The Gazette

February 2009 Vol.13 Issue 1

The Official Publication of the Society for Airway Management

The Society for Airway

Contact us at: Management
P.O. Box 946
Schererville, IN 46375

Telephone: 773-834-3171
Fax: 773-834-3166
http://www.samhq.com

Join the SAM-Forum

By e-mailing:
Bettina.schmitz@ttuhsc.edu

SAM’s Official
Journal !!

The Journal of
Clinical Anesthesia
INSIDE: Board of Directors
President
• Editorial Expressions P. Allan Klock MD
• Your Vote Counts! aklock@dacc.uchicago.edu
• Teaching Flexible Laryngoscopy President-Elect
Elizabeth Behringer, MD
• Scientific Program elizabeth.behringer@cshs.org
• Assessing Competence in Intubations Vice President
• New Members Thomas Mort, MD
tmort@harthosp.org
• Evaluation of LMA Supreme
Secretary
• E-lights of the SAM Forum Maya Suresh, MD
• Tips & Tricks msuresh@bcm.tmc.edu

• SAM Guidelines Treasurer

Richard Cooper, MD
• Application richard.cooper@uhn.on.ca
Editor-In-Chief Executive Director
Katherine Gil, MD Carin Hagberg, MD
k-gil@northwestern.edu Carin.A.Hagberg@uth.tmc.edu

Board Members
Associate Editors
Gail Randel, MD Valerie Armstead, MD
g-randel@northwestern.edu vearmstead@gmail.com
Eugene Liu, MD
Andranik Ovassapian, MD analiue@nus.edu.sg
aovassap@airway.uchicago.edu Alonso Mesa, MD
Administrative Director Alonso.Mesa@moffitt.org
Anne-Marie Prince Irene Osborn, MD
amprince@peds.bsd.uchicago.edu Irene.osborn@mssm.edu
Frank Stellaccio, MD
Gazette Layout Editor
fstellaccio@notes.cc.sunysb.edu
Kathryn N. Gil
Arndt Timmerman, MD
atimmer@gwdg.de

Be sure to save the date!!

September 25-27, 2009

2
 reported ~1300 endoscopies with a high percentage
Editorial Expressions of intubations in ~200 volunteer “anaesthetists”. This
resulted in 36% developing lidocaine symptoma-
tology, 35% sore throats, 10% epistaxis (of those
Colleagues: Here is your chance to vote! Please make nasally instrumented), 3% junctional rhythm, 2%
sure you include your name!! This is the issue where psychological distress, 1% rigors, and <1% with a
you decide if you want SAM to continue publishing lower respiratory tract infection…plus increased
the Gazette in print form or change to having sympathetic output and assorted minor symptoms.
electronic copies only at the SAM website. The In this Gazette, Dr. Geoffrey Lane gives a per-
PDF forms vary from 35-65 MB and are too large for spective of competency assessment in pediatric
e-mailing –fills up boxes; takes a long time. fiberoptic intubation. He has excellent tips that you
You can either vote electronically by email (address won’t want to miss.
below on this page) OR by posting the form below in Further on, Dr. Allan Goldman’s study on sizing the
the mail (i.e. cut out along the dashed lines below and Supreme Laryngeal Mask Airway is a source of
put a stamp on it and mail to the address on the other information that is unique in its description of a
side). methodology not found elsewhere. Not only is it
We have a wonderful issue for you with some likely to help with this device, but perhaps with a
fascinating articles! Dr. Eugene Liu describes a variety of devices.
system of teaching fiberoptic endoscopy through the
use of live human volunteers. He stipulates that
intubation was not permitted and no complications Best regards,
ensued. Interestingly, for decades, clinicians have
utilized endoscopy on live volunteers. For those of Katherine Gil, MD
you wondering about intubations in similar Editor - In - Chief
circumstances, NM Woodall et al (BJA, 2008)

Visit http://www.samhq.com to join now!

LET US KNOW!
Check one, cut out this page,
then submit it back to us!

I would prefer to be sent hardcopies

of the Airway Gazette!
I would prefer only the electronic
version found on the SAM Website!

Your Printed
Name, please:
OR E-MAIL YOUR VOTE TO:
Airwaymanagement@hotmail.com
 Teaching Flexible Laryngoscopy for Volunteers
in a Difficult Airway Management Workshop
Eugene Liu, MBChB, MD
National University Health System
Singapore
Our department regularly conducts difficult airway bronchoscope into the trachea.
management workshops, which include training with We obtained written informed consent from all the
flexible bronchoscopes. Although training in volunteers. We checked that the volunteers were
manikins is useful, such training lacks realism. To healthy, with no hypertension, asthma or nasal
improve learning, we include flexible laryngoscopy problems. We had a formal agreement in which a
training in volunteers in our workshops. volunteer was paid a fixed sum for each workshop
participant who carried out flexible laryngoscopy on
Prior to organizing such training, we sought legal that volunteer.
advice and approval from the Medical Affairs
Department of our hospital. We also consulted with We arranged a trial run before the workshop. The
our institutional review board who decided that a faculty evaluated the suitability of the volunteers to
formal review was unnecessary. The IRB made this be teaching subjects, and familiarized the volunteers
decision as the workshop did not involve patients, with bronchoscope insertion. Importantly, this also
and because the objective was teaching and not enabled the faculty and volunteers to establish
research. rapport ahead of the workshop.

