[New post] Trick of the Trade: A “Fiberbougie” through a supraglottic airway device (King tube)

Graham E. Snyder, MD, FACEP posted: "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 proces" ALiEM Trick of the Trade: A "Fiberbougie" through a supraglottic airway device (King tube) Graham E. Snyder, MD, FACEP Jul 6 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  Comment Unsubscribe to no longer receive posts from ALiEM. Change your email settings at manage subscriptions. Trouble clicking? Copy and paste this URL into your browser: https://www.aliem.com/trick-fiberbougie-supraglottic-airway-device-king-tube/ Powered by Jetpack