Airway Registry learning points reflect the challenges described and wisdom shared by Sydney HEMS personnel and guests at the Clinical Governance Airway Registry presentations. Cases are discussed non-contemporaneously, anonymised and amalgamated over a time period to draw together unifying take-home messages. Details of specific cases are removed and/or changed, such that any similarity to real-life patients or scenarios is coincidental.

Sydney HEMS is proud of its commitment to excellence in airway management. In 2018, we achieved:

387 Intubations

352 RSIs

96.5% First look laryngoscopy success at RSI.

These learning points form part of our commitments to governance, excellence and education. All CMAC videos are shared under a Creative Commons Licence: Attribution 2.0 Generic. Please familiarise yourself with the terms of the licence before reusing our videos.

To view these videos, you will need this password: AiRblogVideos

Focus on: Front of Neck Access & Surgical Airways

Will a 6.0 COETT Create a Seal in an Adult Male Trachea?

We carry a 6.0 ETT in our surgical airway kit to fit through the adult crico-thyroid membrane. Although we have never experienced a leak from our 6.0ETT surgical airways, it has been questioned elsewhere how the outer diameter of the balloon compares with tracheal diameter. For our equipment the following pictures were made:-

Centre of gravity for patient & stretcher stability

It is our practice to reposition the patient with their neck extended for a surgical airway and to achieve this position by placing the head extended over the end of the stretcher. This temporary position may render a change in the centre of gravity of the patient on the stretcher for further moves or interventions and therefore extra vigilance is warranted.

Paediatric Surgical Airways

It is worth remembering that for smaller children (usually <8 years), our standard scalpel-finger-bougie approach to surgical airways may not be appropriate, not only because our fingers are too big but also because we may not be able to site a 6.0 ETT (which is what we carry in our surgical airway pack).

We carry the ENK for oxygenation via front-of-neck in these patients – below is a video made at our Dec 2018 joint HEMS/NETS education day in which one of our registrars (Dr David Gale) explains how the ENK is used.

There is a second ENK video on our YouTube channel, this one from 2017 presented by another registrar – Dr Amy Gospel.

Laryngectomy patients

Patients presenting with a hole in the front of their neck may have a stoma which directly connects trachea to skin. Having had a laryngectomy there is NO route from the nose & mouth to the lungs. All oxygenation & ventilation must occur via the stoma. Management of such airways, including in cardiac arrest, is well described by algorithms and videos by the National Tracheostomy Safety Project at http://www.tracheostomy.org.uk

Hospital Hyperangulated blades

A discussion was had surrounding the use of hospital equipment for intubations in interhospital missions. Some intubation equipment is more familiar to our teams than others. Some equipment, such as the hospital CMAC monitors can appear familiar, but a different blade e.g. plastic disposable rather than metal can make them less familiar than first thought. Hyperangulated rigid introducers are a learned skill.

Video Focus on: Paediatric Intubation with CMAC

This month we are able to share two more good uses of CMAC Mac 4 blade in paediatric intubations. For more information on how/why this works, see this AiR blog post.

Intubation in a 4-year-old:

Intubation in a 23-month-old:

Further CMAC Videos:

Regurgitation During Laryngoscopy

This footage captures regurgitation and soiling of the larynx at laryngoscopy.

Suction Catheter in Pharynx With Bougie

This video shows a Yankaeur sucker being positioned to the left of the Mac blade throughout laryngoscopy for continuous suction. It is worth remembering that our Yankaeur suction catheters currently have side holes that need occluding for suctioning to work. Occluding the hole during laryngoscopy is challenging. Two options would be to use a friend, or to remove the Yankaeur and place the tubing itself into the left side of the pharynx.

You can see all the AiR videos here on our Vimeo page or here on the blog.