In balancing training realism and safety, the work- The bronchoscopes were all brought in by the vendor
shop faculty decided that the main aims were companies specifically for the workshop. We used
handling of the flexible bronchoscope, negotiating 3.8mm OD scopes as these were better tolerated by
the nasal airway and achieving a view of the larynx. the volunteers than larger diameter scopes. We did
The participants would not attempt to insert the not use any existing hospital bronchoscopes, so as not
bronchoscope through the glottis and they would not to compromise the operational capability of the
attempt to insert a tracheal tube over the hospital. As the bronchoscopes were to be used in

Place
Stamp
Here

Society for Airway Management

The Airway Gazette
P.O. Box 946
Schererville, IN 4637 5

4
human subjects, the bronchoscopes were brought in a participants aimed to negotiate the scope through the
few days beforehand to be tested and commissioned nasal passage and to view the larynx, but stopped
by our hospital Biomechanical Engineering Depart- short of inserting the scope through the glottis.
ment We used the ambulatory surgery ward which Participants who had never handled a flexible
was adjacent to the hospital’s training centre for this bronchoscope found it helpful to practice at a
training. All our workshops were held on Saturdays, manikin station and lung model, before learning on
so the physical infrastructure of beds, oxygen and the volunteer. On average, the participants took 5 min
suction outlets, decontamination and cleaning facility to achieve views of the larynx. Grouping the
were all available and not required for normal clinical participants into pairs or threesomes enabled them to
activity. At prior learn from each other’s experiences.
workshops, we
had set up all A limitation of our workshops is that as we stopped
the flexible short of inserting the bronchoscope into the trachea,
bronchoscope reducing the realism of training. This was to prevent
stations in the trauma and discomfort to the volunteer. In clinical
tutorial rooms practice, problems are frequently encountered after
of the training the bronchoscope has been inserted through the
centre. This glottis and when the tracheal tube is railroaded over
necessitated the bronchoscope.
transportation
of much clinical A second limitation is that even with very close
equipment to supervision, the participants may still cause trauma to
replicate a the nasal passages, glottis and airway. While none of
clinical setting our volunteers had oxygen desaturation, bleeding,
in the tutorial hypertension or arrhythmias, the teaching procedure
rooms. It was must be abandoned if these occur. Thirdly, our
much easier to move the participants from the workshop participants had a diverse range of
training centre to the ambulatory surgery ward. experience and ability. Some participants had never
even seen or held a flexible bronchoscope in their
All the volunteers fasted for at least 6 hours before hands and needed much encouragement and much
the workshop session. Volunteers all had intravenous more time for guidance.
cannulation and i.v. fluids, and monitoring with pulse
oximetry, ECG and non-invasive blood pressure. We Rarely, a volunteer pulled out just before or during
applied oxymetazoline and lidocaine spray to the the workshop, so we had to prepare ‘reserve’
nasal passages plus lidocaine spray to the oropharynx volunteers, and to reorganize the roster.
and uvula. We limited the total lidocaine dosage to 4 Despite these limitations, the feedback on this
mg/kg during a teaching session. We did not use training was very good and all the participants felt
antisialogogues or sedatives. that carrying out the procedure in volunteers had
enhanced their learning.
We stationed an anesthesia nurse at each teaching
station to care for the volunteer and to assist the In summary, teaching flexible laryngoscopy in
instructor. The nurses kept records of the drugs and volunteers requires a little more planning and
dosages that had been used. We organized the organization. Safety of the volunteers was our main
volunteers and participants into a teaching station concern. We suggest using a fully equipped clinical
roster. We carried out standard decontamination of location within a hospital, and ensuring skilled
the bronchoscopes when there was a changeover of assistance. We also recommend having a pilot run for
the volunteer. volunteers and faculty to gain confidence in each
other. Lastly, we are extremely grateful to the vendor
The participants were first taught how to hold and companies who have so generously supported our
control a flexible bronchoscope. They were also workshops every year with their equipment and time.
taught how to avoid damaging the scopes. The

