Name: A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation (Video) | JoVE Journal
Uploaded: 2011-01-17T18:00:00.000+00:00
Duration: 4 min 46 s
Description: Learn a novel rescue technique for difficult pediatric airway management using a nasally inserted endotracheal tube. This simple method enables rapid positive pressure ventilation when standard intubation fails.

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5 minutes

We would like to thank the anesthesia department at Children's Hospital of Michigan for their efforts and funding of this project.
We would like to thank the BMC department at St Jude Children's Research Hospital for their art work.

<ol>
	<li>An endotracheal tube size appropriate for the patient's age for endotracheal intubation should be chosen. We use the formula: ETT size = age(yr)/4 +4.</li>
	<li>We chose a one size smaller uncuffed endotracheal tube to be inserted nasally, in case the endotracheal intubation fails after the patient is put to sleep.</li>
	<li>Before nasal insertion of the tube, we measure the approximate distance from the nose to the level of the vocal cords, which is usually at the level of mid thyroid cartilage.</li>
	<li>After the patient is anesthetized, and after a failed endotracheal intubation attempt and failed ventilation, the well lubricated one size smaller endotracheal tube will be inserted nasally to a level just above the vocal cords.</li>
	<li>One has to ensure a good seal of the mouth and nares of the patient. The anesthesia circuit can be attached to the ET tube connector, and with appropriate seal of the mouth and the nose, the lungs can be adequately ventilated.</li>
</ol>
After sealing the nose and the mouth, lungs are adequately ventilated as confirmed by ETCO2 waveform, chest rising of the patient and good oxygen saturation on pulse oximeter.

<ol><li>Heidegger, T., Gerig, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Algorithms+for+management+of+the+difficult+airway%5BTitle%5D)+AND+%22Curr+Opin+Anaesthesiol%22%5BJournal%5D)">Algorithms for management of the difficult airway.</a> Curr Opin Anaesthesiol. 17, 483-484 (2004).</li>
<li>Krafft, P., Schebesta, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Alternative+management+techniques+for+the+difficult+airway%3A+esophageal-tracheal+Combitube%5BTitle%5D)+AND+%22Curr+Opin+Anaesthesiol%22%5BJournal%5D)">Alternative management techniques for the difficult airway: esophageal-tracheal Combitube.</a> Curr Opin Anaesthesiol. 17, 499-504 (2004).</li>
</ol>

This technique is comparable to a supraglottic airway device, such as a laryngeal mask airway1 or a Combitube2, both of which have been successfully described as rescue techniques in CICV situation to ensure ventilation and oxygenation as nonsurgical technique. This ETT technique however has the ease of availability and readiness, not necessitating any special training or equipment. In cases of CICV, and especially in neonates and small infants, oxygen desaturation can happen very quickly and can be...

<table><tbody><tr><td>ETT size appropriate for patient&amp;rsquo;s age: ETT=age/4 +4</td><td></td><td></td><td></td></tr><tr><td>tape to protect the eyes</td><td></td><td></td><td></td></tr><tr><td>decongestant and lubricant to use in the nostril</td><td></td><td></td><td></td></tr><tr><td>ASA standard anesthesia monitors</td><td></td><td></td><td></td></tr><tr><td>red rubber suction catheter</td><td></td><td></td><td></td></tr><tr><td>Anesthesia circuit and mask</td><td></td><td></td><td></td></tr></tbody></table>

