Tag Archives: Airway management

2 Minutes Advanced Airways

14 Feb

My favourite VL view to increase first pass intubation

8 Feb

A debate is ongoing among #FOAMED social media about increasing first passage rate in tracheal intubation and some difficulties when using VL.

At the beginning of my experience with VL I experienced some difficulties, but with a radical change in technical approach I reached a good security on first pass success.

Here are my consideration and I hope will be useful for anyone is starting using VL


There are some fundamental differences in VL technique respect to DL, that makes the DL more easy and intuitive to pass the tube trough the cords.


The 3 axys theory for airway management

“Sniffing position” align the pharyngeal axis with the laryngeal one

Sniffing position

Sniffing position

Perfoming Direct Laryngoscopy with the laryngoscope we align the mouth axis to have a direct view of the cords.

DL view












This view coincide with the route for passing the tube, making this step intuitive and easy.


When using a Video Laryngoscope we take our eyes right in front of the larynx, having a perfect “video” view of the vocal cords, but also minimally modifying the axis of the mouth.

Visione in videolaringoscopia


This difference makes the act of passing the tube not so easy and not so intuitive, cause of the contrast between the perfect video laryngeal view and the not easy passage of the tube trough the cords.

In those cases the stylet, the Bougie/Froban or the external glottic maneuvers, are useful to facilitate the video-intubation.

tubo stylet

Golf stick shape of the tube+stylet

But the first goal is to reach this view on the screen of the videolaryngoscope.


I want to have the epiglottis right at the center of the screen and this comes prior of a good view of the larynx.

Epiglottoscopy is the key point of my management of the airways in general and when prforming VL in particular.

Having the epiglottis in central position on the screen allow to:

  • lower the glottic plane facilitating intubation
  • decrease  the force to apply on the airways minimizing traumatism and neck movement in case of trauma.
  • fits all the difficult airway situations because a poor view of the cords is what you are looking for!

If you agree, memorize my favorite view and reach for it when using a video device to mange the airways.

All comments are welcome so please let me know your thoughts.





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11 Set

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Why the VideoLarygoscopy don’t gonna kill the DirectLaryngoscopy (at least in the near future)

17 Ago

A novel publication goes to enrich the long-living debate on direct laryngoscopy (DL) vs video laryngoscopy (VL) efficacy in emergency intubation.

The recent article, pubblished on JEMS and titled  “Deploying the Video Laryngoscope into a Ground EMS System” ,compares the success rate beetwen DL vs VL in a ground EMS Service. The device used was the King Vision with channeled blade. The partecipants had a prior training on the divide, consisting in didactic orientation and practical skills on manikins.

The result of the study shown that “Within the first 100 days of the study, the video laryngoscope utilizing the channeled blade has shown to be at least as effective as DL in relation to first-attempt success” and considering that “the mean experience in our group with DL is nine years, yet the success rate remains unacceptable” “It’s time to consider transition from a skill that’s difficult to obtain and maintain to one that appears to have a quicker learning curve and will likely result in decreased episodes of multiple attempts at intubation and associated complications.”

So is direct laryngoscopy dead?( Or will be so in a few years)

Laryndo dead

Here are some considerations

There are some fundamental differences in  VL tecnique respect the DL tecnique, that makes the DL more intuitive to pass the tube trough the cords.

We have basically 3 main axis in the airways


When we manage the airways we first put the head in “sniffing position” aligning the pharyngeal axis with the laryngeal one

Sniffing position

Then we use the laryngoscope to align the mouth axis having so a direct view of the cords. This view coincide with the way to pass the tube, making this step intitive and easy.

DL view














When using the videolaryngoscope we take our eyes right in front of the larynx, having a perfect “video” view of the vocal cords, but also minimally modifying the axis of the mouth.

Visione in videolaringoscopia

For this reason passing the OTT is not straight forward, so we need the stylet, the Bougie/Froban or the external glottic maneuvers, to facilitate the intubation.

tubo stylet


This difference in tecnique makes the VL not so intuitive  due to the contrast between the perfect laryngeal view and the not  intuitive passage of the tube trough the cords.

