Advanced Airway Management
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Expanded Guide:
Aintree Rescue Intubation through the LMA
Rescue LMA placed? But need a protected airway?
Take the following steps to fiberoptically intubate the patient using the Aintree. Note that there are numerous methods for fiberoptically converting an LMA to an ETT. The following method is easy to learn, maximizes continuous ventilation time, and has a versatility that makes it compatible with virtually every type of the 40+ FDA approved LMAs on the market (the notable exception is the Teleflex Supreme LMA, as this LMA's lumen is simply too small and will not readily accommodate an Aintree catheter).
Read on to learn more.
PART 1: LMA PLACEMENT
Rescue LMA reestablishes ventilation.
Following failed efforts at intubation and mask ventilation, an LMA can reestablish ventilation and oxygenation. The next steps can allow for the safe transition of the rescue LMA to a secure airway with an ETT.
1
A "rescue" LMA is emergently placed following failed attempts at mask ventilation and tracheal intubation
2
Confirm ETCO2
3
Take a breath
You've successfully created new options for your patient:
1. Intubate thru the LMA
2. Wake patient up
3. Maintain LMA for duration of case
4. Place surgical airway under significantly less emergent circumstances with the functioning LMA in place
4
If the patient needs a protected airway, you can proceed with the following steps to place an ETT using the Aintree technique
Part 2: Equipment Preparation
Gather equipment. Call for help.
All necessary equipment should already be stocked with every bronchoscope stand or tower. Mobilize early assistance, including with anesthesia techs, to ensure essential equipment availability.
1
Equipment
* Aintree
* Intermediate scope
* Bronch elbow
* Lubricant
* 7-0 ETT
* Defogger
* Functioning LMA
2
Lubricate
Don't make this too complicated. Also, don't skip this step. Just give a light spray to the proximal inside of the ETT, Aintree and LMA.
3
Load Aintree onto INTERMEDIATE SCOPE and secure with tape or use this hack
"Intermediate scope" means the Olympus 4-0 or the Verathon 3.8 mm
4
Defogger
Apply a small amount to scope tip. Keep additional defogger nearby if reapplication needed later
In a pinch, an alcohol swab works
5
Bronch Elbow
Place it onto the LMA and reconnect circuit.
6
For Aintree placement,
1. Continue 100% O2 & ventilation.
2. Confirm adequate anesthesia & muscle relaxation.
Part 3: Put the Aintree in the Trachea
Continue ventilation. Continue oxygenation.
Use the scope, preloaded with the Aintree, and drive through LMA, vocal cords and down to the carina. Then railroad the Aintree into the trachea. Take care not to advance past the carina.
Tip
A well seated and midline LMA yields the best view of the cords. Adjust as needed.
Ask an assistant to apply jaw thrust to improve cord view during Aintree placement
1
Place scope tip thru bronch elbow. Sequentially drive down thru LMA, cords and into trachea.
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2
Continue advancing scope down to carina.
3
Railroad Aintree over scope and visualize blue Aintree just above carina before removing scope.
4
Note depth of Aintree and make efforts to maintain depth during remaining steps
Tip
Knowing airway dimensions is helpful
23cm - Average distance from incisors to carina in adult females
26cm - males
Part 4: Railroad ETT into trachea
Apneic portion of procedure.
Up until this point, the patient has been continuously oxygenated and ventilated, expanding the safety window for the patient and giving you more time to complete all steps to this point. These next steps will take place during apnea.
1
Disconnect bronch elbow and circuit from LMA
2
Carefully back LMA out of oropharynx until only the Aintree remains.
3
Railroad 7-0 ETT over Aintree and into trachea
4
Remove Aintree from ETT
5
Inflate ETT cuff, reconnect circuit, confirm ETCO2 and appropriate ETT depth. Secure ETT
One less, one less problem
Hold my coffee: Equipment factors that can make this all go south
Problems & Solutions
The disposable bronchoscopes have inferior textile fidelity, especially with the smaller scopes. Fiberoptic intubations can simply be more frustrating when using this scope.
One specific point for failure, however, has occurred despite excellent visualization of the vocal cords. Rarely, even when the procedure is handed over to experienced faculty, there has just been extreme difficulty or eventual failure in advancing the scope through the vocal cords. The cause remains unclear, though it likely has something to do with the flimsy nature of this bronchoscope tip.
For especially concerning or failed airways, request the Olympus tower