00:01
This is the position we get
the patient in before we intubate.
00:06
We try to flex
at the lower cervical spine.
00:12
Down at C6-C7,
flex forward,
and then extend that C1- C2.
00:17
This is known as the
sniffing position.
00:20
You have to adjust that pillow one
to the head,
sometimes underneath
the shoulders
to lift the shoulders
to improve the extension,
to get a good airway.
00:32
You should always have something
under the head.
00:35
One of the fallacies of people
who don't intubate frequently
is that they throw the pillow
across the room
to get it out of the room.
00:42
And then an anesthesiologist
has to come in, put it back
and intubate the patient.
00:47
The laryngoscope is placed
on the right side of the mouth,
avoiding touching the teeth.
00:54
It pulls the tongue to the midline,
and it's lifted.
00:57
To never ever do you
turn your wrist
when you're doing this.
01:02
You put the laryngoscope in
and you lift,
And the lifting lifts the tongue
and the mandible,
and allows the cords to be seen.
01:10
You can see in this example,
the cords are very easy to see.
01:14
And that's a dream intubation.
That's going to be very easy to do.
01:18
So in this situation, you can see
how difficult you can make things
by positioning the patient
incorrectly.
01:26
In the picture on the left,
the patient doesn't have a pillow.
01:30
I just finished mentioning
how important that is,
but you can see what's happened here
is the next to flexed.
01:36
The lower part of the neck
is kind of pushed forward
and you can't get good
at lateral occipital extension.
01:42
In the second picture,
it's better.
01:46
And there should be
a fairly straight line
from the mouth down
the airway.
01:52
And that you can see
in the third picture,
there's a fairly good view
but it could be argued
that this is too extended.
02:01
That they've extended
the whole neck
rather than just
the lateral occipital area.
02:09
So, the Macintosh blade,
the curved blade
should be positioned
anterior to the epiglottis
in the valleculae,
that's the base of the tongue,
and should not contact
the epiglottis.
02:20
The Miller blade,
the straight blade,
on the other hand
actually lifts the epiglottis.
02:24
And you can see that in the picture
to the right of the Macintosh blade,
it actually lifts the epiglottis.
02:32
And there's some hemodynamic changes
that can occur when you do that,
particularly vagal stimulation.
02:37
So you can get bradycardia,
and things that
I’d just as soon avoid,
so I don't use a straight blade.
02:44
This is what you should see.
02:47
The endotracheal tube
is at the top.
02:49
You can just kind of see
that shiny device
above the epiglottis.
02:54
The epiglottis is that organ
sticking out towards you
and it's all lifted up
and you're looking right down
at the cords.
03:01
Easy to incubate that.
03:05
This position where
you're looking at the cords
it can be then further categorized
according to its
Cormack-Lehane classification.
03:16
And the ideal position is a Class I,
which is perfect view of the cord,
you're looking right
at the arytenoids,
which are the the little bumps
at the bottom of the slide
just at the bottom of the cords.
03:30
And you're looking
right down the airway,
That's the ideal position.
03:33
And you should be able to intubate
in that situation
very quickly and easily.
03:37
Class II is also pretty good.
You've got a little less of a view,
You've got the epiglottis
coming down.
03:44
A little bit over the cord.
03:45
So you're losing the top
of the cords,
but you're still seeing
50% of the cords
and you should be able
to intubate.
03:52
It's when you get to III and IV
that things become more difficult.
03:55
With a Class III airway,
you may see
a little bit of the airway.
04:00
And what this is where
a bougie sometimes helpful
because you can slide the bougie
underneath that epiglottis
and get it in through the cords
and then pass the tube
down over the bougie
but this is a difficult situation
and then the worst is Class IV,
where you can't see
the airway at all
all you can see is epiglottis.
04:20
Sometimes what you
see is the epiglottis
kind of stuck to the
posterior pharyngeal wall
and it just won't move.
04:26
And this is where
you're getting into trouble
with the intubations.
04:30
So this is how we can use an LMA
to intubate a patient.
04:34
We can either use
a standard LMA
and pass a narrow gauge tube down it
about a 6 and it's a tight fit.
04:43
I've done this,
and it's a tight fit,
but you can get it down
you should use
the fiberoptic scope
to look and make sure that the end
of the laryngeal mask
is actually adjacent to the cord,
so you can see where you are.
04:55
Because as I mentioned earlier,
even with the LMA is out of position
you can sometimes ventilate.
05:01
Okay.
05:02
And with the bronchoscope
you can tell exactly where you are.
05:05
So you could force a tube down
through that.
05:08
With the intubating LMA
or the Fastrach LMA,
it comes with a size 8
endotracheal tube
that is made of silastic,
which is a plastic material
that slides more easily.
05:24
It's got a bigger barrel
than a standard LMA
and you can get the 8 tube through.
05:30
So, particularly for a man,
that's a better size than a 6.
05:34
A 6 is small for a man or woman.
05:37
So, this is intubating
through the nose.
05:42
And it's interesting,
when you pass a tube down
through the nose
after you've prepared the nose,
as I mentioned earlier,
sometimes you don't have
to do much of anything
to guide it towards the curve.
05:52
The natural shape of the
endotracheal tube is such that
you can often just push it down,
look through the mouth
and you'll see the tube coming
past the palate
into the oropharynx,
and it comes forward very nicely
right through the cords.
06:08
If it doesn't, you use
this right ankle forceps
called a Mcgill forceps
to lift the tube end
the tip of the tube
and direct it down
through the cords.
06:17
So this is intubation using
fiberoptic bronchoscope
both orally
on the left side of the diagram
and nasally,
on the right side of the diagram.
06:28
And it basically just shows
how the fiberoptic scope
is passed down
through the airway.
06:34
And then the tube
is slid down off the scope,
keeping the scope in place
until you've got the tube
down off it
and into the airway.
06:42
And then you can remove the scope,
check for position of the tube,
and hopefully,
you'll be home free.
06:49
This is what the cords look like
through a bronchoscope.
06:51
Look basically the same
as the way they looked
just using a Macintosh blade.
The only thing is you're closer.
06:57
You can see
you're a little bit closer.
06:59
And if you were doing
an awake intubation,
this is where you would spray a
little bit of lidocaine on the cords
before you pass
the bronchoscope any further.
07:09
And then this picture
you can see the endotracheal tube
going underneath the epiglottis,
and through the cords.
07:15
And that's what
you should be able to see
once you've intubated
and you have another look
just to make sure
you're in the right place.