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Step into the dynamic world of airway management with Dr. Jeremy Heiner as he brings a wealth of knowledge and innovative approaches directly to you. This session on airway management adventures, with real-life anesthesia case studies, promises to enrich your understanding and skills in handling complex clinical scenarios.
Learn about the challenges and quick decision-making involved in managing airways in emergency situations, the technical aspects of procedures like rapid sequence induction, the strategic use of tools like a GlideScope or bougie, plus the importance of team communication and preoperative planning.
Dr. Heiner’s engaging storytelling and practical insights make this episode a must-read for anyone looking to master the art of airway management in anesthesia and critical care. Join CSPA and the team from The Nurse Anesthesia for this and more educational content that bridges the gap between academic learning and real-world nurse anesthesia practice.
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The Nurse Anesthesia with Dr. Jeremy Heiner
Hello, future CRNA. Welcome back to CSPA podcast. I’m so excited to welcome another guest host episode with Dr. Jeremy Heiner, who is a distinguished CRNA educator. Dr. Heiner started his academic career in 2008 with a passion for advancing nurse anesthesia education. He has served and chaired on multiple committees with the NBCRNA contributing significantly to the field of nurse anesthesia. He is also the founder of The Nurse Anesthesia, an innovative educational platform focusing on key topics like airway management, which we will explore in today’s session. Thank you Dr. Heiner, we’re so excited to welcome you back to the show. Without further ado, let’s go ahead and get into airway management adventures.
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Hello everybody. My name is Jeremy Heiner and I’m one of the educators at The Nurse Anesthesia and together with Sass and Mark, we’re on a mission. We are on a mission to build a community of learning in anesthesia and critical care. We feel super fortunate to be the editors on the core textbook used in our profession, Nurse Anesthesia. And in the seventh edition, I had the awesome opportunity of authoring the airway management chapter.
I’m also super excited to announce the recent release of our pocket guide, Emergency Management in Anesthesia and Critical Care. We like to call it EMAC. Now we developed EMAC to ride along with you in the OR, in the ICU or in the emergency department and provide you with critical knowledge of emergencies that you might encounter in those areas. Before I get going with this podcast, I want to thank CRNA School Prep Academy for this opportunity to talk with all of you.
Case Studies in Airway Management
Today I get to talk to you about one of my favorite topics, airway. And what we’re going to do today is go over airway management adventures. When I was in school years ago, I remember talking with my classmates about the cases I was involved with in clinical anesthesia as a student and it was one of my favorite parts. There was no structure to it at all. We would just talk clinical anesthesia and what we experienced. I swear I learned so much in those discussions with my classmates.
So today what I want to do with all of you is go over three airway cases. One of the cases I was recently involved in, another one is a friend of mine who’s been in anesthesia for over 20 years- and it’s a pretty substantial case that he was involved in. Then the final case involves one of the students from the anesthesia program that I teach, he’s a senior anesthesia student here. It’s a pretty amazing case. Now, as we like to say in our podcast, The Nurse Anesthesia Podcast, it’s time- let’s talk some airway.
The first case we’re going to discuss is a case that I was involved in recently and this happened in a small rural, community hospital. On the side, I have a job where I go and cover for a friend of mine and we are the only anesthesia provider in that hospital. It’s a one OR hospital. We frequently respond to the emergency department there in order to provide anesthesia services such as pain management and airway management; This was one of those times we were called in to provide airway management. So here it is, Airway Adventures Case One.
Airway Management Adventures: Case One
A 57-year-old male presented to the emergency department. He arrived initially intoxicated with hemoptysis and in DKA. And I’m going to tell you about that coming up his initial appearance. When I got there, I noticed that he was sitting straight up in the gurney. He was pale, his skin, it was clammy. He had sweat on his forehead, he was breathing fast, he had dried blood around his mouth.
When I talked to him during the preoperative assessment, he had of course a history of alcohol abuse, which was no surprise since he arrived intoxicated. He had diabetes and his current blood glucose was 527, which would explain the DKA. He also had a history of esophageal varices. They had bled before and they were currently bleeding now. Now other pertinent facts, he had a potassium of 5.8. He had a hemoglobin and hematocrit of 9.2 and 27.3.
These were his vital signs: His heart rate was 111, blood pressure was kind of high at 158 over 97, and his O2 sat was 96% on a nasal cannula. So he did have oxygen going, but it was still just 96%. His respiratory rate was 22. Now when we’re talking about DKA and we’re talking about potassium, usually what happens is there is a hypokalemic state, but initially the patient may appear hyperkalemic with a higher potassium because it’s leaving the cells in DKA.
