AIRWAY EQUIPMENT

- To ensure an adequate seal
  - The left thumb and index finger should be placed around the collar of the facemask at both the mask bridge and chin curve.
  - The left palm compresses the left side of the mask onto the face.
  - The middle and ring fingers raise the mandible into the mask and lift the chin.
  - The fifth finger is situated at the angle of the mandible to thrust forward in an anterior direction.

If inadequate BMV:

- Place an oral or nasal airway
- One provider can use both hands to ensure an adequate seal while a second provider manages the bag.
- If BMV proves to be impossible, proceed to LMA or intubation.
- The adult face mask is designed to reduce the anatomic dead space by improving the face-mask seal.

Positioning is key for successful BMV

- - “Sniffing” position
  - Occiput elevated
  - Head extended at the atlanto-occipital joint

Laryngoscopes

DL is a direct line-of-sight approach and requires the alignment of the oral, pharyngeal, and laryngeal axes, and an unobstructed view of the larynx

RIGID

All direct laryngoscopes (DL) have 3 common features: handle, blade, and light source.
The DL blade is used to create an axis of visualization to the larynx.
The blade spatula compresses the tongue into the mandibular space, while the flange moves the tongue laterally to create a visual lumen.
The distal end of the blade is called the tip and is used to lift the epiglottis.

Macintosh, or curved

- Place laryngoscope tip in the vallecula
- Tension to the glosso-epiglottic ligament is applied by lifting
- Indirect view of the vocal cords

Miller, or straight

- The tip is placed posterior to the epiglottis
- Gentle force lifts the epiglottis providing a direct view
- Curve begins 2 inches from the tip

VIDEO LARYNGOSCOPE

These devices include illumination and a small camera on the laryngoscope blade that allows the user to see on an external screen. The glottic visualization is indirectly viewed.

Advantages:

- Head and neck manipulation is minimal; oral, pharyngeal, and laryngeal axes do not need to be aligned
- The airway is magnified
- Blade design and anterior angulation allow for better visualization than direct laryngoscopy (DL)
- External viewing allows for other users to participate
- Capable of recording

Disadvantages:

- Cost
- Blood and secretions can obscure view
- Because the ETT is advanced indirectly, trauma/injuries can occur

GlideScope
- Most widely used video laryngoscope
- Provides equal or better view without head manipulation than DL
- Hyperangulated blade with a distal 60^o anterior bend
- A camera in the middle of the blade transmits a signal to the LCD screen via a cable
- The GlideScope comes with a rigid stylet
Karl Storz C-MAC
- Blade designs are similar to the Miller and Macintosh blades and there is also an option for hyperangulated blades
- Screen viewing of the airway requires a cable to an external device
McGrath
- Portable, battery operated
- Rotational color LCD screen that is attached to the handle
Channel Scope Devices-
- Pentax Airway Scope, Res-Q-Scope II, and King Vision

Flexible Fiberoptic Bronchoscope / Optically Enhanced Scopes

Formerly known as fiberoptic bronchoscopes which had glass fibers that transmitted light.

Now referred to as Flexible intubating scopes (FIS), they have a camera at the distal end of the flexible tip that transmits images to an external screen.

Uses:

- Evaluate the airway
- Awake intubation
- Check ETT placement
- Change an existing ETT
- Perform post-extubation evaluations
FIS has different channels/ports for supplying oxygen, suction, and administering local anesthetics.
The handle has a toggle for up and down manipulation. Horizontal view change requires the operator to rotate their hand. Light is supplied externally.

Limitations of FIS:

- Fogging
  - Interventions: soak the scope in warm saline, use an antifog solution, or placing scope in the mouth for 5 seconds
- Secretions and/or blood
- An inflamed/irritated airway that is partially obstructed can become completely obstructed; e.g. epiglottitis, laryngotracheitis, or bacterial tracheitis
- Airway trauma limits FIS use because of the presence of blood, edematous tissue, or secretions.
- Patient must be alert and understand the process if awake intubation is carried out.
- Oxygenation and ventilation may suffer because of time constraints. Meaning, if the process of intubating with a FIS is time-consuming, the patient may desaturate resulting in the need to abort and ventilate or to choose a different method.

Indications for FIS

- Anticipated difficult airway
- Cervical spine immobilization
- Anatomic abnormalities of the upper airway
- Failed intubation attempt

The most common use of FIS is for awake intubation.

