New video-assisted laryngoscopes are making a significant change to intubation techniques - see AirwayCam.com.
Confirmation of ETT Position
Feel the bag, look at the chest, listen for burping, check equal breath sounds at the apices, check flow curves, check for exhaled CO2 or fogging.
If in doubt, look again, directly, with the scope, to confirm that the tube is between the cords.
If ventilation is poor, and direct visualisation is inconclusive, always remove the tube before hypoxia occurs; ventilate via mask or LMA until you can intubate, decide to give up, or get a surgical airway. Never hesitate to call for help - the earlier the better!
Failed Intubation / Can't Intubate / Can't Ventilate
Double Lumen Tubes
My personal insertion technique:
I prefer not to put my hands in the mouth! The LMA must be well lubricated, inside the spoon and along the shaft.
The patient's head should be in the sniffing position, on two pillows.
With my left hand on the forehead and my right under the tip of the jaw, I use both hands to extend the neck; my left hand stays on the forehead to keep the neck extended. My assistant passes the LMA to my right hand then helps open the mouth. The LMA is inserted into the mouth in whatever angle or position is easiest - typically in the midline - with the cuff softly inflated .
Once the widest part of the LMA is past the teeth, I endeavour to shift it to the right side of the tongue, and I advance it between the right side of the pharynx and the tongue with the cuff facing leftwards and upwards. Sometimes a 'jiggling' motion helps the tongue come forward as it is pushed in. As the tongue moves forward, the LMA will slide easily into the hypopharynx, especially if directed downwards (caudad) from the side of the mouth.
Rarely the LMA must be put in backwards and rotated 180 degrees when far enough in.
Make sure the LMA is well lubricated, otherwise the tongue sticks and is pulled backwards and inwards.
Persisting if the patient starts to gag or bite is not a good idea! I use the same technique for the ProSeal (i.e. I don't use the introducer).
Done this way you should almost never see any blood on the LMA.
My personal approach is to stand facing the patient with them sitting bolt upright in the sniffing position. Bolt upright is the best position for a patient with significant respiratory compromise.
I locate the TV stack immediately to the left of the patient, and stand facing the patient.
TCI propofol and remifentanil infusions are useful to provide conscious sedation - ensuring the patient remains awake at all times is important! I vasoconstrict and anaesthetise the nose using using 5% lignocaine/phenylephrine mixture - three sprays each nostril repeated three times at 5 minute intervals. I also spray the pharynx and larynx with 3-4 sprays of 5% or 10% lignocaine at 5 minute intervals. With a suitable malleable spray nozzle it is possible to direct the spray directly onto the larynx.
Adequate local anaesthesia of the larynx is indicated by a change in the voice.
After softening the tip of the ETT in hot water - a Parker style tube is best - I then place it into the hypopharynx via the nose. Keeping the 'point' of the ETT medial and inferior minimises the risk of damaging the turbinates, and the vasoconstriction from phenylephrine reduces the risk of bleeding to near-zero.
In patients with high cervical fractures and anterior haematomas it is probably better to carefully pass the scope into the pharynx first, then run the tube over the scope.
With the ETT stable in the nose, it's tip can be advanced close to the larynx. The well-lubricated scope can then be guided under direct vision through the cords, and then the ETT can be railroaded over the scope. Sometimes the point of the tube can catch on the larynx, so be ready to rotate it as you go in, and ask the patient to breathe in. I typically give a small bolus of remifentanil before passage of the ETT into the nose and into the trachea. Coughing if any is brief. There are a lot of other ways to topicalise the airway, but this technique is simple, safe and reliable. ENT Technologies can provide the sprays and malleable nozzles.