Combined Video Laryngoscopy, Nasal O2, and Nasal Bougie Intubation

Brazil - Your First Nasal Bougie You will Never Forget.

  Credit - SAM Clinical Forum

The combined use of Video Laryngoscopy with other advanced Procedures is well established and can create a powerful strategy with much improved safety.
Dr Marcelo Ramos , Dec. 11 , advanced the art by posting a combined Technique.

1. Patient with predicted difficult airway   BMI 32, TMD 5 cm, upper incisors 3 cm forward of inferior,  MP 4,
2. Nasal Oxygen was used
3. A highly angled video Laryngoscope was able to view the Glottic opening
4. Placement of a nasal bougie was possible under direct vision.
5. Endotracheal tube was threaded over the Bougie.

Discussion:
1. Nasal Oxygen is highly desirable to produce the oxygenation safety boost and there are 3 methods  available.  1.Nasal prongs with a maximum flush. 2. Thrive high volume (up to 70 L per minute) humidified high flow nasal O2 which can give prolonged apnoea oxygenation (Patel , BMJ 2015 vol 70 3, pg. 323-329. ) or Nasal CPAP (TSE PAP) using a nasal CPAP mask as per Dr James Tse.
2. The highly angled VL is essential for these cases.
3. Bougie or FOB may be used to guide the ETT via the nasal or oral route.

Elegant technique by an excellent Brazilian team - Congratulations.

Airway Culture - UK Airway Lead Concept -Alistair McNarry (Edinburgh)

Society For Airway Management 2016

"any process that is measured will improve"

Medical education and practice culture .

 1. The tools available for  airway management continue to improve annually and have now reached a stage of development that permits excellence in care of normal and difficult airways.

2. The Human Factors and Culture have become the critical area for improvement. If one has a plan that includes available tools, a knowledge of the patient variables, skill in selecting and applying the tools should virtually always produce a desirable result.

3. There remains a disturbing variation in the availability of equipment and skill applied in various hospitals and regions.

4. As the understanding of our art improves it is imperative that we develop a more orderly way of applying it.

The UK "Airway Lead" Concept.

The development of a systems approach in the UK is very instructive. The recognition of serious problems in difficult airway management resulted in assembly of a highly motivated team of investigators who produced a National study document - NAP4- which investigated the scope of unfortunate events and propelled changes. This ultimately was distilled into the  

Difficult Airway Society 2015 guidelines for

management of unanticipated difficult intubation

in adults.     

 British Journal of Anaesthesia, 115 (6): 827–48 (2015)

       The Problem: How to propel the change into the entire NHS System?

The "National Airway Lead"- Alistair McNarry

To organize the knowledge rollout a National Airway Lead was appointed with a goal of developing local Hospital Airway Leads whose mission is to :

1. Identify and master the changes that are evolving.

2. Identify the essential tools to make excellence possible.

3. Develop a local airway culture.

4. Measure and adapt local results.

The British example is extremely well conceived and in my view should be embraced to produce  a culture of excellence proven by measurement. Haphazard approaches will not produce the kind of changes that we need.

As my Engineering friends remind me: 

"any process that is measured will improve"