5
SESSION I: Airway Management Outside the OR
Cardio-respiratory Arrest related Ventilation and Airway Management –
Airway Disasters –
Locations outside the O. R. –
SESSION II: Establishing Competency in Airway Management
Nuts and Bolts of Competency –
Emergency Medical Technicians –
Emergency Medicine Physicians –
Certified Registered Nurse Anesthetists –
Anesthesiologists –

SESSION V: Six Abstracts

SESSION IV: Hands-on-Workshops and Airway Simulator
Adult Fiberoptic Intubation Retrograde Intubation
Pediatric Fiberoptic Intubation Airway Nerve Blocks
Lung Isolation: Double-Lumen Tubes and Bronchial Blockers Rigid Bronchoscopes
Laryngeal Mask Airways Patient Simulator
Combitube/Easy Tube/King LT Alternatives CPR Assessment and Feedback
Rigid Video Laryngoscopes (Glidescope, Airtraq, McGrath, Storz)
Lighted Stylets (Lightwand, Bonfils, Levitan, Shikani, FAST)
Other Supraglottic Devices: Air Q, Ambu LA, I-gel
Transtracheal Jet Ventilation and Cricothyroidotomy
SESSION V: Current Controversies in Obstetric Airway Management
GA for Obstetrics: Is it a Dying Art? –
Mask Ventilation and Cricoid Pressure during Rapid Sequence Induction –
CICV Situation – Which Supralaryngeal Device to Reach for? –
SESSION VI: Jackpot
DAS Representative: History of the Airway – David Wilkinson
\Airway Management in China in 2009: An Overview – Ming Tian
Ovassapian Lecture: Airway Pharmacology – Ron Miller
SESSION VII A: Expert’s Round Table Discussion (includes lunch)
Sedation-Analgesia by non-anesthesiologists: What you need to know about Joint Commission Standards and ASA Guidelines –
Creating and Maintaining an Adult and a Pediatric Difficult Airway Cart –
Acquiring and Maintaining Airway Management Skills Beyond Residency –
What is new in ACLS?: An Update on CPR –
Status Asthmaticus –
Airway Pharmacology in the ER–
SESSION VIII: Development of an Airway Device: Concept to Reality
Ergonomic Face Mask –
Intubating Laryngeal Airway –
Videolaryngoscope –
Endobronchial Blocker –
Company Perspective –
SESSION IX A: Expert’s Round Table Discussion
Advanced Uses of the LMA –
Percutaneous vs. Surgical Cricothyrotomy –
What Equipment is Really Necessary in Your Day Surgery Center? –
New Preoxygenation Strategies –
SESSION X: Crap Shoot
Infection Control in Your Practice –
What’s New in Extubation of the Difficult Airway? –
Airway Disasters – Dare to Share –

SESSION XI: The Future of Airway Management

Review of the ASA Algorithm and Its Future –
Critical Appraisal of the Literature/Research in Airway Management –

6
 Assessing Competence in Pediatric Fiberoptic Intubations
Geoffrey Lane, MB, MD
University of Colorado Denver
Denver, Colorado

How many fiberoptic intubations must a trainee limp nature that challenges the novice.
complete to assure competence? My first experience with bronchoscopy was in the
This question was debated at the recent SAM early 1970s, during my thoracic anesthesia rotation in
meeting and on the web site, with answers ranging up England. At the end of the daily schedule, our
to 100 intubations needed to ensure adequate irascible thoracic surgeon would take the
training. There are suggestions that training programs ‘Anaesthetic Registrar’ down to the endoscopy room.
should document that each resident or fellow has We anaesthetized the patients with thiopentone and
successfully completed whatever number is agreed succinylcholine, and he would then hand us a rigid
on, as part of the requirements for graduation. bronchoscope. It seemed about 36 inches long, had
But that may be the wrong question. “How can we no optical magnification or telescope, and the light
assess competency?” is the real challenge. source was about 1 candlepower. We had to
Competency is “the ability to do something well, demonstrate our proficiency by passing the
measured against a standard, especially ability instrument into the larynx without using a
acquired through experience or training.” laryngoscope, and without any trauma to the mucosal
What we need is a simple objective tool to assess surfaces of the mouth and pharynx.
competency in this and other skills. This assessment Success depended on recognizing and following the
can then be used to determine when the individual mid-line landmarks. In front, the furrow in the
has achieved the necessary skills, and to guide the surface of the tongue led down to the epiglottis, while
efficient use of educational resources. behind the midline raphe (or white line) in the palate
In this article, I will discuss our ongoing development led to the uvula. If you strayed from these marks,
of a simple assessment tool, which we are applying to failure was guaranteed!
airway training in our pediatric fellowship program. These skills have likewise proven invaluable for
performing and teaching fiberoptic intubation in our
Background. little patients.
Fiberoptic intubation can be a technically challenging
skill especially when used in uncooperative infants Pediatric intubation instruction and evaluation
with small mandibles associated with dysmorphic Since our fellows have already done fiberoptic
disorders and syndromes. intubations in adults, use of a mannequin is less
Our fellows are graduates of prestigious residency helpful than instruction on patients. We are fortunate
programs from across the USA. They have all been in having several dental rooms every day, where
taught fiberoptic intubation, but their skills usually children usually 2 to 6 years old have extensive
require some ‘adjustment’ for success with our little restorations and extractions. To assess occlusion, the
patients. dentists prefer nasal intubation. At this age, adenoid
Our difficult airways range from the neonate with the hypertrophy is common, and fiberoptic nasal
Pierre Robin sequence scheduled for distraction intubation can help minimize trauma and epistaxis.
osteogenesis, to the 20+ year old with Hurler’s An oral tube can be placed first both to gauge the
syndrome scheduled for valve replacement for correct size ETT and secure the airway. When a
intractable cardiac failure. trainee is assigned we will often place the oral tube
Our equipment includes Olympus LFV fiberoptically. Using the video-bronchoscope, the
bronchoscopes with a digital output that can be intubations are recorded onto my laptop, using the
recorded on my MacBook Pro, using a FireWire iMovie program that is preinstalled on the computer.
cable that simply plugs in to the back of the image Editing the video to remove waste clips is simple,
processor. For infants, we use the LFP scope that is and I then replay the intubation to demonstrate any
affectionately known as “the spaghetti scope” for its flaws in technique, and to evaluate performance. At
the end of the day I can give the trainee a copy of