In fact the available evidences almost accordingly demonstrate an equivalent success first pass rate beetwen traditional laryngoscope an video but a prolonged intubation time in VL groups.

As the previously cited article demonstrate the learning curve for VL is short and easy to perform, and this make this tecnique surely suitable for emergency intubation.

But for emergency professionals well trained and familiar with DL I think this has to be the first choice approach when managing an emergent airway.

Emergency field is not the place to make trianing or experience with novel devices or drugs.

The still not widely availability of video-laryngoscope makes this device a perfect alternative in all the casess when is not possible to obtain a good laryngela view with DL, but still not the gold standard tecnique.

In the future the increasingly diffusion of videoleryngoscopes (due mostly to more affordable prices), will chenge the airway management scenario. Novel emergency medicine operators will grown up parallel experience wid DL and VL so the latter will be more suitable as first choice device.

Bottom line

Wich way you prefer to go home?

The quickest and the shorter one for sure!

Do you use the GPS to go home?

Agree, me neither!

And when you use it?


Right! When you are lost!

So that’s why Direct Laryngoscope il still my Plan A

My straight way home!

straight road

Prehospital Airway Management Action Plan



The occasional intubator needs a plan. I have got one! Have You?

15 Lug

want you

Following some discussion on who owns the airway (see the comments at the post Paralytic is the answer on EMPills Blog)

Have to admit: I’m an occasional intubator.

I manage something like 10 airways per month, all of them are “non conventional”, (no operating room, no chance to wake the patient, no chance to call an expert), and usually I have no time to evalute any of common indicators to predict difficult airway (time is often a rare issue in ground or air prehospital scenarios).

Half of the airway I manage are CRASH, half needs an RSI, so, shame on me, I’m also an occasional “paralytic agents user”.

So I desperatley need a plan

But lissen, I got one!

Or open the presentation from “Advanced airway on the field

Dear collegue, wathever intubator you are, occasional or regular,  feel free to submit any comment on the plan and also fell free, if you think it’s useful, to use and share it.

It will be appreciated.

See also:
Algoritmo per la gestione avanzata delle vie aeree
Anticipate Difficult airway
Protocollo SIARTI/PAMIA sulla gestione delle vie aeree in ambito preopedaliero
Prehospital Airway Management mind map


MEDEST you tube


Do you needle cric?

26 Apr

Great demonstration from Minh Le Cong on how to needle cric in emergency prehospital situation. Visit PHARM Blog for more great FOAMED stories.

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MEDEST you tube

Mind about the airway!

9 Gen

Are you scare about the airway?

bridge airway_ENG

Keep CALM and make it SIMPLE!




Airway manifesto

  • ACT

Microsoft Word - PHAM eng.docx


Thanks to everyone on #FOAMed world

amleto_laringoLogo MEDEST2

Cardiac arrest complicating emergency airway management

24 Ago


Incidence and factors associated with cardiac arrest complicating emergency airway management

Sux Roks and Roc Suks? Succinilcolina vs Rocuronio nella RSI.

25 Giu

Dichiaro subito un conflitto di interessi: sono innamorato della Succinilcolina.Sux vs Roc image

E’ stato un amore a prima vista. La uso spesso e volentieri e nella mia esperienza clinica funziona e come! Non mi ha mai dato problemi e si adatta bene a tutti i pazienti, sia traumatici che medici.

Ma come tutte le coppie di lungo corso sono anche conscio dei difetti della mia “compagna”.

Conosco i possibili effetti collaterali, ma finora ho sempre visto pendere la bilancia dalla parte dei benefici, e di gran lunga direi.

Da qualche anno però la sempre maggiore diffusione del Rocuronio come bloccante neuromuscolare nella sequenza rapida d’intubazione mi ha posto di fronte ad un doloroso dilemma. E visto che Ferragosto (siamo in anticipo ma torna bene) moglie mia non ti conosco mi sento pronto a guardare avanti.

