Episode 03: The Keys to Direct Laryngoscopy & Intubation

(upbeat music) - Hello everybody and thanks for joining us for another episode of The Nurse Anesthesia Podcast. I'm Jeremy Heiner. - And I'm Seth Silesia. - This is a podcast where we talk about clinical anesthesia, pharmacology, case management, critical events, and really the most up-to-date topics. And we do it in a power packed and concise episode. - And today we're gonna be talking about something that you new people are gonna be very interested in. And that is the keys to direct our angoscopy. And because anesthesia people are incredibly impatient, we just say DL. - That's right, DL. And we'll talk a little bit about intubation, but the whole process of intubation involves direct learning angoscopy. - Now this episode is brought to you by The Nurse Anesthesia and we are a CRNA owned company that wants to give you the edge in your nurse anesthesia education. Maybe it's been a few years since you've been in the classroom and there's so much to prepare for, for that first day of your nurse anesthesia education. We provide courses that will give you an advantage that you will need to stay ahead of the curve and then help you succeed during your anesthesia journey. So let's do this together. Check us out on our website at thenurseanesthesia.com or on social media at The Nurse Anesthesia. Now we know that your time is important, so we are going to get right to it. Let's take some deep breaths and pre-oxygenate ourselves because it is go time. (upbeat music) - Okay, so direct learning angoscopy, as Sass mentioned, this is something you're gonna be very, very interested in. And this is a skill that you will learn during your anesthesia training. Now, in the era of video learning angoscopy, which is right now, anesthesia providers are probably some of the only remaining healthcare professionals that are experts at this airway technique. And what we wanna talk about today is we want to help you maximize what's known as a first pass success. So what is this concept of first pass success? It's essentially getting the endotracheal tube in the right place the first time. And even with the most pristine, easiest intubation that you're ever gonna see someone do, please do remember, you're putting a steel blade in someone's mouth, you're lifting up. - Or a plastic blade these days. - Or a plastic one. - It's still hard. - Hard, right, and very traumatic. And the possibility of damaging tissue causing edema is there with every laryngoscopy that you do. - Yep, absolutely. So what we want to do here today is to provide you with some primary keys when both preparing to perform a direct laryngoscopy and when actually performing a direct laryngoscopy. - Okay, so with number one, Jeremy talked about keys. So the first thing is we're always gonna prepare. So with every patient, unless it's a dire emergency, we're gonna do an airway assessment to try to look at different factors related to the patient's face in terms of what we can see in terms of their oral structures to try to make a determination whether they may be difficult or not difficult. - Yeah, and then maybe if they are difficult, we're in a later episode, we'll talk about difficult airway, but there are several options, video options and even flexible intubation options. - While the patients are awake. - Yeah, and of course, video laryngoscopy has completely revolutionized airway management. You know, in the distant past, dinosaurs like me, when you intubated, you really only had DL, and then there was the possibility of doing a flexible intubation. But because now we have video laryngoscopy, it has made our lives so much easier and so much better for patients. - Exactly, so now kind of going along the lines of preparing for direct laryngoscopy, and really you'll do this for video laryngoscopy too. Anytime you're going to instrument the airway, you wanna have adequate preparation. And I remember the mnemonic when I was in anesthesia school called Soap Me. - Hey, hey, hey, this is a G-rated podcast. What are you talking about there, Dr. Heiner? - Yeah, do not drop the soap. So what it stands for is suction, oxygen, airways, positioning, medications, and equipment. - Okay, so, Seth, let's run the listeners through what the mnemonic, the acronym Soap Me, means. - Yeah, so the S, suction. So we have to have suction available at all times. We'll have a yank our suction device that is hooked up to our anesthesia machine most often, and we have the suction running constantly. We can either place it on the OR table near the patient's head or in the newer machines, we can actually have it right on the machine. But again, it is available anytime we need it. We may need it if the patient vomits during the induction. We're certainly going to need it at the end of the procedure prior to extubation. If you have someone who is at risk for aspiration, such as someone having a GI bleed, you're probably gonna be asked to put down an esogastric tube and a suction at that point in time. And then last, people when they have general anesthesia and an endotracheal tube, they develop secretions. So suction is absolutely essential for every anesthetic that you're going to do. - Yeah, you never want to forget that. All right, the next soap, in soap, the second letter is O, and that stands for oxygen. And what this means is have a secure oxygen-fitting device, and in anesthesia, we'll use the