7
their exploits saved as a QuickTime movie on a CD, analogue scopes, but there are other ways to import
or in other formats. video using analogue to digital converters. Likewise,
I have been using the video-recording system for other manufacturers may not have FireWire outlets,
almost a year, and the improvement in instruction and but the digital or analogue signals can still be
response from the fellows has been satisfying. While imported using appropriate cables and converters.
developing criteria for the evaluations, I noticed that
our Gastrointestinal (GI) staff was already evaluating
their fellows, using 3x5 cards pre-printed with the
specific criteria for each of the standard GI
procedures (from upper endoscopy to colon-
oscopies.) I now use similar cards, preprinted using
an ink-jet printer, to assess our fellows. (Fig 1 & 2).
The advantages of this system are many. I can tell
when a fellow has achieved competence and is ready
to move on to more challenging airways. The
assessment also gives us an objective index when
asking for the fellows to have more instruction in the
dental rooms.
What does it mean when we have this system working
efficiently?
I am impressed how video recording has advanced
our educational efforts. But at the same time,
advancing technology is working its way down into
pediatric practice. With the latest Glidescope
Cobalt/GVL system using disposable blades, we at
last have a video-laryngoscope suitable for our entire
size range including neonates.
As we see the use of the delicate fiberoptic scopes
start to decline, how much experience with fiberoptic
intubation will be required? And which of the other
practical skills in pain management, cardiac
anesthesia etc. must our fellows demonstrate
The Future competence in prior to graduation? While those of us
We are developing scoring cards for use with the with interests in airway management rightly regard
“spaghetti scope” and other situations. our airway skills as the most important to learn and
Unfortunately, economic troubles may delay practice, our colleagues and the program directors
purchase of a digital camera for use with our have to balance other (albeit less important?) needs.

Welcome New Members to SAM!!!

Javier Ramirez Acosta, M.D. (Mexico) Mark T. Pickett, M.D. (Washington)

Michele Carter, CRNA (Virginia) Robert Reardon, M.D. (Minnesota)
Sherri Cohen (North Carolina) Jean-Corentin Salengros (Belgium)
Andrew Heard, M.D. (Australia) Tara Stevenson, M.D. (Michigan)
Daniel Perin, Ph.D. (Brazil) Naredra Vakharia, M.D. (Canada)
 Evaluation of the LMA Supreme:
a Sizing and Troubleshooting Study
Allan J. Goldman, M.D., Daniel Langille, CRNA, Michael Flacco, MD
Michael Hom, MD, Roxanne Hertzog, M.D.
University of Washington
Seattle, Washington
Introduction:
The LMA Supreme (SLMA) is a new disposable If the choice was between two sizes, we chose the
supraglottic airway, which combines the features of smaller device. If after inserting and taping the
the LMA Proseal (gastric access tube- to separate SLMA in place, the fixation tab was pressing on the
the alimentary and respiratory tracts) and the LMA upper lip, we then changed the SLMA to the next
Fastrach (ILMA) (having a fixed curve shaft- to bigger size. A proper fit was determined to be1
ease insertion). All LMA manufacturers’ sizing fixation tab .5 – 2.5 cm from upper lip, tidal volume
recommendations are based upon patient weights. > 8ml/kg, oropharyngeal leak pressure > 25 cm/H2O,
Early in our SLMA evaluation, we experienced and a positive suprasternal notch test2. If the fit was
occasional failures using those weight guidelines, poor, one of the following maneuvers was preformed:
usually due to the device being too large. We then deeper insertion, an up-down maneuver (slowly
observed that the shape and length of the SLMA withdrawing the inflated mask 5-6cm and reinser-
fixed curve shaft is similar to a Guedel oral airway ting)3, or exchanging the device for a different size.
(fig 1). We proposed that using an oral airway-sizing fixation tab
guide might offer a better method for selecting the
correct SLMA size. A secondary outcome from our
sizing study was identifying which maneuvers
improved the SLMA fit.

