Money and technology…goodness, wouldn’t it be great to have lots of both? In the words of a famous science fiction writer, William Gibson, “..The future has arrived—it’s just not evenly distributed yet.” In other words, off-the-shelf techniques and equipment exist to take airway management to the next level. Do we need “new” equipment, or do we need a “new” plan to use the existing equipment? Let’s briefly discuss both recent new technologies and some new plans. Approximately 5 months after this lecture was delivered at SMACC 2015, the Difficult Airway Society of Great Britain (DAS) published its revised guidelines on difficult airway management (coinciding with the World Airway Meeting in Dublin, Ireland in November 2015). The new guideline was simple, straightforward, and relied on the major planning points of a 4-step progression from “ plan “A” (intended to represent a best initial approach to plan “D”, representing the prompt performance of a surgical airway. “A-B-C-D” is thus the progression of the DAS plan. What is interesting about the DAS guideline is: #1—The lack of readiness of most Emergency Medicine and Critical Care practitioners to formulate and implement a plan “B” (Use of Supraglottic airway for ventilation rescue and as an intubation conduit), and #2—The lack of applicability of plan “C” to the same group, namely, the possibility of allowing the patient to awaken from anesthesia should an airway attempt prove unsuccessful. The lecture on the Airway Toolbox pays homage to the great “Plan B”, the legacy of the brilliance of the creator of the Laryngeal Mask Airway and all the brilliant clinicians who developed the techniques to make these types of Supraglottic airways quite potentially the most solid method of difficult airway management that will ever grace the planet. As an add on to SGA’s, consider the use of video endoscopy (bronchoscopy or video stylets) to assist DL and VL.

1. The Airway Toolbox
James DuCanto, M.D.
Anesthesiologist and Quality Officer
Director of Simulation Lab
Aurora St. Luke’s Medical Center
Milwaukee, Wisconsin, USA

2. No COI’s to Declare
• …But I do regularly receive quite a bit of
equipment for evaluation
• No product endorsements per se—but I do
have my own preferences, of course.

3. There was Stuff.
But not a lot of stuff.
The world of Medicine was limited to what
could be found in the Forest or the Swamp

4. “Finest Cricothyrotomy Tool Devised by
Nature”—M. LeCong
Brown Kiwi (Apteryx australis),
Chicago Field Museum

5. • …And there was a proliferation of
stuff, beginning with tools to
intubate and ventilate
Draeger Pulmotor, 1907-1940’s
Battery operated
laryngoscope

6. So, Where Does That Leave
Us Today?
• Multitude of devices, techniques
and choices
• Choice of small-purpose based
kits in addition to
the larger bundles

7. In the words of William Gibson,
• “The Future Has Arrived — It’s Just Not
Evenly Distributed Yet”
http://quoteinvestigator.com/2012/01/24/future-has-arrived/
French Video conferencing concept

8. In other words…
• Off-the-shelf techniques and equipment
exists to take airway management to the
next level

9. So here are the first relevant
questions…
• #1-Where Are We with Emergency Airway
Management with respect to equipment and
techniques?
• 2-Why do we need new devices and
procedures to augment an already “crowded”
discipline like airway management
• #3-How are we going to implement these
tools and methods in our practice?

10. Question 1: Where are We?
• We are at Steps 1-2-3!
– Step 1 is DL, VL, Bougie, etc...
• We call it “Plan A”
– Step 3 is Cricothyrotomy.
• Most of us call this “Plan C”
• Step 2 is a known but largely “Missing Link”
– Step 2 is Supraglottic airway based techniques
• Should be “Plan B”, but is still a bit sketchy to
Emergency Airway Management

11. Question 2: Why all this new stuff?
• Because…Every Now and Then, You Step in It,
and the backup plan to a missed “Step 1” is
sorely lacking.