Allora vediamo quali sono gli argomenti comunemente addotti a favore della Succinilcolina e se oltre all’esperienza clinica hanno anche una base di evidenza scientifica.

  • La Succinilcolina con la sua breve durata d’azione protegge nei casi in cui l’intubazione è difficile o in quella ancora peggiore del paziente “non intubabile e non ventilabile”

In realtà molti studi dimostrano che l’ipossia (intesa come una desaturazione dell’emoglobina al di sotto di valori critici) si instaura molto prima che riprenda un drive respiratorio valido (1,2,3), quindi il concetto che nei casi critici (paziente non intubable e non ventilabile) si possa attendere la ripresa dell’attività respiratoria spontanea non è supportata dalle evidenze scientifiche, anzi è pericolosamente rassicurante.

Sembra inoltre che la somministrazione di un paralitico depolarizzante, come è la Succinilcolina, risulti in una desaturazione più veloce rispetto a quella che avviene con il Rocuronio, verosimilmente per l’aumentata richiesta di O2 indotta dalle fascicolazioni (4,5).

La breve durata d’azione inoltre, nel paziente non intubabile e non ventilabile, può offrire al professionista sanitario un falso alibi psicologico per ritardare la manovra definitiva, mentre nei casi di via aerea difficile con più tentativi di IOT, induce a somministrare ripetuti boli di paralitico aumentando considerevolmente il rischio di effetti collaterali in pazienti di cui molto spesso non conosciamo la storia clinica.

  • La Succinilcolina è stata storicamente associata a migliori condizioni per l’intubazione (in termini di tempo e di percentuale di successo al primo tentativo) rispetto al Rocuronio

Gli studi alla base di questa convinzione più che ad una caratteristica intrinseca del farmaco devono le loro conclusioni ad un sottodosaggio del Rocuronio nell’impianto degli studi stessi. Una Review di Cochrane del 2008 “Rocuronium versus succinylcholine for rapid sequence induction intubation” analizza retrospettivamente questo aspetto dei due farmaci; non si identifica differenze statisticamente significative anche se gli autori concludono dando comunque la preferenza alla Succinilcolina e indicando il Rocuronio solamente come valida alternativa.

Esiste comunque una vasta gamma di studi successivi che evidenziano come le condizioni di intubazione sono sostanzialmente simili quando il Rocuronio è adeguatamente dosato (6,7,8).



  • Il suo breve onset ed il rapido wash-out è sicuramente un vantaggio per il medico d’emergenza. Molto meglio ventilare “manualmente” un paziente critico per 5 minuti che non per 20.
  • Ci sono a questo proposito comunque delle considerazioni da fare:
  1. Non si può attendere il ritorno della ventilazione spontanea del paziente senza un’assistenza ventilatoria adeguata (ventilazione a maschera o con presidio sovraglottico).
  2. Non bisogna dimenticare che quel paziente deve esere comunque intubato; non è un paziente in elezione che può essere risvegliato e rimandato al giorno dopo.
  3. Un nuovo tentativo di intubazione richiede la somministrazione di una nuova dose di paralitico aumentando il rischio di effetti collaterali anche in pazienti potenzialmente non a rischio.
  4. Nel paziente non intubabile e non ventilabile, non bisogna ritardare l’accesso chirurgico. La rapida ripresa dell’attività respiratoria spontanea non risolve il problema!