Methods:
With IRB approval and Fig 3 (up-down maneuver,
Fig 2 (4’8”, 91kg, BMI 44) jaw thrust)
informed consent, we
prospectively collected
insertion data from 100 Results:
patients. After a prop- Size #3 was chosen for women and size #4 was
ofol induction, we waited chosen for men 77% of the time [table 1]. In the
till there was lack of remainder of patients, the next larger size was
response to a jaw thrust before inserting the SLMA. chosen. In 5 patients (5%) the device was removed
The SLMA size was chosen according to transitional and exchanged for another size1. The SLMA was an
oral airway size selection (angle of jaw to corner of effective airway in all patients in this study. The up-
the mouth). down maneuver was performed and gave a better fit
in 27% of the patients. Most of these patients were
obese or morbidly obese.

Fig 1 (oral airways & SLMAs, sizes 3-5, left to right)

80 mm oral airway (#3) = #3 Supreme

90 mm oral airway (#4) = #4 Supreme
100 mm oral airway (#5) = #5 Supreme
Table 1

9
Discussion:
Oral airway sizing is an effective method for
choosing the correct SLMA size, and is a
measurement already familiar to most anesthesia
practitioners. The up-down maneuver improved
SLMA fit in 27% of the patients. This maneuver is
performed with the ILMA and CTrach to reposition
a down-folded epiglottis, and may also work
similarly with the SLMA. Further studies to confirm
this maneuver’s efficacy with the SLMA are needed.
4. Tips to Increase SLMA Insertion Success:
1. Wait 2-3 minutes after giving propofol before
inserting the SLMA - A sign of adequate anesthetic
depth is lack of response to a jaw thrust. References:
2. Size #3 & #4 SLMA will usually work for women 1. The LMA Supreme Instruction Manual. San Diego:
and men respectively - Oral airway sizing is an LMA N.A., 2007
effective method for choosing the correct SLMA 2. C. O’Connor, C. Borromeo, M. Stix. Assessing ProSeal
size. Laryngeal Mask Positioning: The Suprasternal Notch Test.
A&A2002; 94: 1374-75
3. Don’t over-inflate the mask - Start with ½ the
3. Goldman A, Rosenblatt W, The LMA CTrach in Airway
maximum recommended mask volume. Resuscitation. Anesthesia 2006; 61:975-77
4. The up-down maneuver often improves the
SLMA’s fit - A jaw thrust may improve the Dr. Goldman has received speaking honoraria from LMA
maneuver’s effectiveness. N.A. Video link http://www.youtube.com/AJGoldman1

10
 E – LIGHTS OF THE SAM FORUM
Seth Manoach, MD
Assistant Chief Medical Officer, Assistant Professor of Emergency Medicine
SUNY Downstate

This is my first time writing the E-Lights column. devices in their curriculum. Each group or locality
Many people know me from the site, some don’t. I’m may have somewhat different training and
an ER doc, but rest assured, many of my closest background to airway management ... what is
academic colleagues and friends in medicine are important is proper monitoring of ventilation and
anesthesiologists. I was asked to bring a little more fast recognition of inadequate ventilation,
emergency-airway management related content for esophageal intubation etc. One of the basic ideas
this version, which I will do. I believe there’s so of the Society for Airway Management was to
much overlap, that the content should be interesting bring all those (physicians and non-physicians)
to everyone. who are engaged in resuscitation and airway
management together so that all of us can learn
Four-tier system of redundant safety: from each other. During SAM meeting special
sessions can be arranged for EMT & Paramedics
I can tell you from experience that the… if we have enough membership and participation
GlideScope is an excellent tool for both pre- in the meeting.
hospital and ED… once it became highly portable
(ed: the Ranger) the EMS Company that I work Videolaryngoscopes such as Glidescope offer new
with purchased one. Also as a Paramedic The approach to tracheal intubation and easy
EMS Company allowed us to borrow the recognition of a misplaced endotracheal tube.
GlideScope for cadaver lab and our Program Videolaryngoscopes may become first line use
Medical Director got to use it for the first time…. device for people who do infrequent tracheal
our systems use Millers and Mac… and bougies intubation.
…..for the airway of last choice, (we use) the —Andranik Ovassapian, M.D.
Sheridan Combitube and the King Airway…some
well meaning physicians are beating the drum to More VL:
remove airway control from EMS….As a
paramedic and paramedic educator, open your I have expressed this point of view before, and at
OR and offer to help your local EMS Service with the risk of repeating myself, I'll state my beliefs
some training and you experience. We would be again. When laryngoscopy doesn't yield a view of
very grateful. the larynx, it's not "difficult" or "awkward"--it is
—Austin G. Rinker, Jr., MS, NREMT-P a "failed laryngosocpy" regardless of whether
intubation is successful. Unless we call what we
Taking away of airway management from EMT- see, we will continue to advocate for marginal
paramedics is neither practical nor necessary. technology and care for patients with prayers for
What is important is to increase the time and level divine intervention or good luck. I call blind
of training and include supraglottic airway intubations a "near miss." Shiga's meta-analysis