anesthesia face mask, make sure that the mask is an adequate size, and provide adequate time for pre-oxygenation. The next letter, A, stands for airways, and this simply means having oral airways, oral pharyngeal airways, OPAs, readily available in your anesthesia workstation, so that you can provide that if you need to mask ventilate the patient. A lot of people will also have on standby nasal pharyngeal airways, or NPAs, and have those readily available in case they need dose. - The next letter is P, so for positioning. So there's a particular position. Many people in anesthesia don't know this, and it's called the sniffing position. The reason it's called that is because, if you can imagine like sniffing a rose, that's exactly what it is. So the head will be elevated several centimeters, and the chin will be pulled into extension. What you want to do in order to achieve the sniffing position is to have the tragus of the ear, or the outside of the ear, lined up with the patient's sternal notch. What that does is it provides the most direct view when you do your laryngoscopy of the cords. There are three distinct axes that it helps to align. The oral, laryngeal, and pharyngeal axis. And Jeremy and I always say this, and I'm a huge believer of this, having someone positioned perfectly prior to starting the induction of anesthesia is absolutely essential because if you have difficulty, you're gonna be doing that while the patient is apnoic. So make sure you start in the perfect position. And lastly, not only the patient's position related to sniffing, but also your position in relation to the patient's head. Some of you are taller, some of you are not as tall, and therefore making sure that the patient's head is approximately at about your xiphoid process is gonna be really important for you to be able to see optimally. Next, medications. We're gonna have medications available for induction. We'll talk more about that in the future. That means putting the patient to sleep. And we're also gonna have emergency medications drawn up ready to go labeled, certainly in case we need them in an emergency. - Yeah, so the last letter in "soap me" is the E, and this simply stands for equipment. And this is the laryngoscopy equipment you wanna have readily available. So your laryngoscope with multiple blade options. Many people, when they're just starting this to learn this particular procedure, we'll have both a Macintosh and a Miller blade ready to go. And of course they've checked that the light source is working. Now, in anesthesia, there are a lot of strong opinions in terms of which blade you as an anesthesia provider prefer to use. So are you Team Macintosh or Team Mac, or are you Team Miller? Now, what's most important here is as you work your way through your anesthesia training, that eventually you're able to use both blades. You're gonna learn that most of the time we start out on a Mac blade because of the design of it. It makes it a little bit easier for learners. However, a Macintosh blade, for some people, that's their go-to blade for their entire career, and it works perfectly fine. Now, in addition to the laryngoscope blades, other pieces of equipment that we can consider having available would be a bougie stylet, as well as a laryngeal mask airway. So something for rescue ventilation and to help you with rescue intubation. That would be the bougie stylet. In later episodes, again, we'll talk about these devices. So let's transition here, and now let's talk about some of the keys that we can use when performing direct laryngoscopy. All right, so the first thing, and I already mentioned it, alluded to it, and that is optimizing your position. So making sure you're standing upright, we don't do hunching over. It's certainly gonna hurt your back. And we talked about the patient's position in a good sniffing position, and also your position in relation to the patient's head, which is you want the patient's head somewhere around your xiphoid process when you go to intubate. In terms of actually doing the laryngoscopy, so the patient will be put to sleep, they'll be completely anesthetized, they will stop breathing, and then you will at some point be doing a laryngoscopy. Hold the laryngoscope, hold it easily in your left hand with the thumb pointed toward the base of the blade. And you don't wanna be squeezing the laryngoscope handle as tightly as you can. - Don't hold on with a death grip. - Yes, we call that the death grip. The death grip is representative of someone who is new and who is starting to learn how to intubate. This will help you to avoid as much pressure as possible on the patient's teeth, and again, their oral structures. You can do a tremendous amount of damage to someone while doing a direct laryngoscopy. Don't insert the laryngoscope blade until the patient is fully paralyzed. And we will talk about induction and paralysis in the future. We paralyze people so that when we go to do a DL, their jaw muscles are relaxed and their vocal cords are nice and open. I say this to our students. If you're gonna give a drug for a particular reason, you have to give it time to work. Otherwise, there was no reason to give that drug. Open the mouth and making sure that you're opening it gently. Be careful of the patient's teeth as you open the mouth because those patients with really poor dentition, you can just push a tooth out. Insert the blade easily to try to avoid