Tag Archives: intubation

Airway Pic-of-the-Week 2014_0825

Kudos to those that responded with answers to the last picture – I hope you found it stimulating!  Jesse Mumba gets the virtual prize (perhaps a sponsor of real prizes will manifest!) for sending in a complete and thorough answer first.  He correctly identified a tracheosophageal fistula on the Gross C (Voit 3B) type, which is the most common (about 86% of cases).  To be fair, it could be the much rarer Gross D, which features a proximal fistula with the oesophagus as well, but this is very unlikely.
The main anaesthetic challenge (other than surgery in a small neonate with a significant chance of other, including cardiac, abnormalities) is the difficult in providing positive pressure ventilation, as the gas flows preferentially into the stomach via the fistula rather than the lungs.  The conventional technique is to maintain spontaneous ventilation through a gas induction until the fistula can be occluded.  We achieved this in the above case by passing a Fogarty balloon catheter into the fistula under vision with a 2mm rigid telescope and then intubating with a 2.5mm ETT.  Significant simultaneous tachycardia and sympathetic stimulation was noted in the anaesthetic personnel, but the infant did very well.
This week’s picture of the week comes with complements of the September edition of Anesthesiology:
Reproduced from Anaesthesiology online (article and image openly accessible by clicking the image above); credit to the authors, dos Reis Falcão et al.
Reproduced from Anaesthesiology online (article and image openly accessible by clicking the image above); credit to the authors, dos Reis Falcão et al.
Transorbital intubation!  Yip, you read that right.  The case report in the September 2014 edition of Anaesthesiology is accessible here and will fill in the details.  Remarkably, this is not the first time this technique has been described in the literature, although prior reports involved the use of a fibreoptic scope rather than direct laryngoscopy.  It goes a long way to illustrate that a good knowledge of the anatomy, technical skill with a wide variety of devices and a flexible approach are the cornerstones of excellence in airway management.
Eye can’t beat that this week…nor will anyone else around the globe.

C-MAC Self-laryngoscopy

Today, we acquired a new toy… uh, I mean tool on loan at work.  It’s a Storz C-MAC video laryngoscope.  (If that doesn’t mean anything to you, you’re allowed not be be excited and stop reading now.  Still here?  OK – it’s a thingymegummy for looking down the throat for putting in a breathing tube in patients under anaesthesia, with a video camera built in so that you can see better.  Practical AND technogeeky… who could ask for more?)

We’ve had a GlideScope on loan for quite some time, but it regularly gets withdrawn from theatre for training, so we obviously want our own.  There is of course a lot of competition in the video laryngoscope market, with many different devices and philosophies behind their construction.  I’ve really enjoyed the GlideScope, which (after you’ve ascended the learning curve) is a wonderful device, but it is good to play…uh, I mean work with as many different tools as possible.  Hence, it’s the C-MAC’s turn.

Typically, when the device arrived we had no suitable patients on which to use it, so I had to improvise:  10% lignocaine spray in my own oropharynx eased the process.  The C-MAC has an SD card slot and records photos and video at the touch of a button, so I was able to take a nice picture of my own vocal cords (that’s a Cormack-Lehane grade 2 view for those studying airways) and a video of the process:

If the video is not working you can watch it on YouTube (a goldmine for medical training, by the way):  C-MAC Self-Laryngoscopy