation with face mask in normal upper airway anatomy is real or is related to the pharmacological sequence of anesthesia induction ?

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Juan F GutierrezMazorra MD, FAAP Istitution e State Pediatric Anesthesia Associates PC Birmingham AL Stati Uniti 

Excellent presentation .

Una lección Magnifica, Muchas Gracias 

 

Ahmed Omar • Thank you Dr Francesco for this fruitful discussion. I have never used this combination but I found the use of Airtraq is very useful in easy-to-ventilate difficult-to-intubate cases. Indeed, the failure rate in laryngoscopy grades 3 and 4 may reach 0% with Airtraq in experienced hands.

 

Francesco Sgalambro • Dear Omar thanks for the comment . Visit www.intubation-sgalambro.info. 
In the Background section are shown video clips of difficult cases. In the Technique section describes the technique with video clips demo. 
I agree that aitraq in experienced hands can solve the problem but not always 
("An Algorithm for Difficult Airway Management, Modified for Modern Optical Devices (AirTraq Laryngoscope; CTrach LMA ™): A 2-Year Prospective Validation in Patients for Elective Abdominal, Gynecologic , and Thyroid Surgery Amathieu, Roland MD *; Combes, Xavier MD *, et al Anesthesiology: January 2011 - Volume 114 - Issue 1 - pp 25-33) 
Experts need to be a long and expensive training 
(AirTraq is disposeble!). 
Test the combined technique, it costs nothing.. 
Try it first in the easy cases


Jasmine Kerr • **As my Linked In profile states I work for Karl Storz** 

Thank you for sharing this article. I have heard of injuries that have resulted from blind ETT insertion using a video laryngoscope, however, not all video laryngoscopes (VL's) are the same and not all VL's carry the same risk. 

Increased field of view is a factor that helps reduce blind spots in VL's. A wider field of view allows visualization of the ETT earlier. The C-MAC provides an 80 degree field of view vs. competitive devices that are in the 45 degree range. 

Additionally, visualization of the tip of the video laryngoscope blade helps to increase patient safely. The tip of the C-MAC blade is always visible so you can control blade placement in the anatomy. 

Have you ever tried the approach outlined above with a C-MAC instead of a direct macintosh blade? The C-MAC blades come in standard Macintosh and Miller blade shapes (Miller 0-1, Mac 2-4). 

I recently saw a case with a Cormack-Lehane grade IV and serious facial deformities where they successfully intubated the patient using a flexible intubation scope and a Mac 2 C-MAC blade. With the addition of the video monitor, it was easy to outsource suction and both the flexible intubation scope operator and C-MAC video laryngoscope operator had improved visualization during the entire procedure. 

Grazie dottore! (Who say's a semester abroad in Italy was a waste of money? I am finally putting my limited knowledge of the Italian language to use! Haha)

8 mesi fa

Francesco Sgalambro • Dear Jasmine Kerr 
Parla Italiano ? sono felice !!!!! 
Da quasi un anno sto usando il C Mac e il vostro broncoscopio 
flessibile per la tecnica combinata . 
Il C mac pur mantenendo , le stesse funzioni di leva e di puntatore, 
rappresenta una evoluzione rispetto al Mcintosch per la sua visione 
prossimale all'epiglottide ,perchè permette di registrare le immagini e 
di indirizzare gli operatori in training . Ho raccolto un archivio di 
immagini rilevate sia col CMac che con il broncoscopio collegato ad un 
sistema di videocamera sempre Stortz riguardante casi anche estremi 
tutti risolti in tempi rapidi e senza lesioni utilizzando la tecnica 
combinata . 
For almost a year I'm using the C Mac and your flexible bronchoscopy 
for the combined technique. 
The C mac while maintaining the same functions leverage and pointer, 
represents an evolution compared to Mcintosch for his vision proximal 
epiglottis, because it allows you to record images and target operators 
in training. I collected an archive of images detected with both the 
CMAC that with the bronchoscope is connected to a camera system always 
Stortz concerning extreme cases even all resolved rapidly and without 
lesions using the combined technique. 
Sorry for tranlation

 

Jasmine Kerr • Your English is much better than my Italian and you are far more experienced than I am in the bronchoscope & C-MAC technique! I have a lot to learn :) 

Grazie per la risposta e per l'utilizzo dei nostri prodotti! 
I hope that translates to, "thank you for your reply and for using our products!"

 

KT Jung • Thanks for the discussion. 
Can you explain more detail please? 
Actually, we use MacIntosh laryngoscope to secure the space for fiberoptic bronchoscope in our hospital.