But once the blood glucose is corrected and especially with insulin, the potassium goes right back in those cells and we end up with a hypokalemic patient. So initially I was called in to manage this patient and provide a central line. The ER physician wanted to give fluids, they wanted to give vassopressors and I wanted to avoid the neck because of the hemoptysis. So I placed a femoral central line and got that in relatively easily using an ultrasound.
Airway Management Adventures: As an anesthesia provider and airway management expert, there will be times that you’ll be the leader and it is up to you to get the team in a shared communication type of a state so that everybody understands what the plan is.
Now the discussion was intubation and here’s why: The rural hospital that I work in is a small community hospital in a mountain town. Believe it or not, in southern California, here where I work, there are mountains and there are hospitals in those mountains. I was working at this hospital and it was during the winter; there was bad weather, it was snowing so we could not fly the patient out. We had to do a ground transport. Between the discussion with the ER physician and myself and the nursing staff, we all felt more comfortable transferring this patient out intubated, as opposed to not intubated, all the way down the mountain to a level one facility.
So as an anesthesia provider and as an airway expert, there will be times that you will be in charge. You’ll be the leader and it is up to you to get the team in a shared communication type of a state so that everybody understands what the plan is. So what I did was I got everyone together. I said, “Listen, this is what we’re going to do. Plan A is going to be a rapid sequence induction. We’re going to rapidly give the induction agent, the paralytic, and then I’m going to use a GlideScope and intubate the trachea. Now if that doesn’t work, plan B will be ventilation with an OPA and a bag valve mask. If that doesn’t work, we’re going to have a supraglottic airway readily available so that I can ventilate through that. Now if I have problems with that, let’s have some cricothyrotomy equipment at the bedside just in case.”
In case everything goes out the window and we end up in a cannot intubate, cannot ventilate situation, it’s always best to have your plan A, B, C, and D ready to go. So we talk together as a team with the ER physician, with the emergency room nurses, and we realized that we needed to preoxygenate this patient well. So I put a nasal cannula on, we increased the flows. I put a non-rebreather mask over the nasal cannula; that gets you pretty close to a hundred percent preoxygenation with those two things outside of the OR. If you’re in the OR, you can simply use your anesthesia mask and the circuit.
We preoxygenated the patient with the patient sitting up and before I did the rapid sequence induction, I looked at the team, I had a respiratory therapist there who was ready with the ventilator. I had two nurses, one on one side of the bed, one on the other side of the bed, one was in charge of administering the medications. The other was going to hand me the tube, the endotracheal tube, and then the ER physician was at the foot of the bed.
At this point we did the rapid sequence induction- I did a rapid sequence induction with propofol and succinylcholine. Now one thing that we need to be aware of is that succinylcholine can increase the serum potassium. It’s transient, but it can increase it. If you remember, the serum potassium in this patient was 5.8, which is slightly high.
Why did I decide to use succinylcholine? Here’s the simplest explanation: Succinylcholine provides the most rapid onset of paralysis out of any of our neuromuscular blocking medications, even faster than rocuronium at high doses. And because this patient had a history, he arrived in the ER vomiting blood. Because of that, I wanted to paralyze him as soon as possible and get that tube in the trachea as soon as possible to protect his airway and prevent aspiration.
I felt like a potassium level of 5.8 gave me a little bit of leeway. I didn’t see any dysrhythmias on his ECG, and so I decided to go with it. I felt like that outweighed the risk; the benefit of getting rapid control of the airway outweighed the risk of potential dysrhythmias.
Well, I did the RSI and I put the video laryngoscope in the mouth, but I could not get it in. Here’s why- he was NPO. He had been vomiting. His mouth was so incredibly dry that I could not get the video laryngoscope to pass by his tongue. There was absolutely no secretions in his mouth. This was the one and only time in my anesthesia career that I have ever, ever asked for lubrication stat.
No, I’m serious. It’s the only time I’ve ever said get me lube stat, which they did. I was able to put lubrication on the video laryngoscope blade and that made it so that I was able to pass the tongue easily and then view the larynx, the glottic opening, and I was able to intubate the trachea.
All of that took about a minute between doing the RSI and then placing the tube, which a minute in an airway situation is like an eternity. But this patient did not desaturate because we had adequately preoxygenated him. He didn’t have any conditions that decreased his functional reserve in his lungs, so he was able to draw upon that reserve of oxygen that we had provided him. Now this case is a pretty advanced airway case, and the other two that we’ll talk about are also advanced airway cases.