e-mail address for letters to the editor and articles for the Gazette:
samgazette@gmail.com

11
shows that of >50,000 patients, 5.8% were C/L>2 necessarily improve overall outcome if the new
(i.e. 3 or 4). Rose and Cohen found this to be the technology leads to deficiencies in other areas, or
case in 10% of non-pregnant adults with if the new technology is not fully adopted
anticipated normal airways. (standardized) throughout the community of
airway managers.
If DIRECT LARYNGOSCOPY has failed, the —Lloyd Faul, MD
patient is not necessarily a difficult of failed
laryngoscopy--they're a FAILED DIRECT Videolaryngoscopy is not always so easy as stated.
LARYNGOSCOPY (F-DL?). As lightwands, In particular, there may be a technical gap
videolaryngoscopy, optical stylets, fiberoptic between seeing the larynx and getting an
scopes and intubation conduits become more orotracheal tube into and through it.
available, future care providers would be alerted —Charles Watson, MD
early to the alternative equipment and would not
persist with previously unsuccessful strategies. TOPICALS:
Clearly, we have to have the skills to use these
devices. We acquire these skills by incorporating VL is really not much more traumatic than an
them into our daily practice. oral airway. If the VL allows people to topicalize
—Richard Cooper, MD better, and see what the glottis looks like, then
great. The important point to remember, that so
I am just learning to use VL for "awake looks". many SAM members have emphasized, is that the
The last one I did about a month ago involved a view may not improve with induction of
big guy that had been told by another local anesthesia. So we must be ready to go to an
hospital that he was a "difficult intubation". This awake technique.
occurred within the past year and I know the —Lloyd Faul, MD
other hospital has VL. So I had no idea what
"difficult intubation" meant. We topicalized and I have had a number of recent intubations
did an "awake look" with the GlideScope. We including 2 completely awake, non-sedated ones,
only saw the epiglottis. There was a "temptation" i.e. nothing on board except fatigue and
to think the view would "get better" with pathophysiology. In these cases, both critically ill
induction; however, I remembered our discussion patients who were conscious but with no reserve, I
of this in the forum/Gazette. So we proceeded w/ used 3 sprays of Exactacain (not my first time
awake FOB by holding the tongue and going using this product, this is below what I have
midline orally. It was very easy, where I think VL calculated to be a problem dose), which is
asleep could have been very difficult. Hopefully benzocaine, butamben, and tetracaine. I am
people who are not doing FOB, will realize that it impressed that this spray provides better patient
is really no harder to "look" with an FOB, than it comfort than do the older topical sprays. In
is to "look" w/ a VL. The keys are topicalization, emergencies in patients with severe respiratory
and a large flexible scope if secretions are an issue. distress who are unable to sit and fully cooperate,
it is easier to use this than an atomizer or
New technologies like VL or FOB have enormous nebulizer
potential; However, a new technology may not —Seth Manoach, MD

Visit http://www.samhq.com to find all SAM Gazette

Publishing Guidelines.

