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 . 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.
- Disposable bronchoscope
- Endotracheal tube
- 50 mL syringe
- Laryngoscope (video or direct)
- Trauma shears
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
Video Tutorial of the Fiberbougie Technique to Exchange a King Tube
- 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
During medical simulation, the inherent unpredictability of learners’ performances and decisions can make it challenging to consistently achieve desired learning objectives. The amount learned and the errors made can vary wildly between groups. Paradoxically, a stellar student can minimize the learning for the other providers if he or she takes over and effortlessly completes the case. Likewise, the visceral impact of seeing a case go horribly wrong can have tremendous teaching value.1
In addition to these challenges, the COVID-19 pandemic has introduced additional barriers to medical simulation training; physical distancing measures have resulted in limited or canceled simulation activities for most emergency medicine residency programs.