  • Non ha effetti collaterali,e per i pazienti critici in medicina d’urgenza in cui la storia clinica non è nota questo è sicuramente un vantaggio.
  • E’ a medio rischio per anafilassi (mentre la Succinilcolina è ad alto rischo) (9)
  • Il suo onset è sovrapponibile a quello della Succinilcolina, quando adeguatamente dosato.
  • Le condizioni d’intubazione sono simili.
  • La dose deve essere 1-1,2 mg/Kg calcolata sul peso ideale del paziente e non quello attuale del paziente (13).
  • La sua lunga durata d’azione consente:
  1. in caso d’intubazione difficile una migliore ventilazione con maschera o presidio sovraglottivo essendo il paziente completamente rilassato
  2. in caso di nuovo tentativo di intubazione di non dover sommare boli di paralitico
  3. in caso di paziente non intubabile e non ventilabile di procedere immediatamente alll’accesso chirurgico senza false aspettative
  • Esiste un antagonista selettivo, il Suggammadex, che consente in tempi rapidi (3 minuti) dalla sua somministrazione la ripresa dell’attività respiratoria spontanea (10,11)

Allora Succi o Roc nell’intubazione farmacologicamente assistita?

La Succinilcolina visto la storia e la pratica oramai consolidata mantiene una leggera preferenza.

Il Rocuronio dovrebbe comunque fare parte del nostro kit farmacologico, nell’ottica di una valida alternativa per tutti i casi in cui è preferibile un bloccante privo di effetti collaterali, con onset rapido e lunga durata d’azione.

Download English transcript

Thanks to:

Sean Davis “Suxamethonium versus Rocuronium in rapid sequence induction: Dispelling common myths.”

Amit Maini: “ED RSI: Rocuronium vs Suxamethonium”

Who inspired this post!

  1. Benumof JL, Dagg R, Benumof R. Critical haemoglobin desaturation will occur before return to an unparalysed state following 1 mg/kg intravenous succinylcholine. Anesthesiology. 1997; 87:979-82.
  2. Heier T, Feiner JR, Lin J, Brown R, Caldwell JE. Hemoglobin desaturation after succinylcholine-induced apnea. Anesthesiology. 2001; 94:754-9.
  3. Neguib M, Samarkandi AH, Abdullah K, Riad W, Alharby SW. Succinylcholine dosage and apnea-induced haemoglobin desaturation in patients. Anesthesiology. 2005; 102(1):35-40.
  4. Taha SK, El-Khatib MF, Baraka, AS, Haidar YA, Abdallah FW, Zbeidy RA, Siddik-Sayyid SM. Effect of suxamethonium vs rocuronium on onset of oxygen saturation during apnoea following rapid sequence induction. Anaesthesia. 2010; 65:358-361.
  5. Tang L, Li S, Huang S, Ma H, Wang Z. Desaturation following rapid sequence induction using succinylcholine vs. rocuronium in overweight patients. Acta Anaesthesiol Scand. 2011; 55:203-8.
  6. Is rocuronium as effective as succinylcholine at facilitating laryngoscopy during rapid sequence intubation?
  7. Patanwala AE, Stahle SA, Sakles JC, Erstad BL. Comparison of Succinylcholine and Rocuronium for First-attempt Intubation Success in the Emergency Department. Acad Emerg Med. 2011; 18:11-14.
  8. Perry JJ, Lee JS, Sillberg VAH, Wells GA. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev. 2008:CD002788.
  9. Rose M, Fisher M. Rocuronium: high risk for anaphylaxis? Br J Anaesth. 2001; 86(5):678-82.
  10. De Boer HD, Driessen JJ, Marcus MA, Kerkkamp H, Heeringa M, Klimek M. Reversal of rocuronium-induced (1.2 mg/kg) profound neuromuscular block by sugammadex. Anesthesiology. 2007; 107:239-44.
  11. Mirakhur RK. Sugammadex in clinical practice. Anaesthesia. 2009; 64:45-54.
  12. Lee C, Jahr JS, CandiottKA, Warriner B, Zornow MH, Naguib M. Reversal of profound neuromuscular block by sugammadex administered three minutes after rocuronium. Anesthesiology. 2009; 110:1020-5.
  13. Fujimoto M et al. In non-obese patients, duration of action of rocuronium is directly correlated with body mass index. Can J Anaesth 2013 Jun; 60:552.

Gestione delle vie aeree nel trauma cranico severo: un caso clinico

20 Apr

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