Preparation includes:
- Topical anesthesia
- Nerve blocks
- Drying agents, e.g. anticholinergics
- Sedation
Oral intubation with FIS can be assisted with a guide, like Williams, Berman, or Ovassapian airways. These also help to prevent scope damage in the event the patient bites down.
The FIS is advanced through the glottic opening until the tracheal rings are seen. The ETT is advanced and FIS is removed.

Semirigid fiberoptic stylet
- Shikani optical stylet (SOS)
  - Malleable, semirigid intubating fiberoptic stylet
  - Battery-operated light source with a high-resolution eyepiece on the handle that is attached to the stylet
  - Useful for a rigid or unstable cervical spine
Levitan First Pass Success (LFPS) or Levitan FPS
- Similar to the SOS but is used with a standard laryngoscope
Rigid fiberoptic stylets
- Bonfils Retromolar Intubation Fiberscope
- Ideal for patients with limited range of motion because the oral, pharyngeal, and tracheal axes do NOT need to be aligned.
Airway rigid intubation fiberscope laryngoscope (RIFL)
- Hybrid design that incorporates the rigid stylet with a flexible tip.
  - Bullard laryngoscope

SEMIRIGID AND RIGID FIBEROPTIC STYLETS PROVIDE AN INDIRECT VIEW OF THE GLOTTIC OPENING.

Contraindications to fiberoptic bronchoscopy:

Hypoxia, thick airway secretions, airway bleeding, local anesthetic allergy, and unable to cooperate.

Endotracheal Tubes

Oral tracheal intubation is indicated for:

- Positive pressure ventilation
- Pulmonary toileting
- Airway protection

Tracheal tubes are made of polyvinylchloride (PVC) because it is inexpensive, resistant to kinking, and conform to the patient’s airway

Tracheal tubes must conform to the International Organization for Standardization (ISO)

- Specifications for internal and outer diameters
- Distance markers from the distal end to the anesthesia circuit adapter
- Material toxicity
- Angle and direction of the bevel
- Size and shape of the Murphy eye
- Tube curvature radius
May be cuffed or uncuffed. Cuffed tubes are more common because they provide a seal between the tracheal tube and trachea that helps protect the trachea from gastric content aspiration.

ORAL

Armored tubes
- - Embedded metal or nylon wire in a spiral fashion throughout the tube shaft
  - Resistant to kinking and compression, ideal for head/neck/tracheal surgeries and when the neck is flexed
  - Disadvantage: Once the tube is kinked, it is cannot return to its original shape.
Preformed tubes
- Used for oral/facial/nasal surgeries to increase surgical view
Laser-resistant
- Conventional PVC tubes are flammable
- Cuffs are prone to rupture, so they are filled with saline or water with dye. This makes it quick and easy to identify a cuff rupture.
Hunsaker Mon-Jet Tube
- Designed for elective jet ventilation
- 3-mm laser resistant shaft
- Can be used with carbon dioxide and yttrium-aluminum-garnet (YAG) lasers

NASAL

Preformed tubes most used in oromaxillofacial and nasal procedures
- Ring-Adair-Elwyn (RAE) tube

Condensation in the ETT is seen because of water vapor.

Direct visualization of the laryngeal inlet with the endotracheal tube positively identified in it is the most reliable method of verification. ETCO₂ with capnograph/mass spectrometer also provides reliable evidence of tracheal rather than esophageal intubation.

The murphy’s eye is a safety feature of an endotracheal tube that allows for air to enter the trachea if the distal tip is occluded

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Endobronchial Tubes

Absolute indications for one lung ventilation:

Isolation to prevent contamination of healthy lung
Control of distribution of ventilation to one lung
Unilateral lung lavage
Video-assisted thoracoscopic surgery

Relative indications for one-lung ventilation:

Surgical exposure
High: thoracic aneurysm, pneumonectomy, etc
Low: esophageal, middle and lower lobectomies, mediastinal mass

All DLTs have two ETTs that are combined.

One lumen is longer for the main stem bronchus.
The other lumen ends in the distal trachea.
- Lung separation occurs by inflating both these cuffs (proximal tracheal and distal bronchial).

Left-sided DLTs are the most preferred for lung isolation in both right and left procedures.

For the patient with a difficult airway, several options exist:
- Awake intubation
- Single lumen tube is placed. A tube exchanger is inserted and replaced with a DLT.
- Single lumen tube is placed and a bronchial blocker is used for the desired bronchus.

