Resuscitation before intubation is a critical construct in modern emergency medicine. The prevention of peri-intubation arrest by correcting pre-intubation hypoxia, hypotension, and acidosis is often easier said than done. Worse yet, the intubation process itself, especially if difficult, can worsen hypoxia and hypotension which is often unrecoverable [1, 2] Supraglottic devices, such as a King Airway or laryngeal mask airway, can be placed quickly, and they effectively oxygenate and ventilate patients with a high degree of success [3]. Unfortunately, when the King (or similar device) is exchanged for an endotracheal tube, success is far from guaranteed. Ideally the King could be blindly changed over a tube exchanger however it is quite easy to lose the airway completely during this process. We describe a potentially safer and more effective alternative.
Trick of the Trade
After a patient is stabilized after initial resuscitation, the supraglottic King airway device should be exchanged. A disposable, single-patient-use bronchoscope can serve as a bougie-like guide.
Equipment Needed
- Disposable bronchoscope
- Endotracheal tube
- 50 mL syringe
- Laryngoscope (video or direct)
- Trauma shears
- Suction
- Capnography
Left: Demonstrating the technique inserting a single-use bronchoscope through a supraglottic King tube in a simulation patient. Right: Corresponding view of the vocal cords through the King side port in a real patient.
Description of the Trick
- Insert a disposable bronchoscope through the airway port of the King airway
- Guide the bronchoscope to exit through the side port of the King and into the trachea until you approach the carina
- Cut the disposable bronchoscope at the level of the handle, leaving a “fiberbougie” in the trachea above the carina
- Remove the King airway over the cut fiberscope in a modified Seldinger technique while suctioning airway
- Insert the endotracheal tube over the “fiberbougie”
- Use video or direct laryngoscopy to visualize the tube sliding over the “fiberbougie” into cords
- Confirm placement with capnography and/or with direct visualization and x-ray
Insertion of the endotracheal tube over the “fiberbougie” with video laryngoscopy confirmation with a simulation patient. The inset image was captured from a Glidescope on a real patient during the exchange.
Video Tutorial of the Fiberbougie Technique to Exchange a King Tube
References
- April MD, Arana A, Reynolds JC, et al. Peri-intubation cardiac arrest in the Emergency Department: A National Emergency Airway Registry (NEAR) study. Resuscitation. 2021;162:403-411. doi:10.1016/j.resuscitation.2021.02.039. PMID 33684505
- Russotto V, Tassistro E, Myatra SN, et al. Peri-intubation Cardiovascular Collapse in Critically Ill Patients: Insights from the INTUBE Study [published online ahead of print, 2022 May 10]. Am J Respir Crit Care Med. 2022. doi:10.1164/rccm.202111-2575OC. PMID 35536310
- Burns JB Jr, Branson R, Barnes SL, Tsuei BJ. Emergency airway placement by EMS providers: comparison between the King LT supralaryngeal airway and endotracheal intubation. Prehosp Disaster Med. 2010;25(1):92-95. doi:10.1017/s1049023x00007743. PMID 20405470
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