Keychain Emergency Airway Device (Video)

Health professionals who know how to perform cricothyroidotomy to obtain an emergency airway in someone who is obstructing can appreciate a nifty keychain device called LifeStat.

LifeStat can be carried around and immediately utilized to perform emergency cricothyroidotomy in any setting.

Watch a video here to see how it works.

It can be purchase from Shippert Medical for $145 here.

Reference:
Utilization of the LifeStat emergency airway device. Ann Otol Rhinol Laryngol. 2008 Jan;117(1):1-4.

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Best Ballpoint Pen for Emergency Cricothyroidotomy?

I recently blogged about a man who choked to death on an airplane and the impossibility of saving this man's life with a surgical airway like a cricothyroidotomy without a sharp object around inside the plane (ie, knife or scalpel).

I also stated that "Some surgeons would argue a strong, stiff ball-point pen could have been used to perform the cricothyroidotomy, but as someone who has performed a dozen emergency cricothyroidotomies and tracheotomies in the past, even under the best of circumstances with a knife and being on a hospital floor with help around, it is hard. Furthermore, skin and the windpipe is made of tough 'fabric' and trying to punch a ball-point pen through is laughable. Try doing it yourself on a chicken with the skin on."

Well... it got me thinking... Let's assume for argument's sake that it IS possible to perform a cricothyroidotomy by literally punching through with a stiff ball-point pen into the airway. Would it actually work???

Believe it or not, there are two studies (listed below) I was able to find that tried to answer that very question. Contrary to popular belief... even IF a ball-point pen is able to secure an airway, the majority were found to be unsuitable due to inadequate internal diameter with too high an airway resistance for breathing.

In fact, the only TWO pens that might work (from a breathing standpoint) are the:

Baron retractable ballpoint

BIC soft feel Jumbo

I can't even find these items on Amazon.com.

A sports bottle straw apparently works better than a pen.

Reference:
Bystander cricothyroidotomy performed with an improvised airway. Mil Med. 2002 Jan;167(1):76-8.

Airflow efficacy of ballpoint pen tubes: a consideration for use in bystander cricothyrotomy. Emerg Med J. 2010 Apr;27(4):317-20.

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Man Chokes to Death During Air Flight... Preventable?

Image courtesy of digitalart / FreeDigitalPhotos.net

News media reported on Sept 5, 2011 about Robert Rippingale who choked to death during a flight from Singapore to New Zealand. He was with his girlfriend who noted he was shaking and turning blue after eating an in-flight meal. A doctor and two nurses attempted to save him though unsuccessfully.

The article reports that CPR was performed to try and save the man, but the obvious question is whether a Heimlich maneuver was done. Obviously, as long as an obstruction is present, doing CPR is bound to fail.

Assuming a Heimlich maneuver was performed and failed to remove the airway obstruction... what could have been done to save this man's life?

Let's assume best case scenario of having an experienced ENT surgeon was on board.

The surgeon could try to relieve the obstruction manually by looking down the throat using a laryngoscope and using instruments to remove the food obstruction from the airway.

If that fails, an emergency cricothyroidotomy would have saved this man's life. This emergency life-saving procedure is in essence making a hole in the neck directly into the airway. It is slightly different from a tracheostomy in terms of where anatomically this hole is made, but the end-result is the same.

Question is, EVEN if you had an experienced ENT on board, would an airplane even have a laryngoscope as well as instruments to remove a food impaction? Would an emergency cricothyroidotomy even be possible due to prohibition of sharp objects in airplanes? After all, you still need a knife of some sort to make the incision and to dissect down to the airway. Without a sharp instrument, this step would be impossible even if you have someone who knows what to do.

According to Appendix A to Part 121 of Title 14 of the Code of Federal Regulations (14 CFR 121), the specific requirements for US carriers regarding first aid and emergency aid kits are as follows:

For 0-50 seats, one kit is required; 51-150 seats, two kits are required; 151-250 seats require three; and more than 250 seats require 4 kits.

These kits must include, at a minimum:

• 16 Adhesive bandage compresses, 1-inch
• 20 Antiseptic swabs
• 10 Ammonia inhalants
• 8 Bandage compresses, 4-inch
• 5 Triangular bandage compresses, 40-inch
• 1 Arm splint, noninflatable
• 1 Leg splint, noninflatable
• 4 Roller bandage, 4-inch
• 2 Adhesive tape, 1-inch standard roll
• 1 Bandage scissors

Also, at least one approved medical kit must be on board that includes at a minimum:

• 1 Sphygmonanometer
• 1 Stethoscope
• 3 Airways, oropharyngeal (3 sizes): 1 pediatric, 1 small adult, 1 large adult or equivalent.
• Self-inflating manual resuscitation device with 3 masks (1 pediatric, 1 small adult, 1 large adult or equivalent).
• CPR mask (3 sizes), 1 pediatric, 1 small adult, 1 large adult, or equivalent.
• 1 IV Admin Set: Tubing w/ 2 Y connectors
• 2 Alcohol sponges
• 1 Adhesive tape, 1-inch standard roll adhesive.
• 1 pair Tape scissors
• 1 Tourniquet
• 1 Saline solution, 500 cc
• 1 pair Protective nonpermeable gloves or equivalent
• 6 Needles (2-18 ga., 2-20 ga., 2-22 ga., or sizes necessary to administer required medications).
• 4 Syringes (1-5 cc, 2-10 cc, or sizes necessary to administer required medications).
• 4 Analgesic, non-narcotic, tablets, 325 mg
• 4 Antihistamine tablets, 25 mg
• 2 Antihistamine injectable, 50 mg, (single dose ampule or equivalent).
• 2 Atropine, 0.5 mg, 5 cc (single dose ampule or equivalent).
• 4 Aspirin tablets, 325 mg
• 1 Bronchodilator, inhaled (metered dose inhaler or equivalent).
• 1 Dextrose, 50%/50 cc injectable, (single dose ampule or equivalent).
• 2 Epinephrine 1:1000, 1 cc, injectable, (single dose ampule or equivalent).
• 2 Epinephrine 1:10,000, 2 cc, injectable, (single dose ampule or equivalent).
• 2 Lidocaine, 5 cc, 20 mg/ml, injectable (single dose ampule or equivalent).
• 10 Nitroglycerin tablets, 0.4 mg
• 1 Basic instructions for use of the drugs in the kit.

It seems that there are airways of different sizes available, but no laryngoscope or other instruments to remove airway foreign objects.

Nowhere is a scalpel or knife listed either. You have needles and syringes which theoretically can be used to "poke" into the airway. However, though an 18 gauge needle might work for a chipmunk's airway, it is not sufficient for a full-grown man. It would be like breathing through a straw, but 50 times smaller and even more difficult to breath thru.

So it appears that in the event of an airway obstruction during an air-flight for which Heimlich fails, you can have the world's best surgeon present, and the man still would have died.

Some surgeons would argue a strong, stiff ball-point pen could have been used to perform the cricothyroidotomy, but as someone who has performed a dozen emergency cricothyroidotomies and tracheotomies in the past, even under the best of circumstances with a knife and being on a hospital floor with help around, it is hard. Furthermore, skin and the windpipe is made of tough "fabric" and trying to punch a ball-point pen through is laughable. Try doing it yourself on a chicken with the skin on.

Read the news article here.

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Tonsillectomy Airway Fire

ABC News reported in 2008 about a California family suing doctors as well as Conmed, an electro-surgical instrument company, for an airway fire that occurred on April 18, 2003 on an 8 years old child during a routine tonsillectomy surgery.

Apparently, an electrocautery device was being used to remove the tonsils when the endotracheal tube caught fire resulting in burns to the child's mouth and airway (no death). It is suspected that the electrocautery device during the surgery either burned a hole into the endotracheal tube where it encountered oxygen resulting in the fire or there was a leak around the endotracheal tube which caught fire. The jury found the surgeon to be negligent, but returned a defense verdict for the device manufacturer Conmed. The other defendants settled.

Use of electrocautery is still popular among ENT surgeons removing tonsils, but has been abandoned by an increasing number of surgeons (including our practice) over the past few years due to risk of airway fire as well as concern for unnecessary thermal injury to surrounding normal peritonsillar tissues. Electrocautery produces temperatures between 400 to 600 degrees Centigrade which both cuts and stops bleeding simultaneously. However, as can be seen in this unfortunate case, it can also burn through an endotracheal tube and cause an airway fire.

Airway fire is another reason why laser tonsillectomy is rarely performed as the risk is the same if not greater than electrocauterization.

Our office uses coblation technology to remove tonsils. Coblation uses a radiofrequency plasma field to cut and stop bleeding simultaneously at near room temperatures thereby avoiding risk of airway fire as well as thermal injury to surrounding oral tissues.

Of note, there are about 500 cases of operating room fires related to use of electrosurgical instruments every year of which 20-30 causes serious injuries.

Read the ABC News report here.

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Awake Endotracheal Intubation Video

It is a common misconception that you need to be completely asleep and sedated in order to be intubated. That is patently false.

With good local anesthesia, intubation can be performed on a wide-awake patient without any sedation. Take a look at this video where an anesthesiologist instructor essentially intubates himself in front of an audience... I didn't make it, but I wish I did...

This little-used technique is a very important skill to have because in certain dire situations where a patient's breathing is compromised due to upper airway swelling (whether from infection or mass), attempted sedation and intubation may result in airway loss and need for emergency tracheostomy. At worst, death may happen. In such patients where there is airway compromise, awake intubation needs to be performed.

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Real-Time MRI Imaging During Vocal Performance (Soprano and a Beatboxer)

A colleague of mine shared this amazing video demonstrating what is going on in the upper airway during a vocal performance of a soprano and a beatboxer via real-time MRI imaging.

Check it out here if the video is not showing correctly below.

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Olympic Athlete Hopeful With Vocal Cord Dysfunction

There was a recent article about Hannah Lupton, a heptathlete, who suffers from vocal cord dysfunction. This disorder is basically when the vocal cords come together during inhalation when it should be apart resulting in shortness of breath localized to the throat area.