DOUBLE-LUMEN TUBES

Robertshaw tube
- A modification of the Carlens tube. The Carlens tube had a carinal hook but the Robertshaw tube omitted that feature. Available in both left and right forms.
  - Advantages:
    - Large diameter lumen to allow for suctioning
    - Low resistance to gas flow
    - Fixed curvature to facilitate positioning and prevent kinking
    - Endobronchial cuff is blue so its easy to visualize with fiberoptic bronchoscopy

PVC disposable DLTs with sizes:

35 Fr- women < 63 in. (< 1.6 m)
37 Fr- women > 63 in. (> 1.6 m)
39 Fr- men < 67 in. (< 1.7 m)
41 Fr- men > 67 in. (> 1.7 m)

Average depth of insertion from the lips of left DLT in a 170-cm person is 28-29 cm

The design of the right-sided endobronchial tube helps to minimize occlusion of the right upper lobe.
- Placement:
  - Check both the tracheal cuff (20 mL) and bronchial cuff (3 mL) and coat with water-soluble lubricant
  - The stylet should be removed, lubricated, and placed in the bronchial lumen.
  - Macintosh blade is preferred because it provides the largest area to pass the DLT.
  - Insertion involves the distal concave curve of the tube facing anteriorly
  - Once the tip passes the vocal cords, the stylet is removed and the tube is rotated 90^o (left-sided tubes are to the left and right-sided tubes to the right).
  - Stop advancing the tube when moderate resistance is met.

Checking placement:

Inflate the tracheal first and ventilate. Bilateral breath sounds is expected. If they are not equal, the tube is inserted too deep. Withdraw 2-3 cm and recheck.
Clamp the right side (left-sided tube) and remove the connector cap. The bronchial cuff is inflated (usually 2 mL or less) slowly.
Remove the clamp and ensure ventilation is bilateral.
Clamp each side and ensure ventilation occurs on the opposite side (right side is clamped and ventilation occurs in the left lung, and vice versa).
Flexible fiberoptic bronchoscopy
- Helps to identify malpositioned tubes.
- Left-sided DLT
  - Scope is inserted via the tracheal lumen. The carina should be seen but no bronchial cuff herniation. The blue endobronchial cuff should be visible just below the carina.
  - Scope is passed through the bronchial lumen and the left upper lobe is visualized.
- Right-sided DLT
  - Scope entering the tracheal lumen should be able to see the carina as well as the right upper lobe.

Malposition and correction:

ANYTIME THE DLT IS TO BE ADVANCED OR WITHDRAWN, DEFLATE BOTH CUFFS BEFORE. ADVANCING THE DLT WITH INFLATED CUFFS CAN RESULT IN TRACHEAL OR BRONCHIAL LACERATION OR RUPTURE.

Due to the anatomy, the right upper lobe can be obstructed easily. If a tube is positioned on the wrong side, the DLT should be withdrawn and reinserted correctly.
Breath sounds are distant OR only heard on one side when bilateral is expected. This means that the DLT is advanced too far and should be withdrawn 2-3 cm and rechecked.
The tube is not advanced enough. Bilateral breath sounds can be heard when ventilating through the bronchial tube but no ventilation occurs when attempted through the tracheal lumen (because the bronchial lumen obstructs the trachea). Advance the tube and recheck.
Right-sided DLT can occlude the right upper lobe. The slanted doughnut shape of the bronchial cuff allows for ventilation of the right upper lobe. Because the right upper lobe orifice is only about 2 cm, the margin of error is small. Corrective movements to adjust the cuff should be small.
The bronchial cuff can herniate and obstruct the bronchial lumen if too much air is used to inflate the cuff.

The bronchial cuff should be deflated during any repositioning of the patient.

Silbroncho tube
- Flexible wire-reinforced bronchial tip that allows the tube to be inserted >50^o angle without kinking the bronchial lumen.
- Useful in patients who have had left upper lobectomy.
- Only comes left-sided
Papworth Bivent tube
- Divided single-lumen tube with a forked tip that rests on the carina.
- A bronchial blocker can then be advanced into the operative lung.

BRONCHIAL BLOCKERS

Bronchial blockers are associated with less postoperative hoarseness and vocal cord lesions. However, DLTs are preferred because they can be placed quicker and more reliably.