 

Dhirja Sharma • yes, we have also used the MacIntosh l'scope especially in large soft tissue masses in upper airway- to clear the path so to speak. It does help a lot.

 

Francesco Sgalambro • Dear Dhirja Sharma 
Combined technique adapted to the dexterity of the anesthetist (it took three years!) Is used on a daily basis, even in the case of subversion of anatomical structures. Since that is used in our Department there are no more fears of difficult intubations also among the less experienced colleagues .

 

1

Glenn Thomasson • Is there any way you can post a video

 

Francesco Sgalambro • Dear Glenn Thomasson 
If you give me an email address I try to send the video clips. 
It 'difficult but the files are large. 
Sorry for the translation 
F. Sgalambro

 

Muhammad Akhtar Qureshi • Dear Mr Francesco, thanks for excellent discussion. I just wanted to know if you are expecting any local abnormalities like as you mentioned in you discussion "you are being encountered with patients who have cancers located in the head and neck region",can we omit muscle relaxant till we are sure about airway, specially now a days life is more easier with availability of Ramifentanyl and Precedex?

 

Craig Troop • Please add to the discussion the importance of good positioning no matter what the technique... visit www.troopelevationpillow.com

 

Francesco Sgalambro • Dear 
Muhammad Akhtar Qureshi 

In patients with tumor localization in the head -neck region always check the ventilability before administration of the muscle relaxant. The algorithm used is this: 
Preoxygenation-Induction of anesthesia-Check ventilability face mask-Administration of Muscle relaxant-Ventilation (100% O2 three minutes) - Intubation. 
Yes. Can be used Remifentanil and Precedex but the administration of the muscle relaxant in our experience ensures a total absence of reflex movements facilitating the use of the bronchoscope even by inexperienced anesthetists. 
Sorry for translation

 

Francesco Sgalambro • Dear Craig Troop 

Yes. Position is very important for the execution. 
The sniffing position with support under the head is the most natural and allows easy sliding of the bronchoscope. 
The bed should be as low as possible to avoid too many curves of the bronchoscope. 
visited the site you've indicated. As described may be useful. 
My experience for the obese is limited to 62 procedures with the combined technique performed in the standard position. So I can not make a reliable judgment

 

Ronald Vonlanthen • "The second phase, insertion of the endotracheal tube, is sometimes performed blind, which carries a risk of trauma and bleeding.The only instrument that provides full visualization throughout intubation is the flexible bronchoscope". 

I disagree with that. During insertion of the tube the tip of my bronchoscope should usually lay endotracheal - therefore i cannot see the vocal cords when inserting the tube - there still is a risk of trauma and bleeding with this method!! 
If you want to see vocal cords when passing them with the tube you for sure need a VL.

 

Francesco Sgalambro • Dear Ronald Vonlanthen 
"The fiberoptic bronchoscope is considered as the most reliable tool in patients with difficult airways." (Takashi Asai ) 
The risk of trauma and bleeding is minimal because the flexible bronchoscope. with its movements can overcome the vocal cords and into the trachea under visual control access smoothly and with the combined technique under general anesthesia with muscle relaxation, the tracheal tube properly lubricated (silicone spray) slides in gently on the bronchoscope .. 
It is true, the passage of the tube past the vocal chords can only be viewed with the VL. 
For almost a year I'm using the C Mac and your flexible bronchoscopy 
for the combined technique. 
The C mac while maintaining the same functions leverage and pointer, 
represents an evolution compared to Mcintosch for his vision proximal 
epiglottis, because it allows you to record images and target operators 
in training. 

The combined technique VL-Bronchoscope under anesthesia with muscle relaxation allows the entire procedure under visual control. It 'important that execution is smoothly and after training on simple cases 
If you give me an email address I'll send you the clips recorded with the video laryngoscope (C-Mac) and with a bronchoscope . 
Sorry for translation

 

Ronald Vonlanthen • I do not dispute the usefullness and evectiveness of the bronchoscope - I use it a lot and also use the GlideScope. It was the imprecise statement about the risk of passing the vocal cords that was bothering me. 
I found your video on youtube and gonna try that.

 

Francesco Sgalambro • Dear Ronald Vonlanthen 
I have not posted the video on Youtube. You could tell me how to see it ? 
Thank you.

 

Nick Angelis • In the cases of masses or cancers especially, the first attempt will have the least likelihood of causing trauma. No matter how gentle and plush the flex bronch is, we all know that repeated attempts with any device quickly lead to edema. That said, the Mac/bronch combo sounds like an excellent idea, as you can always substitute the endotracheal tube for the bronchoscope if direct laryngoscopy reveals the cords instead of the expected Grade III/IV view. 

