Emergent Airway Adjuncts

Emergent Airway Adjuncts is a topic covered in the Washington Manual of Medical Therapeutics.

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  • Gum elastic bougie is a flexible rubbery stick with a “hockey stick” tip. The bougie can be used blindly but is better suited for direct laryngoscopy where the person intubating cannot visualize the cords. The goal is to obtain the best view possible and for the coude tip of the bougie to be distal and anterior. When the bougie is in the trachea, the tracheal rings are felt as the bougie is slid back and forth. Alternatively, the bougie can be advanced down the oropharynx as deep as possible without losing control of it. If in the esophagus, the bougie will slide all the way down past the stomach with minimal resistance. If in the trachea, the bougie will quickly hit a bronchus and meet resistance. Once in the trachea, one can simply slide an endotracheal tube (ETT) over the bougie and verify placement as usual.
  • Laryngeal mask airway (LMA) is an easy-to-use rescue device for nearly all airway events. It is an ETT with a balloon at the end that is inflated to cup the trachea while occluding the esophagus. It should not be used in patients with an upper airway obstruction that cannot be cleared or patients with excessive airway pressures such as with chronic obstructive pulmonary disease (COPD), asthma, or pregnancy. There are models of LMAs (which are preferred) that allow an ETT to be passed through them when a definitive airway is desired. Excessive bagging through an LMA can lead to emesis.
  • Supraglottic airway devices are placed blindly in the oropharynx and inflated with air. An upper balloon obstructs the oropharynx, whereas a lower balloon obstructs the esophagus, allowing ventilation in a similar fashion to an LMA with the same limitations. Intubation is not possible through the supraglottic device as it is with an intubating LMA.
  • Fiber-optic/digital airway devices are considered by many to be the new standard of care. These devices allow the person intubating to get a view of the vocal cords via a camera or fiber-optic scope without direct oropharyngeal visualization, making intubation much easier. Excessive secretions or blood can obstruct the camera, so the operator needs to be capable of direct laryngoscopy as well as indirect fiber-optic laryngoscopy.

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  • Gum elastic bougie is a flexible rubbery stick with a “hockey stick” tip. The bougie can be used blindly but is better suited for direct laryngoscopy where the person intubating cannot visualize the cords. The goal is to obtain the best view possible and for the coude tip of the bougie to be distal and anterior. When the bougie is in the trachea, the tracheal rings are felt as the bougie is slid back and forth. Alternatively, the bougie can be advanced down the oropharynx as deep as possible without losing control of it. If in the esophagus, the bougie will slide all the way down past the stomach with minimal resistance. If in the trachea, the bougie will quickly hit a bronchus and meet resistance. Once in the trachea, one can simply slide an endotracheal tube (ETT) over the bougie and verify placement as usual.
  • Laryngeal mask airway (LMA) is an easy-to-use rescue device for nearly all airway events. It is an ETT with a balloon at the end that is inflated to cup the trachea while occluding the esophagus. It should not be used in patients with an upper airway obstruction that cannot be cleared or patients with excessive airway pressures such as with chronic obstructive pulmonary disease (COPD), asthma, or pregnancy. There are models of LMAs (which are preferred) that allow an ETT to be passed through them when a definitive airway is desired. Excessive bagging through an LMA can lead to emesis.
  • Supraglottic airway devices are placed blindly in the oropharynx and inflated with air. An upper balloon obstructs the oropharynx, whereas a lower balloon obstructs the esophagus, allowing ventilation in a similar fashion to an LMA with the same limitations. Intubation is not possible through the supraglottic device as it is with an intubating LMA.
  • Fiber-optic/digital airway devices are considered by many to be the new standard of care. These devices allow the person intubating to get a view of the vocal cords via a camera or fiber-optic scope without direct oropharyngeal visualization, making intubation much easier. Excessive secretions or blood can obstruct the camera, so the operator needs to be capable of direct laryngoscopy as well as indirect fiber-optic laryngoscopy.

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