Indications for use:

Difficult airway
- Avoid the need to exchange the tube
- After laryngeal surgery
- Tracheostomy
- Aneurysm or tumor that compresses the bronchus
- Nasotracheal intubation

Management

Bronchial blockers may allow for blockade for certain segments in those patients who cannot tolerate OLV
Morbid obesity
Small stature or pediatric
ICU patients already intubated
Non-pulmonary surgery
- Esophageal
- Trans-thoracic approach for spine surgery
- Minimally invasive cardiac surgery

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Airways

ORAL

An oral airway is indicated for an obstructed upper airway in an unconscious patient

Oral pharyngeal airways:

Bypass the nasal cavities, nasopharynx, and soft palate obstruction in inspiration and exhalation
Lift the tongue
Support mandibular advancement
Improve BMV

Not well tolerated in awake or inadequately anesthetized patients

Complications include trauma and airway hyperreactivity
Dental damage can occur when patients bite down or “clamp down”; dental damage is more likely with dental decay

NASAL

The distal end of the nasal airway ideally rests 10 mm above the epiglottis
Nasal airways are tolerated better than oral airways in the awake patient
A nasal airway would be preferred with loose teeth.
Airway sizing can be estimated by measuring from mandible or nostril to the external auditory meatus
Inserted through the caudad part of the nasal passage
Most common complication is epistaxis

Contraindications:

- Nasal fractures
- Marked septal deviation
- Coagulopathy
- Basilar skull fractures
- CSF leak
- Pregnancy
- Transsphenoidal procedures
- Sepsis
- Pathology
- History of nose bleeds requiring treatment

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Tracheostomy Tubes

If the patient has received radiation treatment to the tumor, the obstructing mass may be stiff and friable, and furthermore, temporomandibular joint mobility may be compromised. In this case, a tracheostomy is preferable as attempts at intubation risk serious hemorrhage and edema which may lead to complete obstruction of the airway

Tracheotomy is the process of gaining access to the trachea. It involves:
- Incision of the skin and subcutaneous layers
- Muscle separation
- Thyroid gland division
- Establishment of a stoma
- Insertion of a tracheostomy tube

Tracheotomy may be performed by a surgeon electively or emergently, or by an anesthesia provider in an emergent situation.

Types:
- Catheters
- Kink-resistant for jet ventilation
- Single lumen tubes
- Cuffed
- Tracheostomy tube

New tracheostomy tubes are irritating and often result in coughing.

Changing a tracheostomy tube
- Stoma is stable and many months old, the process is generally uncomplicated.
- A fresh stoma site can easily close and changing out a tube in this case should only be done if necessary (e.g. leak).
One-lung ventilation
- DLT placed through a tracheostomy is prone to malposition because of the shortened upper airway and the DLT is too long.
- Single lumen tube with a bronchial blocker
- Cuffed tracheostomy tube and bronchial blocker
- Replacing the tracheostomy cannula with a short DLT designed for tracheostomy patients

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Supraglottic Airways

Devices that sit above or surround the glottis are supraglottic.

The acronym LMA is marketed by TELEFLEX; otherwise, other devices are referred to as supraglottic airways (SGAs)

The silicone cuff is permeable to nitrous oxide; hence, the intracuff pressure will increase with nitrous oxide anesthesia.

Indications for LMAs:
- Rescue ventilation for difficult or failed intubation
- Alternative to endotracheal intubation
- Conduit for endotracheal intubation
Insertion:
- Classic technique
  - Fully deflating the cuff and applying water-soluble gel on the posterior side
  - LMA is inserted midline with the posterior side pressed against the hard palate of the mouth
  - The LMA is advanced with the index finger along the palatopharyngeal curve.
  - Resistance can be met at the posterior pharyngeal wall which usually means the distal tip has folded back. This can be fixed by retracting and re-advancing the LMA OR manually correcting the folded tip with index finger.
  - “Final resistance” denotes proper placement in the hypopharynx and the black line on the tubing will be even with the upper lip.
  - Cuff inflation seals the airway (cuff pressures should not exceed 60 cm H₂O)
- Alternative techniques
  - (1) Tongue blade moves the tongue into the thyromental space creating more oral space for the LMA
  - (2) The LMA can be inserted with the opening facing the hard palate. It is advanced until it reaches the oropharynx and then is rotated 180^O.
  - (3) The cuff can be partially or fully inflated during insertion.
  - (4) The CRNA can also guide the LMA with a bougie or laryngoscope

LMAs are classed either as 1^st or 2^nd generation, based on the inclusion of a gastric drain

