Airway Triad

1. Preoxygenate ridiculously well

2. Use Capnography

3. Use a (DL&VL) device for intubations


1. Preoxygenate ridiculously well

I cannot stress more the value of pre-oxygenation. I pre-oxygenate all of my patients having a GA, commencing as soon as they’re on the theatre table with 100% O2 with a mask that seals on their face – ambubag or similar most appropriate outside hospital – you cannot pre-oxygnate properly with HM or non rebreather (?sucking eggs perhaps but I can’t stress enough the importance of pre-oxygenation). It prolongs the time to hypoxia.

The best way to ensure a tight seal with the facemask during pre-oxygenation is to observe a capnograph trace.


2. Use Capnography
Don’t just use Capnography to confirm intubation, use it to ensure adequate mask ventilation and that you have an adequate seal during preoxygenation. A saturation monitor cannot provide this crucial information. Waveform capnography has become very portable recently e.g. Masimo EMMA 
Do not use a colour change CO2 assessment device (hazardous to patient care as institutions may purchase them instead of waveform capnography).
If you were to provide anaesthetists with a choice of capnography or or a choice of all other monitors (pulse oximetry, NIBP, ECG), most would ask for capnography hands down – it gives immediate real time information about Airway,Breathing, and Circulation.
We have several paramedics come and train in theatre with us. They are often surprised that what they previously considered was effective mask ventilation was in fact not at all – observed by the lack of capnography trace.


3. Use a (DL&VL) device for intubations
The first attempt at intubation should be your best (and ideally the only) attempt. A laryngoscope that offers the combination of direct and video laryngoscopy serves this well.

My background:

I have only performed 1 intubation outside hospital = minimal/no experience. I respect there are several differences with the in and out of hospital environment.

I have been an anaesthetic consultant for 10 years with half of my work being in a large public tertiary referral hospital. I have experienced most in hospital difficult airway scenarios.

The tertiary hospital I work at may be unique in that for the past 4 years in all 26 theatres there exists a McGrathMAC. To my knowledge nothing has been published about this in the literature so if airway secrets truly exist then perhaps this is one that I am happy to reveal. (I hope the Illuminati don’t mind).

At this hospital most anaesthetists, when intubating adult patients with a laryngoscope, will elect to use the McGrathMAC first line. Most accept that if they are going to perform direct laryngoscopy with a standard MacIntosh blade they are only doing this to maintain their skills in case they work in an environment where a video laryngoscope is not available. (A cover may also be put over the McGrathMAC screen to simulate this)

I have experience with and have used pretty much all of the other video laryngoscopes on the market. I still use them at hospitals that have purchased them as their video laryngoscope.
I have not found much difference between the video view they provide, however I will note:
– I would shy away from channeled video laryngoscopes (most hospitals I work at have not purchased them) – I like the freedom of being able to manipulate the ETT where I want to (perhaps the mannequins provided by companies marketing channelled VLs have perfectly aligned airways for their products – I’m sure this is not the case in the real world).
– We did use some McGrath series 5 laryngoscopes for a few years however found them to be temperamental – the screens occasionally blacking out because of poor contact between blade and handle. I would not recommend them.
– Video laryngoscopes requiring a midline approach to laryngoscopy (such as the Glidescope) provide a less familiar approach to laryngoscopy.
– Video laryngoscopes that allow the screen to be in front of you avoid you turning your head sideways during intubation.
– Big screens and great optics improve the screen appearance however the bigger the screen the less portable the equipment.
– From my own experience, and from speaking to my colleagues, we do not envisage a situation where if we attempted intubation with a C-Mac or McGrath and failed that we would then attempt with a different video laryngoscope. (Note C-Mac has the D Blade and McGrathMAC has the X Blade- they are curvier – this may be the only reasonable additional step, however most of us would like to think we could have predicted the need for this prior – however never sure)
– I have seen but never used the Airtraq even though it is available at some institutions – frankly it is not a video laryngoscope, it is a dangerously inferior product that is detrimental to patient safety as some institutions may purchase it instead of a true videolaryngoscope.

A device that allows VL&DL at the same time offers the advantage that the first attempt at intubation is the best attempt – therefore less airway trauma, and so more likely to be able to ventilate if can’t intubate (excessive airway trauma may render a patient who was previously ventilatable non-ventilatable). Also it will lead to a shorter time between an attempt at intubation (which fails) and subsequent attempts at ventilation or surgical airway. (If a surgical airway is required always better to do this when saturations are still close to 100%)

Also when intubating with a VL&DL the assistant (and others) have a view. The assistant is able to visualise any necessary manipulation of the trachea (not cricolol), and will know (prior to any verbalisation) difficulties presented – in turn they can be obtaining or thinking about obtaining necessary equipment for the next step before you’ve even mentioned it.

Randomly, in the middle of writing this post an urgent assist was called by an anaesthetist to endoscopy suite – elective gastroscopy (not bleeding), portal hypertension, 20 weeks gestation, sedated, left lateral position. During gastroscopy bleeding from varices. Required intubation in left lateral position with torrential bleeding in airway. McGrathMAC was used by 3rd year registrar – used direct view with laryngoscope however we were able to view what registrar could see, offer tracheal manipulation, and contemplate what the next step would be without the registrar needing to describe the view. Intubation was successful in very difficult circumstances.

The C Mac and McGrathMAC both offer VL&DL.

The McGrathMAC has the advantage of being portable, and is positioned cost wise to allow numerous devices in multiple locations. I do not envisage every theatre having their own dedicated C Mac, and also they do not seem like an option for paramedics.

I believe that the routine, first line use of a laryngoscope which offers VL&DL offers a significant patient safety advantage, and the sooner this practice is adopted the better it will be for our patients overall.
I have bought my own McGrathMAC to take to other hospitals and day surgeries. I have no financial interest with McGrath, Covidien, or any other suppliers of this product. I welcome the introduction of similar products to the McGrathMAC – their introduction to the marketplace will competitively improve the price.

I am very happy to answer any questions, criticisms, queries etc. I congratulate everyone who gets involved in these discussions, which may at times become heated, but are always in the best intentions for our patients.

Keep it simple too (I’m a big fan of the Vortex).

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