contact with the teeth and the gums. When you are actually going to be lifting, making sure that you're lifting forward. And when I say forward, if you can imagine the front wall and the ceiling, you wanna be lifting where they intersect. So it's lifting forward and lifting upward. If you wrench backward, there is a good chance that you're gonna break their front teeth, their upper teeth. And lastly, you wanna avoid catching the lower lip on the lower teeth because what will happen is the teeth will actually tear the lip and the patient will bleed a little bit. So we wanna do gentle and we wanna make sure that we clear that lower lip from the lower teeth in order to not lacerate the lip. - That's when you're inserting the laryngoscope blade, right? That lip can get caught between the teeth and the blade. - Correct. - Okay, great. So SAS has gone over the first two keys for direct laryngoscopy, optimizing your own position. And then gentle laryngoscope insertion, the third key. And this is one of the most important keys to direct laryngoscopy is looking for the epiglottis. That is the primary structure that is the easiest to find when you're doing a direct laryngoscopy. I've heard it termed before epiglottoscopy. Now, the traditional approach to direct laryngoscopy using a laryngoscope blade is to start on the right side. When you insert the blade, is to start on the right side of the mouth and then to sweep the tongue out of the way before advancing that laryngoscope blade and looking for the epiglottis. Many times this works. However, if you're having trouble, if this is unsuccessful by putting the blade on the right side of the mouth and trying to sweep the tongue out of the way, an alternative approach is to advance the blade in a stepwise, slow, very slow, gradual fashion directly down the center of the tongue. So in the midline position, as you advance the blade along the midline, the epiglottis should lie right at the base of the tongue. And this is directly within the course of your laryngoscope blade. So again, key number three, look for the epiglottis. Now, key number four in terms of direct laryngoscopy is now positioning your laryngoscope correctly. With the Macintosh blade, we are going to fully insert the blade within a structure known as the velecula. And what we wanna do is engage with the very tip of that Macintosh blade, engage the hyalepaglottic ligament. This is what's going to help lift the epiglottis out of the way in order for us to see the glottic opening or the opening between the vocal cords. Now, if you're using a Miller blade, what you'll do is you'll advance the Miller blade down, identify the epiglottis, and then you'll pick up the epiglottis with that Miller blade. There are a couple of problems. If you do not insert the Macintosh blade deep enough, if it's too shallow, then what'll happen is you will not be able to fully lift that epiglottis out of the way, and it'll be hanging downward and obstructing your view of the glottic opening. If either the Macintosh or Miller blade is inserted too far, which I've seen with novice intubators, then all you'll see is pink. You won't see any of the structures that you need to identify in order to effectively perform a direct laryngoscopy. So one thing that I'll really take a look at when somebody's learning to intubate, and I'll talk to them beforehand, is don't bury that blade, don't insert it too deeply. Now, in terms of the correct displacing force, I already talked about where you want to lift once the blade is in the mouth. So again, lifting forward and upward, not wrenching back toward the teeth. When you start to learn about direct laryngoscopy, you will also learn that if you pull back and wrench back, not only will you break teeth, however, if you're using a Mac blade, you will no longer be engaging in the velecula, meaning that it will not improve your view. In terms of the amount of force, I've actually read a study in the past that says that novice intubators use three times more force as compared to people who intubate often. I would recommend if you want to watch intubation prior to coming to anesthesia school, go on YouTube. There are lots of videos out there where you can watch people intubate and what will impress you is the amount of force that's being used seems like not very much. And again, it's the best for decreasing the possibility of trauma. All right, so then we have key number six, which is to have a strategy for improving your laryngeal view. We've already talked about the sniffing position, so that's the patient's position. And then secondly, the patient's head in relation to where you are in terms of your height. So their head at about your sternal notch. After that, so now you're doing your direct laryngoscopy, you're actually looking for the vocal cords. In order to further improve your view if you're having trouble, is something called bimanual laryngoscopy. The handle and the blade are in your left hand. What you can do is you can bring your right hand around and actually push on the laryngeal structures to try to push the vocal cords and improve your view. There's one other procedure called burp. Burp stands for, it's a pneumonic stands for, applying backward, upward and rightward pressure on the larynx specifically to help improve the view of the cords. If you were to do this with your hand, either with the bimanual laryngoscopy technique, which is also known