- First generation LMAs
  - Classic, Unique, Flexible, and Fastrach
- Second generation LMAs
  - Improvements from first generation:
    - Incorporate a channel for decompressing the stomach and suctioning secretions
    - The tip is reinforced to prevent folding
    - The cuff was redesigned to allow for higher ventilation pressures
    - Increased rigidity to prevent rotation and for easier insertion
    - Supreme, ProSeal, i-Gel, AuraGain
  - Compared to the Classic:
    - ProSeal takes a few seconds longer
    - Airway seal is increased by 50%, peak pressure up to 28-30 cm H₂O
    - ProSeal is reusable; Supreme is the disposable version of the ProSeal
    - Supreme has a fixed curve, gastric port, and integrated bite block; peak pressures are slightly lower than the ProSeal 26-28 cm H₂O
    - The i-Gel is single use; the cuff is soft, gel-like, and transparent but noninflatable. The i-Gel has a lower incidence of sore throat than other LMAs. A 14-French gastric tube can pass through the gastric channel.
    - Ambu AuraGain is anatomically curved and single use.

- King LT does not have a mask that covers the laryngeal opening. It is a one-time use device, double lumen tube with a large oropharyngeal balloon and a smaller esophageal balloon. The newer King LTS-D is disposable and has a gastric vent. The King LTS-D is a blind insertion

Laryngeal mask airways (LMAs) provide:
- An alternative to ventilation through a face mask
- Partial protection of the larynx from pharyngeal secretions
- Hands-free ventilation

The two cranial nerves that can be damaged with LMA insertion are the hypoglossal and vagus.

Contraindications for LMA:
- Aspiration risks (e.g., morbid obesity, pregnancy, trauma, delayed gastric emptying, or full stomachs)
- Fixed decreased pulmonary compliance (pulmonary fibrosis)
- Cannot answer questions or instructions
- Hiatal hernia.

Maximum cuff inflation for a LMA ProSeal #5 is 40 mL of air.
Maximum cuff inflation for a LMA Supreme #4 is 30 mL of air.
Maximum cuff inflation for a LMA Unique #3 is 20 mL of air.
The LMA that allows for the highest peak ventilation pressure is the LMA ProSeal.

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Intubating Supraglottic Airways

Intubating LMAs
- LMA Fastrach, Air-Q, and the Aura-I
  - Fastrach
    - Most known
    - Can be used in the “cannot intubate, cannot ventilate” situation
    - Rigid curved design aligns the mask with the glottis
    - The opening can accommodate an 8.5 mm ETT
    - Integrated guiding handle at proximal end for insertion
    - Vertically oriented semirigid epiglottic elevating bar
    - Guiding ramp built into the floor of the mask
    - With appropriate disinfection between uses, it may be used up to 40 times before disposal
    - The purpose of the two vertical bars on an LMA Fastrach are to prevent obstruction of the ETT by the epiglottis.
  - Air-Q
    - Designed as a routine LMA with intubating capabilities that would allow a normal ETT
    - Non-rigid
    - Provides pediatric sizes
  - Ambu Aura-i
    - Built-in anatomical curve
    - Disposable and best for situations when intubation isn’t needed but can be used to convert

Newer LMAs, like Unique EVO and Protector, are both preformed and have color-coded cuff pressure monitoring systems.

Supraglottic tubes
- The esophageal obturator airway (EOA) was the first device that took advantage of the observation that blind passage of a tube often entered the esophagus.
- Combitube, King LT, Rusch Easy Tube, and LaryVent
  - All placed blindly through the mouth and positioned into the esophagus.
  - Distal balloon occludes the esophagus and a large proximal balloon occludes the posterior oropharynx.
  - Ventilation port is between the two balloons at the trachea
  - The Combitube configuration allows for either esophageal or tracheal insertion; however, 95% of blind insertions occur in the esophagus. In the esophageal position, ventilation occurs via the pharyngeal lumen (blue).

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Jet Ventilation

Hand-held, manually operated jet ventilation valve powered by a 50-psig oxygen source
Can be used in elective cases where surgeon requests no tracheal tube or cannot intubate, cannot ventilate situations.
The airway must be unobstructed and paralyzed. Exhalation is passive and breath stacking can occur which could result in a pneumothorax.

The least effective means of delivering transtracheal jet ventilation is via an ambu-bag.

A complication of transtracheal jet ventilation is tracheal mucosal damage.
The main sign of laryngotracheal damage associated with jet ventilation is stridor.