a novel rescue technique for difficult intubation and difficult ventilation

A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which works especially well with poor mask fit.
Can not intubate, can not ventilate" (CICV) is a potentially life threatening situation. In this video we present a simulation of the technique we used in a case of CICV where oxygenation and ventilation were maintained by inserting an endotracheal tube (ETT) nasally down to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.
A 13 year old patient was taken to the operating room for incision and drainage of a neck abcess and direct laryngobronchoscopy. After preoxygenation, anesthesia was induced intravenously. Mask ventilation was found to be extremely difficult because of the swelling of the soft tissue. The face mask could not fit properly on the face due to significant facial swelling as well. A direct laryngoscopy was attempted with no visualization of the larynx. Oxygen saturation was difficult to maintain, with saturations falling to 80%. In order to oxygenate and ventilate the patient, an endotracheal tube was then inserted nasally after nasal spray with nasal decongestant and lubricant. The tube was pushed gently and blindly into the hypopharynx. The mouth and nose of the patient were sealed by hand and positive pressure ventilation was possible with 100% O2 with good oxygen saturation during that period of time. Once the patient was stable and well sedated, a rigid bronchoscope was introduced by the otolaryngologist showing extensive subglottic and epiglottic edema, and a mass effect from the abscess, contributing to the airway compromise. The airway was secured with an ETT tube by the otolaryngologist.This video will show a simulation of the technique on a patient undergoing general anesthesia for dental restorations.

We describe a technique to maintain oxygenation and ventilation using an endotracheal tube inserted nasally to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which ...

Hi, I'm Dr.Maria Zeto from the Department of Anesthesiology at the Children's Hospital of Michigan. Hi, I'm Dr.Roland Kado from the Department of Anesthesiology at St.Jude Children's Research Hospital. As anesthesiologists, we provide medical care to patients before, during, and after surgical procedures.This includes the safe delivery of anesthesia to patients, maintenance of intraoperative life support, and especially airway management. Airway management can be challenging. Often airway difficulty can be predicted beforehand.Other times, an anesthesiologist may face unexpected difficult airway during the induction of anesthesia. Much physician education focuses on the difficult and failed airway. This teaching often includes rescue strategies as well as the utilization of airway devices.Okay.Many airway aids exist for the rescue of patients when unexpected scenario of cannot ventilate, cannot intubate occurs. These devices include the laryngeal mask, airway, the fiber optic scope, the light stylette, and the video laryngoscope to name a few. However, most airway aids take time and additional hands to initiate.Today we will show you a novel and simple rescue technique for difficult ventilation in a child. We will demonstrate how an endotracheal tube can be used to create a temporary artificial airway. This readily available tube can be placed in the oropharynx or nasopharynx while sealing the mouth and nose and applying positive pressure ventilation.It's that easy. With the establishment of this temporary airway and with improved oxygenation, the stress of a difficult pediatric airway can be alleviated. It is the ability to rescue a lost airway rapidly and effectively that makes the simple maneuver so important to learn.So let's get started. To prepare for this procedure first, select an endotracheal tube size or ETT that is appropriate for the patient's age by using this formula. ETT size equals age in years divided by four plus four.In this demonstration, we'll use an uncuffed ETT that is one size smaller in case the nasal endotracheal intubation fails. After the patient is put to sleep a mask, anesthetic induction is performed, eyes are protected with tape and monitors are placed. Next, measure the approximate distance from the anesthetized patient's nose to the level of the vocal cords, which is usually at the level of the mid thyroid cartilage.To reduce the risk of bleeding, spray a decongest and lubricant into the nose and lubricate the ETT before insertion. Now insert the ETT nasally or orally to a level just above the vocal cords. Seal the mouth and nose of the patient by hand.Then attach the anesthesia circuit to the ETT connector with appropriate seal of the mouth and nose After insertion of the ETT, the lungs can be adequately ventilated as confirmed by noticing the end tidal carbon dioxide wave forms on the monitor, chest rising of the patient, and good oxygen saturation. On the pulse oximeter, We've shown you a novel and simple rescue technique for difficult ventilation in a child by using an endotracheal tube to create a temporary artificial airway. When doing this procedure, it's important to remember to insert endotracheal tube to the level of the posterior pharynx to ventilate the airway and minimize the air into the stomach.It's also important to have a good seal of the mouth and nose so that positive pressure ventilation is effective. Remember that in an emergency, it is easier to use the tools that you are used to using rather than new and fancy equipment with, which you may not be familiar. It is the ability to rescue a lost airway rapidly and effectively with simple tools that makes this maneuver so important to learn.So that's it. Thanks for watching and good luck with your patience.

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Learn a novel rescue technique for difficult pediatric airway management using a nasally inserted endotracheal tube. This simple method enables rapid positive pressure ventilation when standard intubation fails.

A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation

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