as external laryngeal manipulation or burp, as soon as you see the ideal view, you are gonna have your assistant hold exactly where you are because then with your right hand, you're gonna need to place that endotracheal tube. - Okay, so direct laryngoscopy key number seven is avoid obscuring your view of the larynx when you're placing that endotracheal tube itself. There are a couple of different configurations that you can do, that you can use when you are getting an endotracheal tube ready in order to place it. And when you're placing the stylet within the endotracheal tube, one of them is keeping a curvature, the natural curvature of the endotracheal tube. Another one is called the straight to cuff where essentially what you're doing is you're creating a hockey stick type of an endotracheal tube. In other words, the endotracheal tube looks kind of like a hockey stick. And this is not creating a 90 degree bend at the end of the endotracheal tube. No, that's not a hockey stick orientation. It's instead more of like a 45 degree bend or up to maybe a 60 degree bend at the distal tip. And what this configuration does, this straight to cuff, so straight endotracheal tube and bend at the cuff, what this allows is for you to place the endotracheal tube in the mouth and not obscure your view of the larynx. What you do is you advance the endotracheal tube until the very last moment and then you tilt it down and that will bring the distal tip up and that way you can then place it between the vocal cords. Now, also realize that the epiglottis where you see that within the airway and the actual location of the vocal cords is at two different locations within the airway. And there are, once you pass the tip of the epiglottis, there are several centimeters before you reach the laryngeal opening at the vocal cords. The eighth key to direct laryngoscopy is do not force the endotracheal tube into the airway. If the endotracheal tube passes through the vocal cords but then gets stuck, well, most of the time, this is because the tube, the very distal portion, the end of the tube is getting caught on the anterior part of the cricoid cartilage or even the tracheal rings and a simple rotation of 90 degrees of the tube should help to resolve this. - Yeah, two words, force and airway. Those two words should never be used in the same sentence. - They don't really go together, do they? - No, they don't, not unless you wanna harm the patient. - And you want bleeding in the airway, which is not fun. - All right, so then our number nine is always to have a bougie stilett available. And when you start anesthesia school or you can also look this up on YouTube, you'll see what a bougie stilett is. Not only will you have a bougie, but you will have other emergency airway equipment available to you. You'll hear this in anesthesia school. We have plan A, we have plan B, we have plan C. And if all hell happens, then we have plan D. - And someday we'll do a podcast on plan D. - Absolutely. And finally, last number 10 is to confirm placement. I always say to my students, and you guys are our students now, the catastrophe when placing an endotracheal tube is not placing it in the esophagus because that will happen to everybody. However, leaving it in the esophagus and not realizing that you are. So in terms of what we do, first confirm placement, we directly visualize the endotracheal tube between the vocal cords. Next, we immediately look for chest rise and fall. That is gonna be the first thing that you're gonna see when you correctly intubate someone between the vocal cords. Next, we are going to listen or auscultate for breath sounds to make sure that we have clear, equal, and bilateral breath sounds. We're gonna make sure that when we give a title volume breath that that air comes out back in and refills the anesthesia bag. We can look for condensation in the endotracheal tube during exhalation and our gold standard is looking for the presence of end title CO2. It's not going to be immediate. It's gonna take a couple of seconds for it to be sensed by the machine. But when you confirm in all of those ways, it is more likely than not almost absolutely that your tube is in the trachea. All right, so that does it for the keys to intubation. We will put the keys to direct laryngoscopy and intubation in the show notes. And just so everyone knows, it takes time. It takes time to learn this procedure. Just like learning an IV, it took time to get really good at it. Same goes for any procedure you learn in anesthesia and especially for direct laryngoscopy and intubation. - Okay, well, thank you everyone for hanging out with us during this episode. Now, we've got something else for some of you. So listen up here. If you are getting ready to start in a nurse anesthesia program or maybe you're just investigating our profession or maybe you're working in the grind as a nurse anesthesia learner, check us out on the web at thenurseanesthesia.com or on social media at the nurse anesthesia. We will set you up. We will get you ready with short, affordable, power-packed and meaningful courses that will accelerate your anesthesia learning. We will give you the edge, that advantage that you will need in your nurse anesthesia education. Again, that's thenurseanesthesia.com. Check us out and sign up. Okay, TNA Nation, that's it for this episode. Remember, keep ventilating and we'll catch you on the next one. (upbeat music)