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Intubating Stylets

Flex-It stylet
- Articulating and disposable
Trachlite Lighted Stylet
- Uses transillumination in the neck
- When the stylet enters the glottis, the light is well-defined in the anterior neck below the thyroid.
- When the stylet is in the esophagus, the light is more diffuse.
- It is less affected by anterior airways, it is less stimulating than traditional direct laryngoscopy, and has a lower incidence of sore throat.
- Used for patients with small mouths and/or minimal neck manipulation

Not recommended if an upper airway issue is suspected, like foreign body, tumor, polyp, or soft tissue injury.

A characteristic of proper placement of a lighted stylet is light seen just above sternal notch.

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Cricothyrotomy

Indications for cricothyrotomy:
- Cannot intubate and cannot ventilate
- Facial, head, and neck trauma that makes traditional methods time-consuming, difficult, or impossible
- Immediate relief of an upper airway obstruction
- Neck or facial surgery requiring a definitive airway when intubation is not possible

No absolute contraindications

Relative contraindications:
- Preexisting laryngeal/tracheal diseases (e.g. tumors, infections, abscesses)
- Coagulopathy
- Abnormal neck anatomy

There are 3 ways that a cricothyrotomy can be performed:
- Needle cricothyrotomy with transtracheal jet ventilation (TTJV)
  - A large bore needle is inserted through the cricothyroid membrane.
  - The catheter should be kink-resistant.
  - The Cook kit has a 6 Fr catheter and is not occluded by kinking.
  - A jet injector with an oxygen source provides ventilation
  - Frequency should be between 8-10 breaths per minute with an I:E ratio of 1:3 or 1:4. This allows air to be exhaled and prevents barotrauma.
  - Do not exceed 50 PSI
  - Complications include: barotrauma, subcutaneous emphysema, pneumothorax, pneumomediastinum, hypercarbia, esophageal rupture.
- Percutaneous (or wire-guided)
  - Indicated when intubation ventilation are impossible.
  - Needle or sharp trocar establishes access and a tracheal cannula is inserted over the trocar or wire.
  - The cannula that is placed can be cuffed or uncuffed.
  - Avoid this type of cricothyrotomy in children ages less than 12 because the airway is small, pliable, and moves too much.
- Open surgical
  - A scalpel is used to cut down to the trachea and placing a cuffed tracheostomy tube or ETT in the stoma.
- Retrograde intubation
  - Indications:
    - Inability to visualize vocal cords due to:
      - Blood
      - Secretions
      - Anatomy
    - Unstable cervical spine
    - Upper airway malignancy
    - Mandibular fracture
  - Contraindications:
    - Lack of access to the cricothyroid membrane due to:
      - Severe neck deformity
      - Obesity
      - Disease of the larynx/trachea
      - Coagulopathy
      - Infection
    - Technique:
      - Insert a needle into the cricothyroid membrane
      - Aspiration of air to confirm
      - Wire is inserted into the trachea until it is visualized in the hyopharynx
      - The ETT is then passed over the wire until entering the trachea, at which point the wire can be removed.

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Intubation Aids

Eschmann stylet (Gum elastic bougie)

- 15-French flexible stylet
- 60-cm in length
- Has a 40^O bent tip
- Used when the glottic opening is difficult to visualize
- The stylet is advanced into the trachea and the characteristic “clicks” are noted, which is the distal tip sliding past the tracheal rings
- The ETT is advanced over the Eschmann stylet until it passes the vocal cords. Care should be taken to ensure the stylet is secure instead of allowing it to advance which could cause injury.
- Once the ETT is sufficiently advanced, the ETT is secured and Eschmann stylet is withdrawn.

Frova Intubating Introducer

- Firmer than the Eschmann
- Comes with a rigid removable internal stylet
- Has a 35^o coude tip
- Internal lumen for rescue oxygenation

Airway exchange catheters (AECs)

- Help with exchanging an ETT or extubating
- They can provide jet ventilation or oxygen insufflation through an adapter and bag mask.
- As with the Eschmann, care should be taken to not advance this stylet/catheter. Tracheal or bronchial damage can occur with excessive force.

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Difficult Airway Tools (PDF)

REFERENCE: Nagelhout Nurse Anesthesia 7^th edition, pages 456-470; Ehrenwerth et al. Anesthesia Equipment 3^rd edition, pages 307-329; Barash Clinical Anesthesia 9^th edition, pages 1015-1027