Normally, during breathing, the vocal cords are apart as shown in the picture. When talking or swallowing, the vocal cords come together (TVC is True Vocal Cord).

Laryngospasm, which is the most severe form of vocal cord dysfunction, is when the vocal cords come together completely preventing any air from moving into the lungs resulting in a high pitched squeal when trying to breath. People may even faint due to lack of oxygen when this happens.

The vocal cord exercises as described in the news article may encompass these strategies among others:

METHOD 1: Breathing Technique
There are 3 steps to this particular method.

1. As soon as one feels an attack coming, SLOWLY breath in through the NOSE. DO NOT BREATH IN THROUGH THE MOUTH! Sometimes deliberately holding breath for 5 seconds prior to nasal inhalation helps.
2. More quickly exhale out the mouth with pursed lips.
3. Continue slow nasal inhalation, and quick mouth exhalation with pursed lips until the episode passes.

Why does this work? For some reason, nasal breathing reinforces the brain to keep the vocal cords apart when inhaling. Quick inhalation through the mouth seems to do the opposite and encourage the vocal cords to close which exacerbates the problem. Also, quick inhalation reinforces the Bernoulli Principle that as a fluid (air in this case) passes through a pipe that suddenly narrows (the vocal cords), the pressure actually decreases which encourages further narrowing (or vocal cord closure). Therefore, SLOW breathing helps keep the vocal cords apart! You can test this principle yourself by sucking air on a narrow short straw slowly and than quickly. You will find that the straw will tend to collapse when sucking in quickly.

METHOD 2: Straw Breathing

This method essentially forces a person to decrease the speed of breathing allowing for vocal cord relaxation. In essence, cut a regular drinking straw to half its length. When an attack occurs, place the straw in your mouth and make a tight seal. Breath thru the straw (via mouth) until attack passes.

Patients with recurrent laryngospasm attacks typically keep a straw in their pocket/purse to have immediately on hand.

METHOD 3: Pressure Point

Another manuever that may work is firm pressure in the "laryngospasm notch." Basically, with an attack, quickly with your (or somebody else's) index fingers, press very firmly just behind both your earlobes where there is a notch between the bone of your mastoid process and ear. Press deep and forward towards the nose. It should hurt. If it doesn't hurt, you are not pressing hard enough. The attack should resolve within 10 seconds. Here is an article describing this method.

METHOD 4: CPAP

This particular method applies only if laryngospasm attacks occur mainly at night while sleeping. Essentially, one uses a CPAP machine which blows air into your lungs while you sleep. This treatment helps by preventing the body from believing it is "drowning" which would result in vocal cord adduction. By having a persistent positive airflow from the CPAP device, it also reinforces to the brain to keep the vocal cords apart. At worst case, if an attack occurs, the CPAP machine helps push air into your lungs past the vocal cords. Indeed... if you ask any anesthesiologist what they do when a laryngospasm attack occurs during intubation, they'll say apply strong positive pressure by mask (along with other things of course).

Make sure you use heated humidification. Please be aware that the air pressure being applied MAY actually cause laryngospasm due to direct vocal cord irritation of the forced air. Unfortunately, there's no way to predict someone who will respond vs someone who will do worse with this treatment method.

Other Treatments

Oftentimes, the above strategies help enough that a patient finds these attacks occur less frequently with decreasing severity over time until they altogether stop. Rarely, a benzodiazepine medication will be prescribed for these attacks to help with the anxiety aspect until the strategy is internalized. Working with speech pathology has also been found to be helpful. In certain situations, laryngeal sensory neuropathy (LSN) may be contributing to VCD and treatment geared towards LSN improves VCD. Of course, treatment of the trigger whether it be allergy, asthma, or reflux is important.

In rare cases, I will consider injecting BOTOX into the vocal cords which will physically prevent the vocal cords from coming together and as such, prevent the difficulty in breathing should an attack occur. In some people, it decreases not only the severity, but also the frequency of attacks. The way BOTOX is injected into the vocal cords is shown below in the video. Please note that the vast majority of patients upon whom I perform vocal cord BOTOX injections are those suffering from spasmodic dysphonia.



Read the news article here.

Read more about vocal cord dysfunction here.

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Dr. Chevalier Jackson, Laryngologist Extraordinaire

On Jan 10, 2011, the New York Times published an article on Dr. Chevalier Jackson, a pioneer in the field of laryngology, who is perhaps best known for his extensive collection of foreign bodies he removed from patients, young and old, with little or no anesthesia. His genius is documented in a new biography called "Swallow" by Mary Cappello.

Among other achievements by Dr. Jackson was passage of the Federal Caustic Poison Act of 1927, esophageal dilatation in kids, and treatment of many poor children without pay.

Perhaps the one thing Dr. Jackson was mistaken on was the discouragement of high tracheostomies or cricothyrodotomies back in 1921.

Of note, Dr. Jackson's foreign body collection (2000+ items) is now owned by the Mütter Museum of the College of Physicians of Philadelphia... a fantastic museum I may add.

Read the NYT article here.

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New Video On Performing a Tracheostomy

A new video on performing a surgical tracheostomy has been created by our office and uploaded onto our YouTube channel. Watch the video here or below!

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