hi everyone my name is lahiru from abc's of anesthesia and today we're going to go through
a couple of really vital really important things which is laryngospy technique and
intubation this is a laryngoscopy blade this is a size for macintosh blade it's probably one of
the most common ones you'll see it's one i go to pretty much every single time and all it is
is it's this handle and this handle is a power source you can check the light by just depressing
that there and then the blade which comes in pretty much quite a number of sizes but
the common sizes in adults are size four and size three you can just latch it on like that
what i do then is i check that the light is working one of the most important things that
you'll find is that you need a really good light if this light isn't bright enough you'll be in
there trying to find the trachea and everything will be just dark so you really want a bright
light this is what makes or breaks a difficult intubation so there's a couple of different sizes
that you'll be using when intubating adults there's a size three and a size four now
in my opinion i go to a size four every single time a size 4 blade has the length for me to get
down into the velecular that's that spot just at the base of the tongue and where the epiglottis
joins the tongue and that's where you need this to end up to make sure you get the best view possible
sometimes you'll be handed a size 3 blade for smaller adults and females but this i find
occasionally doesn't get down to the molecular for that reason i'll go to a size 4 every single time
the size 3 blade has one advantage in my eyes next time you when you're in theater try this where you
get someone to press down on the tip of the on the tip of the blade and you find that it's far easier
to lift this up than lift the size 4. the size 4 blade has a much larger lever which means that
if someone's pressing down and you're trying to lift here it's far harder to do that
that said most people will gain the strength and technique possible to injure anyone with a size
4. there's quite a few different blades that you might choose there's the straight miller
blade the mccoy blade and also the varying types of blades you can get with video laryngoscopes
like the d-blade and these are hyper-angulated blades i'll talk about those in another video
when i'm intubating the very first thing i do after patient's anaesthesia patients paralyzed
is i tilt the head back what that does is it tilts the head on the atlanta occipital joint
that opens the mouth slightly and also gives me a better aperture down into the trachea
at that point what i do is i then insert the laryngoscope the luring scope most people tell you
to insert it like this now what i do is i insert it slightly to the side you can imagine that in
some people occasionally this handle might get in the way or the chest might get in the way of
this handle if i insert to the side that's never a problem because there's always space around here
and once it's in i then tilt it round now the very next step slide the tongue from the right
to the left at this point i'm pretty much down straight back into the oropharynx at this point
i do a tilting motion what i'm trying to do is get that tip and just trace down the tongue so
the tongue is the road down to the molecular i need to go all the way down into the molecular and
i'm tilting on this axis just to give you another view the laryngoscope blade is now inside the oral
cavity it's straight back down and i'm using that tip to trace down and rotating it on this axis as
it traces down the tongue again the tongue is the road down to the molecular where this tip needs to
be now after you've found the molecular the best thing to do to optimize your view is to do this
lifting motion and that lifting motion it's not what people normally do naturally which is tilting
back that's only going to lever against the teeth and won't provide any kind of aperture down in
through the oral cavity to the trachea what you need to do is lift towards the corner of the room
so what i get my trainees to do is look up at the corner of the room and literally pull there
sometimes you still don't get a view and the very next step is to lift up the head
that's obviously can be quite difficult i can get a really good view by just lifting the head
it opens up everything a lot better but holding that can be really difficult so what i do then
is i get my assistant to help me with that by just holding that head up in the right position
the final thing i want to go through is that sometimes you just don't have
enough momentum or force and what you can do is you can bring your arm to the center
and have that resting say on your chest that way pushing forward even just pushing forward a little
bit improves the amount of force and amount of strength that you can have because you're not
really lifting with your deltoid here there's a pretty weak muscle in most of us you actually
just move your body forward and that helps lift as well sometimes you simply can't get a view in
spite of everything that you've done there's obviously a lot of things you need to follow
i'd follow the das difficult airway society guidelines to make sure that you manage this
the absolutely appropriate way now there's a few things that can happen if you don't get
the right view now the way i think about this is apb assistance paralysis burp bougie blade we'll
go through this in future videos in more detail but i always ask for assistance especially when
you're junior you need to have someone helping you and having extra hands and brains is always
such an important thing because we're dealing with people's safety in people's lives here
so get assistance i think about paralysis is this patient paralyzed to the absolute right level a
paralyzed patient is invariably much easier to treat much easier to oxygenate and ventilate
and so always consider that again make sure you've got your boss there your consultant there
because it's a tough decision to make for anyone especially if you're junior finally the three b's
burp bougie blade imagine i've got my laryngoscope here and i've got a view i get my hands and i put
it on the larynx on the thyroid cartilage and then i move it backwards upwards and rightwards
and that can improve my view amazingly well so that's the first thing i do after that
now i still need my right hand so i get the nurse to put their hands on the thyroid cartilage and i
may move the nurse's fingers as i see fit that's a really good technique so you know exactly where
the hands are placed and that way it really helps them because they can't see what you're seeing
it's really important that they've got their hands on the larynx so that you can manipulate those
hands to make sure that you get the right view and they know exactly where you want that larynx
after burp i asked for a bougie because often even with a bad view at grade 3 view i can still get
the bougie underneath that epiglottis finally the last step is asking for a blade a different blade
often these days of video laryngoscope now just notice the order i had that in
burp bougie then blade i say birth first because you've already got your hands you don't need to
ask for anything else boujee's next because the bougie is often something that's in the theater
just nearby but still takes a bit of time to get out finally a new blade might be in another
room it might be in the theater complex and will take time so i often get the theater technician
or another nurse to go get that while i'm proceeding down these plans so the last couple of
tips imagine you've got a really good laryngoscopy view so you've got a great view of the chords and
now you're about to place your tube in intuitively you think that you just want to have the tube like
this following the contour of your laryngoscope what i find is that that actually blocks your view
so you're never really sure if your tube's in there now it's a really simple maneuver
you just turn your tube that side so it's lateral it's horizontal that way i can see
the larynx i can see the chords and i can see the tube passing in and it doesn't take any more
change than simply a lateral rotation clockwise 90 degrees and that's it now sometimes you just can't
get the angle the end the larynx is maybe anterior and there's a couple of simple things you can
do you can have your tube already bent like that preset or i might just bend the tube on the pillow
like so and as it slowly recovers its shape i then place it through the cords so just to demonstrate
with a video laryngoscope now these first few steps i had to get my right hand on the head
and that allows me to just angle the neck back angle the head back and this opens up the mouth
giving me a much better trajectory to the trachea so as i go in i go to the right side of the tongue
and you kind of sweep the tongue over to the left it's hard to demonstrate on this mannequin
because of the tongue being fixed but that's the step i would take so imagine right now that my
laryngoscope blade is directly back at this point i then use the tongue the tongue is again the road
down to the molecular so i follow the tongue all the way down to the molecular the next step i want
to do is lift towards the corner of the ceiling like so and that opens up everything allows me
to see down into the trachea after this step sometimes you might not get a great view what i
do is i sometimes lift the head like this lifting the head then allows me to you know improve my
view and i might get my technician my nurse to help support there while i get the tube into
the right spot sometimes my blade might be too far in if it is and that happens often when you first
start out all i have to do is slowly trace back until i can see the velocular and see the chords
now just to demonstrate inserting this tube if i insert it this way
it blocks my view completely but if i insert to the side it can really help my view
i hope you enjoyed those tips and good luck with your next intubation