Advanced airway adjuncts

Airway Adjunct	Pros	Cons
Endotracheal tube introducer (ETI)/Gum Elastic Bougie	Higher first pass success when used with direct laryngscope vs. styletted ET tube regardless of whether difficult airway was expected or not^[1]
Lighted Optical Stylets	High success rate - especially good for trauma, c-spine precautions *Use for both reg and nasotrach Lower complication rate	Limited by fogging, secretion, recognition of anatomy, cost, and rare provider experience
Supraglottic airway
Laryngeal mask airway
Combitube- esoph obturator	Good for nurses and paramedics with limited intubation skill Indicated if difficult airway predicted: cannot see glottis with laryngoscope Reduced risk for aspiration compared to face mask or LMA *Can maintain spinal immobilization	Large size predisposes to esophogeal dilatation and laceration as a complication
Percutaneous transtracheal ventilation	Prefered over crithyrotomy in children up to age 10-12 Oxygenates well *Can use for 30-45 min	Can retain CO2 *May cause pneumothorax or barotrauma

Higher first pass success when used with direct laryngscope vs. styletted ET tube regardless of whether difficult airway was expected or not ^[2]
Blind orotracheal intubation

High success rate - especially good for trauma, c-spine precautions
Use for both reg and nasotrach
Lower complication rate
Limited by fogging, secretion, recognition of anatomy, cost, and rare provider experience

Good for nurses and paramedics with limited intubation skill
Indicated if difficult airway predicted: cannot see glottis with laryngoscope
Reduced risk for aspiration compared to face mask or LMA
Can maintain spinal immobilization
Large size predisposes to esophogeal dilatation and laceration as a complication

PTV
Prefered over crithyrotomy in children up to age 10-12
Needle, 16-18ga through cricoid membrane, connected to 50 psi 02^[3]
- Oxygenates well
- Ventilate through glottis and upper airway - can retain CO2
Need adequate oxygen pressure
1 sec insp and 2- 3 sec exp to avoid breath stacking
Can use for 30-45 min
May cause pneumothorax or barotrauma
Contraindications
- Distorted anatomy
- Bleeding diathesis
- Complete airway obstruction

↑ Driver, B. E., Prekker, M. E., Klein, L. R., Reardon, R. F., Miner, J. R., Fagerstrom, E. T., … Cole, J. B. (2018). Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA: The Journal of the American Medical Association, 319(21), 2179–2189.
↑ Driver, B. E., Prekker, M. E., Klein, L. R., Reardon, R. F., Miner, J. R., Fagerstrom, E. T., … Cole, J. B. (2018). Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA: The Journal of the American Medical Association, 319(21), 2179–2189.
↑ Beck, E., Kharasch, M., Casey, J., Ochoa, P., Menon, S., Calabrese, N. and Wang, E. (2011) ‘Percutaneous Transtracheal jet ventilation’, Academic Emergency Medicine, 18(5), pp. e38–e38.

Authors:

Contents