12
we have used 4% lidocaine for many years with presented with some colleagues and residents. —
good success and no evidence of toxicity. We Irene Osborn, MD
actually favored the 10% metered dose spray
when it was available from astra but it is no A free full text article in Archives of Internal
longer produced. in contrast, we have seen several Medicine (2007; 167: 1977-1982) describes a series
cases of methemoglobinemia with benzocaine of 24,478!!!! non-OR TEE's performed at the
sprays Mayo clinic over 7.5 years in which protocol
—Marshal B. Kaplan, MD dictated that all patients were topicalized with the
20% benzocaine preparation. Of this group there
On 4% lidocaine: were 19 cases of methemoglobinemia (rate
0.067%, 95% CI 0.040 - 0.100%). Of the 19
Lidocaine is cheap, universally available and is patients, 18 were treated with methylene blue. All
manufactured in a variety of preparations. If one 19 "did well.”
avoids a "spray" technique (use specific —Seth Manoach, MD
landmarks to apply) and cautions the patient
about the taste, its rarely a problem. In may years of using spray "Cetocaine" and
—Will Rosenblatt, MD other mixes known to cause methemoglobinemia,
we've only seen one case. A warning and judicious
Aerosol 2% lidocaine. application seem to have served in four training
Topical Lido spray 4%, topical cocaine 4%, or programs I've used it/seen it used. Removal of
topical lido/phenylephrine mix. these combinations are like the elimination of
Viscous lidocaine gargle and swallow. meperidine from US practice.... result of well
SL nerve blocks and spray as you go. meaning pharmacists acting to prevent a rare and
SL nerve blocks, topical & cricothyroid lidocaine. usually not significant metabolic complication. Of
All safe when used properly. course, if untrained individuals use these drugs.
—Charles Watson, MD —Charles Watson, MD

Benumof suggested adding 1 packet of Sweet N There is far more useful information than I can cover
Low to 5cc of 4% lidocaine. (1) We did this and it in this now-too-long column. In the next E-lights,
helps but Splenda works even better. If you add we’ll kick off with the approach to the bleeding,
Splenda and a drop of flavoring- it's actually quite obstructed, traumatized patient – the new “can not
nice! This was a project and exhibit that I intubate – can not ventilate”. (sic)

Disclaimer:
Published manuscripts in the Gazette are not
necessarily reflective of the views of the Gazette or
the Society for Airway Management.

13
 A Shortcut to the Glottis using O.I.
Takashi Asai, MD, PhD
Kansai Medical University
Osaka, Japan
the drawbridge.
The fiberoptic bronchoscope is one of the most 3. Estimate the distance from the entrance (mouth) to
reliable tools to aid tracheal intubation in patients the gate (glottis). Before insertion of the fiberscope
with difficult airways. Nevertheless, it may be into the mouth, the distal part of the fiberscope is
difficult, particularly for inexperienced personnel, to placed against the side of the patient’s face, with the
find out the glottis with the fiberscope. Here, I tip of the scope at the ear (Figure 1). The fiberscope
describe some simple tips to reduce the difficulty. is then held at the corner of the mouth. This distance
Suppose that you are starting from the city wall (the from the corner of the mouth to the ear is roughly the
mouth) and aiming at entering the castle (the same distance from the mouth opening to the glottis.
trachea). What you have to do is to find out the ‘gate 4. Walk on the center of a wide smooth road, instead
of a castle’ (or the glottis). There is a rugged motte of climbing up the motte.
(the tongue) on the way to the castle, and a Many people seem to advance the fiberscope
drawbridge (the epiglottis), which would often be alongside the tongue. But, why do you need to climb
raised to close the gate. up a rugged motte (or the tongue), if there is a road
1. Minimize ‘red out’ and ‘white out’ leading to the castle? Look! There is a smooth and
You cannot see anything when the image is obscured wide road leading to the castle gate-the palate to the
by blood (red out) or secretions (white out). So, avoid pharyngeal wall. So, the tip of the fiberscope is
bleeding and excessive secretions, and remove fluids placed on the center of the hard palate, just behind
by suction. the upper incisors. The fiberscope is then advanced
2. “Jaw-thrusting” along the palate and to the posterior pharyngeal wall,
When the patient becomes unconscious, the passage in the center, until the fingers holding the fiberscope
leading to the reach the mouth (and do not maneuver the tip of the
gate may fiberscope). It should be possible to see at least the
collapse, and tip of the drawbridge (the epiglottis), and if you are
the drawbridge lucky, the gate (glottis) as well. Only after you have
(the epiglottis) confirmed where the gate is, you may adjust the
will be raised position of the distal hand to advance the fiberscope
toward the further towards the trachea, and if necessary, you
gate. Ask an may change the angle of the fiberscope tip.
assistant to
thrust the jaw After 5-10 attempts, you should be able to insert the
forward, to fiberoptic bronchoscope into the trachea within 10-20
open up the seconds!
passage and