13. OK, What just happened? CICV.
Briefly, until I went to Plan B
• Unsuccessful “Step 1”
– Marginal preoxygenation with plan for RSI with
Airtraq
– Attached head frame prevents face mask
ventilation
– Larynx visualized but unable to be cannulated
• Successful “Step 2”
– Rescue Ventilation established with SGA
– Video Stylet intubation through SGA

14. How should we proceed when Step 1
(aka Plan A) does not succeed?
• We need to plan for failure. There, I said it.
XXXXXXXXXXXX

15. Step 3 Readiness: The Kit I Don’t
Leave the Locker Room Without
Carrying
--Intubating Catheter (Bougie)
--6.0 mm ETT
--Scalpel (#10 Blade Retractable or #11)
--Syringe
--34 fr Nasal Airway (Split Longitudinal)

16. • The kit you would always carry when on
clinical duty
• Supports readiness for Surgical Airway
• Components also support wide variety of
techniques
– (DL/VL, blind nasal, blind oral, Trans-SGA, Mask
ventilation)

17. Experience with Surgical Airway
March 2015
• “IT HAPPENED SO FAST THAT…
–No pause to activate overhead lights in
the Operating Room!
–Scramble to find the bougie and 6.0
ETT!
Does this sound logical?

18. Analysis, Mr. Spock….

19. Now..for the Second Small Kit
Kit #2: AincA Video
Stylet
Kit #1: Cric-Kit

20. Video Driven Endoscope Designed to
fit Within the Tracheal Tube
--AincA Video
Stylet
à$500 USD
à100 Uses

21. Video Stylet Visualization
Systems…Simplified fiberoptic
intubation systems to support Step 2
(and Step 1)
• Similar handling skills to rigid stylets used w/VL
and DL
– Functions as a stylet, scope or lightwand
– Visualization through tip of tracheal tube
• Easy and quick to setup, integral light source
• Work in a complementary fashion with DL, VL
and SGA

22. Clarus Video Stylet
-Semi-Malleable video driven stylet
endoscope
-Current price $8000 USD

23. UE Medical Stylet
-Rigid Video Stylet (UE
Medical),
-Curved for SGA
Intubation
-Curve set to function through the Air-Q
SGA; also w/ Glidescope
-Current price $3000 USD

24. Video Stylet
Simplicity
--72 yo Male
w/Recognized
Difficult Airway,
elective surgery
--H/o Fusion Skull
Base to T12
--Intubation
performed with
light sedation

26. Jennings Mouth Gag
-First mention medical
Literature 1914 for
Cleft Lip and
Palate repair
-Modification of the
Whitehead Mouth Gag
1877
-Currently used in ENT
and Oral Surgery
Simple Device to Support Step 2 (as well as Step 1)
—Jennings Mouth Gag

27. Jennings Mouth Gag Solves Problem
of Intraoral Space
• Carefully applies force to open oral cavity with
small movements of the locking ratchet
• Intuitively easy to use
• Middle opening opens midline for styletted
ETT delivery

29. Video Stylet Assist Step 1
• Morbid obesity with severe sleep apnea
– Grade 3 to 2B visualization
• Navigation of stylet endoscope to offer
complete visualization during intubation
– Visualization becomes grade 1

32. One More Shift from Step 1/Plan A

33. Last topic—Device to assist
ventilation
• Introducing the Oxylator Resuscitator
– Alternative to Bag-Valve
– Fixed minute ventilation (10-12 liters per minute)
– Suitable for adult and pediatric use (patients greater than
10 kg)
– Fixed flow rate 30 liters per minute

34. The Oxylator Solves Several
Important Problems
• Thorough preoxygenation prior to RSI
• The Problem of Inconsistencies of
Ventilation with BVM’s
– Controls flow rate to prevent high inspiratory flow
rates
• Lead to gastric insufflation and central venous collapse
• Permits Two-Handed Mask Ventilation
Technique

36. In Closing, One Last Question
about Step 3—
What are you going to do when it’s
Time to Cut the Watermelon?
-Step in and cut!” –M. Ueshiba