For those of you who have not managed an airway as an anesthesia provider, don’t worry, you’re going to learn all about that. As anesthesia providers, we’re considered the airway experts. So you will go through and you’ll experience a wide range of different airways and you will become an airway expert.
Emergency Intubation Checklist
One of the things that I like to do, and one of the primary reasons why I developed this Airway Management Adventure series was so that we could talk about airway cases and we could learn and improve. There were several things that I learned from this case that I would do better.
Number one, I would develop an emergency intubation checklist. I would have adequate suction. Make sure your IV is ready to go. Make sure you have intubation devices ready at the bedside. I had a video laryngoscope. I would also have had, if I was to do this case again, a direct laryngoscope ready to go in case my VL failed.
Airway Management Adventures: Make sure you have intubation devices ready at the bedside.
Going back to that suction, I did have one suction, but the fact that this patient had hemoptysis, it probably would’ve been better that I had two suctions available in case the initial suction got overwhelmed. Other things that I would have available- a peep valve on my BVM. I’m not in the OR, I was in the ED at the time, and a peep valve on my BVM would be very, very helpful.
I did not have cricothyrotomy equipment ready to go at the bedside. So in the future I would have that, even though that’s my plan D. In this specific case, I didn’t have it ready. So I want to make sure, and I developed this emergency intubation checklist to have that on the list for in the future. I will always have it ready to go.
Identifying the cricothyroid membrane is very important before you induce the patient, you always want to know where you’re going to place that cricothyrotomy before you’re in that situation where you have to do it. I felt like our preoxygenation was pretty good, and using a nasal cannula and a non-rebreather mask outside of the OR is acceptable. Another thing you can use outside of the OR is the ambu mask with high flow oxygen running through that ambu. And then finally, the roles and discussing my plans with the team. I did this but I wanted to make sure it was on my pre intubation checklist.
BVM, I’m going to do a podcast on BVM. What this is, it stands for Breathing and body position, Visualizing success and Mental imaging success. Having a mantra and getting ready to do it. It’s a technique in a very acutely stressful situation to help you minimize that stress. I call it BVM; I threw it in here on my pre-intubation checklist to remind me to do these techniques, slow my heart rate and get ready to go.
Alright, other things that I would do in the future and improve upon. I would lubricate those lips and tongue. I’m going to lubricate every airway. Make sure that that airway is lubricated before I manage it in the future. And then the last thing, I chose succinylcholine. It worked out. I didn’t have any problems. Rocuronium could have been used in higher doses, and we did give rocuronium after the airway was secured during the transport so that the paramedics had a paralyzed patient when they were transporting them.
Airway Management Adventures: Case Two
Alright, that’s Airway Management Adventures case number one. Let’s jump into the next case. This is Airway Adventures case number two. This was a 62-year-old male who presented to the OR for an AV fistula and required general anesthesia, and this was a friend of mine who did this case. The past medical history of the patient was obesity, chronic renal disease requiring dialysis, diabetes, and hypertension. And this particular patient was an identified difficult airway.
For those of you who have not managed an airway as an anesthesia provider, don’t worry, you’re going to learn all about that. You’ll experience a wide range of different airways and you will become an airway expert. Share on X
So I am now going to show you a video of an interview that I did with my friend, with my CRNA friend, and you can see from his own words what happened in the case.
Dr. Heiner: Thanks for coming in today. Can you tell us your name and how long you’ve been a CRNA?
Hector Martinez: My name is Hector Martinez and I’ve been a CRNA for 32 years
Dr. Heiner: Now. You were involved in a crisis, but before we get to that, can you tell us what the case was that you were involved in?
Hector Martinez: This was a vascular case where the patient needed a fistula and was determined that the patient needed general anesthesia. When I went to see the patient in pre-op area, I noticed that there was a very potential airway because of the anatomy of the patient and also the assessment. He had a short neck, a big head, big tongue and BMI over 40.
Dr. Heiner: Now what happened with the actual case itself?
Hector Martinez: The induction was uneventful because I prepared. It was easy. The surgery went through no problems. Then, in emergence is where I anticipated that could be a problem. So no narcotics, no sedation was used. Precedex was the only thing that was used. I deflated the cuff, the patient was able to breathe around the tube. Then we took the tube out, anticipated that he might have an obstruction. We called for CPAP in recovery.