Nick Angelis, MSN, CRNA 
Author of "How To Succeed in Anesthesia School" 
http://tinyurl.com/b-nstesia

 

Francesco Sgalambro • The free website www.intubation-sgalambro.info. are videoclips of difficult cases and the execution of the combined technique. 
To gain practice with the technique you first use it in easy cases to be ready in difficult cases.Should not use it occasionally but often. It costs nothing but risove difficult cases 
Visit the site and comment !

 

 

 

dr nasir ali baloch • thanks sir for information difficult intubation.......

 

 

 

 

 

 

Darin Swonger • Recently encountered a difficult airway where the trachea had been deviated approx. 5 cm to the cardiac side and slightly posterior by a large tumor (not obstructing). We used an awake intubation technique with topicalized airway, Precedex infusion, 1 mg versed and 50 mcg fentanyl. After being able to visualize the glottic opening, but not being able to maneuver the scope appropriately in an up and over and around movement. We used a glidescope and gently used it to open the posterior pharynx and enable a visualization of structures sufficient enough to pass the ETT with the bronchoscope.

 

Francesco Sgalambro • Dear Darin Swonger 
Thanks for the comment. 
Yes, the videolaryngoscopes (C-Mac , Glidescope , etc) facilitate the procedure but are not present in all operating rooms . 
For almost a year I'm using the C Mac and flexible bronchoscopy 
for the combined technique. 
The C Mac while maintaining the same functions leverage and pointer, 
represents an evolution compared to Mcintosch for his vision proximal 
epiglottis, because it allows you to record images and target operators 
in training. I collected an archive of images detected with both the 
C-MAC that with the bronchoscope is connected to a camera system 
concerning extreme cases ( Anaplastic Thyroid Cancer – Obstructive Pharynx Cancer ) even all resolved rapidly and without lesions using the combined technique. 
Combined technique adapted to the dexterity of the anesthetist (it took three years!) Is used in unanticipated difficulties when anesthesia was induced and given the muscle relaxant without repeated and traumatic intubation attempts in ventilated patients 
Since that is used in our Department there are no more fears of difficult intubations also among the less experienced colleagues . 
The provided difficulty of intubation in our Department are addressed according to the guidelines.. 
Sorry for translation !

 

Curtis Alleyne • I have found the combined use of the MacIntosh laryngoscope and the Levitan scope to be very useful in diffficult airway management.

 

Heidi Koenig • Concur....having an plan , an algorithm prevents poor performance. The additional piece is that the condition of a difficult airway needs to be thoroughly and efficiently communicated to the patient, and the medical record. Like an algorithm for airway management, the difficult airway template detailed in and downloadable form the APSF Newsletter Summer 2010, facilitates this communication.

 

Heidi Koenig • Concur, the combined technique is helpful in certain particularly difficult situations.....and a blind intubation is extremely rarely indicated. Don't forget to formally notify the patient of their diffucult airway. Seehttp://www.apsf.org/newsletters/html/2010/summer/06_diffairway.htm There is a template ( click on and download) which covers the exam, the views, what worked and what did not work, the out come and should be distributed to the patient, PCP and the facility medical records so the next anesthesia provider has all that information. Using the template helps you include all the mportant details nad allows you to communicate effectively much more quickly traditional letters...

 

Francesco Sgalambro • Dear Heidi Koenig 
Thanks for the comment 
The information of the patient after an unexpected difficult intubation is essential for the prevention . Your difficult airway template is very complete ! We use it in our Institute? 
I can insert it into the website I'm preparing for combined technique 
( www.intubation-sgalambro.info ) ?

 

Robert Smith • That's a great technique. I've used a similar technique in children (smaller blade) with craniofacial abnormalities. The technique you describe is yet another get-out-of-jail-free card use when needed. Thank you for sharing!

 

Francesco Sgalambro • Dear Robert Smith 
The free website www.intubation-sgalambro.info. are videoclips of difficult cases and the execution of the combined technique. 
To gain practice with the technique you first use it in easy cases to be ready in difficult cases. Do not keep it in jail and one-time use, but use it often . 
Thank you for comment .

 

 

bijan ebrahimi • I like to practice this method , but it is somehow difficult in our country ,because of the very expensive money value of this kind of bronchoscope .

 

bijan ebrahimi • I have practiced awake intubation with regional block , and I found it great at some situations , like ambulatory surgery , as an alternative . In cases which I visualized the airway anatomy as impossible to be done , then I go to do it with soft bronchoscopy with good sedation + regional block , and I get a good result .