Send in your TIPS and TRICKS by emailing: samgazette@gmail.com

14
SAM Gazette Publishing Guidelines: 5x7 inch photos are accepted.
Please list additional authors with brief descriptions
The Airway Gazette Editorial Board invites all of each one’s position, affiliation, e-mail address, fax
authors to submit reviews, investigations, original and telephone numbers, city and state. Manuscripts
articles, tips and tricks, letters, etc according to these authored by non-SAM members must receive
Guidelines - Katherine S.L. Gil, MD, Editor approval by the Editor for publication in The Airway
Gazette.
Submission: Any published manuscript submitted with the
Please submit manuscripts to The Airway Gazette e- consensus of a committee will be designated as
mail address as follows: having the chairperson of the committee as first
( samgazette@gmail.com ). Manuscripts should author.
contain ≤ 1000 words, with a one-inch margin.
When published, they will cover ≤ two standard Residents: All residents submitting reviews of
double-columned 8 1/2 x 11 inch pages. Suggest a previously - published articles should submit the title,
brief title with all authors listed. All acronyms and authors, and publication information regarding those
abbreviations must be defined unless they conform to articles. Send your professional information and a
the International System of Units or Index Medicus digital photograph (see above). Word count limit =
for journal references. 750. Review should have as a minimum, the
Graphics (tables or pictures) should be submitted in a following sections: 1) Type of study 2) Goal 3)
separate file or scan. Identify them in the text by a Methods 4) Results 5) Discussion (their conclusions
reference number with suitable captions to avoid text and how significant these were in comparison to your
duplication. literature search on the subject). Please have your
mentor or someone with experience in your
Review Policy: department, proofread and critique your submission.
The Airway Gazette editorial board and staff review (See July 2007 issue on website as an example).
all manuscripts regarding format, style and language.
Disclosure:
Duplicate Submission: Any institutional or commercial affiliation that might
To avoid potential for Copyright disagreement and pose a conflict of interest with submitted information
review-effort duplication, manuscripts should not be within manuscripts must be disclosed. All funding
submitted if being simultaneously considered by for projects should be acknowledged. Use generic
other journals or if they were previously published. names for all drugs and equipment whenever possible
or otherwise notify the Editor.
Deadline:
The deadline for submissions is 45 days prior to: The Bibliography:
Airway Gazette’s publication. The Airway Gazette Use superscript to indicate ≤ five numbered
will be published quarterly in February, May, references cited in the manuscript. List the
August, and November, on a yearly basis. bibliography according to the AMA Manual of Style
(Lippincott, Williams, & Wilkins).
Authorship:
Biography of the first author is required, including Copyright Policy:
present position, institutional affiliation, e-mail All published manuscripts become Copyright
address, fax and telephone numbers, city and state of material of The Airway Gazette and may not be
present position. republished or reprinted, in part or in whole, without
The first author should submit a recent portrait-style the expressed written permission of The Airway
photograph (head and shoulders) with a plain Gazette’s editorial board.
background. Digital photos are preferable. with a file All reprint requests will be forwarded to the author(s)
description attached (e.g. jpg, etc). Otherwise, 3x3 – for permission.

15
 M
MEEM
MBBEERRS
SHHIIP
P AAP
PPPLLIIC
CAAT
TIIO
ONN --
S
SOOC
CIIE
ETTY
Y F FOOR
R AAIIR
RW WAAY
Y M MA
AN NA
AGGE
EMME
ENNT
T

S
SAAM
MW WEEB
BSSIITTE
E:: JJooiinn // R
Ree--rreeggiisstteerr O
Onnlliinnee TTooddaayy
http://www.samhq.com
Discounted subscription rate
to the Journal of Clinical Anesthesia
is available for SAM members as listed below:

SAM Membership Application: (Please Print Legibly) Dues for 2009 must be turned in ASAP

LAST NAME………………………………………………………………………………………………...
FIRST NAME……………………………………………………………………………….…….…........
DEGREE(S)…………………………………………………………………………………………………
SPECIALTY………………………………………………………………………………….………………
MAILING ADDRESS……………………………………………………................………………………

CITY……………………………..………..STATE…………………………..ZIP CODE………………...
COUNTRY……………………………………………………………………………………....…………..
PHONE: HOME…………………………WORK…………………..………….FAX……………………..
EMAIL…………………………………………………………………….…………………………………
I wish to thank _______________________________________for encouraging me to join SAM.
Please check appropriate category:
 Physician Member…………………………………………………$100
 Retired Physician.………………………………………….…....….. 75
 CRNA………………………………………………………………... 75
 Individual / Industry Representative………………...……..…….. 75
 Paramedic / EMT / Flight Nurse /Technologist………….……… 50
 Resident / Fellow…………..……………………………………..... 50
 Journal of Clinical Anesthesia (Domestic) …………...…………. 78
 Journal of Clinical Anesthesia (International) ……………………100
 TOTAL……………………………………………………………...$____

 I wish to contribute an additional $____ towards SAM membership for a clinician from a
developing nation.
Please make checks payable to Society for Airway Management.
PO Box 946, Schererville, IN 46375 USA or FAX to (773) 834-3166
Or we accept:
VISA/ MASTERCARD #…………………………………………………... Expires………………..…...
SIGNATURE……………………………………………………………………………………………...…
(To avoid costs of processing international checks, please make payment with a credit card. Thank you!)