The Challenging AIrway

by Jason Greenman, MD

I recently returned from the Levitan (@airwaycam) Yellowstone Advanced Airway Course (#YAAC) last week. It was an awesome experience to get out to the mountains and do some didactic and hands on airway learning. To start with, the view of the Grand Tetons from the course venue was awesome. Would definitely recommend a trip to Wyoming.

photo 1

Here are a few high yield pearls from the course

Have the mind of a warrior when approaching the airway. Be positive and have a clear plan. Call it the challenging airway, not the difficulty airway. Call it the time dependent airway, not the crash airway. Call it the surgically inevitable airway, not the failed airway.

Preoxygenation is key. Get your patient into a position that will maximize preoxygenation. Try the ear to sternal notch position. Use the jaw thrust maneuver to open the airway (NOT the chin lift). Consider putting your patient into reverse trendelenburg to increase FRC.

Focus on the nose. “Blow some O’s up the nose during preoxygenation. Use the expression NODESAT (nasal oxygenation during efforts securing a tube). Studies show that high flow passive nasal oxygenation significantly increases the time before desaturation in the apneic patient.

If you don’t already know, cricoid pressure is OUT! Don’t do it! All the literature shows there are still real risks of aspiration, while causing possible airway obstruction and difficulty in passing the ET tube. Instead, use bimanual laryngoscopy to improve your view, which is external laryngeal manipulation by the laryngoscopist.

Keys to first pass success. Hold the scope low and make it an extension of your forearm. Make intubation a stepwise process. First find the uvula, then keep calm and do epiglottoscopy, followed by laryngoscopy, and then tube delivery. To maximize tube delivery, keep your stylette in a straight to cuff shape with a 35 degree curve. This allows for a narrower long axis dimension and better maneuverability. After passing the cords, consider turning the tube clockwise (to the right) to prevent catching the tracheal rings.

Consider nasal intubation if oral intubation is impossible, or laryngoscopy will be difficult secondary to oral pathology, and if the patient is breathing well and not hypoxic. Use sedation (ketamine is best!), topicalize with lidocaine 4% and afrin. Bevel towards the septum. If blind, listen for breath sounds, or the preferred method is to use fiberoptics if its available. Pass the tube through the cord on inspiration. Depth of insertion to 26-28cm.

photo 3

The hardest part about doing a surgical airway is deciding to do the surgical airway. When your heart starts racing you lose fine motor skills, so instead feel the framework of the airway, move side to side, top to bottom to find your landmark. Do the “Laryngeal Handshake” with the nondominant hand, feel the rhomboid: hyoid, then thyroid, then cricoid. Rest your dominant cutting hand on the sternum for stabilization. During the procedure use good economy of movement, don’t waste effort with extra hand movements. Make your incision vertically through the skin, than horizontally through the cricoid, don’t worry you’ll be cutting into the cartilaginous cage.

photo 2

After an unsuccessful intubation attempt, don’t get stuck on stupid, don’t fixate , try something newMove down your intubation algorithm quickly and confidently.

For more information, check out the course website at or Dr. Levitan’s website at

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s