When we got to recovery, CPAP wasn’t available. I noticed the patient was starting to get restless. The saturation was dropping, so it was determined that we needed to intubate the patient. I attempted to intubate. The anesthesiologist I was working with attempted third time. We couldn’t intubate, so now we had a crisis. We asked the recovery nurses to call EMT to get a tray and to call the surgeon. Things that should have been anticipated, but we have to ask for them.
So the surgeon came in, the vascular surgeon, he noticed that it was a crisis now, so he asked for a scalpel. He made the incision and he tried to put a number five ET tube through. He couldn’t put the tubes through. We had our anesthesia technologist by then who initially wasn’t there. She was anticipating what we needed and I asked for a bougie so that vasular surgeon can use it. He was able to put it through the stoma because he was getting the tube stack through the cartilages.
But once the bougie was put in, he put the tube through and we were able to establish an airway, emergency airway. We took the patient to the OR where our specialist, another laryngologist, was able to put a permanent airway through the mount and they were able to put a trach. But it took him several attempts to do the bronc and to be able to establish an airway. So by that time I was so exhausted that I had to ask one of my colleagues to take over for me.
Dr. Heiner: Did you guys happen to use a crisis checklist?
Hector Martinez: I did not notice a crisis checklist being used. I was very focused myself in ventilating. That’s a very important job that in the past I noticed that if we don’t focus on that, patient will die. But I did not notice a crisis checklist being used.
Dr. Heiner: What was going on in your mind in terms of thoughts and emotions during this crisis?
Hector Martinez: My thoughts were “We’re going to lose this patient if we’re going to do something quick.” So again, I was very focused and emotionally it was very draining. When I went home, I was very exhausted emotionally.
Dr. Heiner: Thank you. What a case.
Hector Martinez: It was difficult.
I want to thank Hector for doing this interview with me. Seriously, what a case. A couple of things I want to highlight from his interview. Number one, this case happened in recovery. It happened in the recovery room, so this was after the patient was extubated. Initially when they were managing the airway, they were ready. They didn’t have any problems because they knew it was difficult. It wasn’t until afterwards when the patient’s airway was swelling that they had some difficulty.
Next, I want to highlight the fact that this was a team effort. Hector called for help and a lot of people showed up and that’s what’s going to happen when you’re in hospitals. You will have support and one aspect of anesthesia practice that you will learn to develop is how to manage that support, how to be a team leader. And I kind of talked about that a little bit in the last case.
Airway Management Adventures: When you’re in hospitals you will have support and one aspect of anesthesia practice that you will learn to develop is how to manage that support, how to be a team leader.
The next highlight I want to talk about in Hector’s case was the fact of ventilation. You heard from him that if you don’t adequately ventilate, the patient will die. And that is absolutely true. The most important skill that you can learn as an airway provider is adequate ventilation. That’s adequate ventilation with a bag valve mask, adequate ventilation with a supraglottic airway device in place with an endotracheal tube in place or rarely, very, very rarely with a cricothyrotomy tube in place. Before we move on, I want to give credit and thanks to Kaiser Permanente School of Anesthesia for making this video available for us to learn from.
Anesthesia Providers- The Airway Management Experts
So we can learn several things from this case, but one that I want to highlight is when Hector mentioned the fact that they didn’t use a crisis checklist- that’s okay. What we need to do as anesthesia providers and airway management experts is have a very solid knowledge on how we’re going to manage that airway so if we’re not using a checklist, we still understand the process and the decision tree of moving through a difficult and failed airway.
Now here on this slide on the left, this is an example of the Stanford failed or difficult airway checklist (video timestamp 21:03) On the right is the failed airway The Nurse Anesthesia checklist. There are difficult airway algorithms out there and what every single one of these difficult airway algorithms ends with, what all failed airway checklists end with in a cannot intubate and cannot oxygenate or ventilate situation is cricothyrotomy. They all end in cutting the neck.
So here on the left, the priority in these situations is cutting the neck, calling for help and doing a cricothyrotomy. In the TNA failed airway crisis checklist, if ventilation is unsuccessful and oxygen saturation is critical, we’ll verbalize that to the team and do a cricothyrotomy.
Now in anesthesia school, we learned about you will learn about, or we did learn about how to do a cricothyrotomy. It’s up to us to maintain that knowledge of what type of cricothyrotomy to do and how to do it. Now in Hector’s situation, he had a surgeon who was willing to do it and that is great, that is fantastic. But as an airway management expert, it is within our scope and it is our responsibility to maintain those skills and maintain that knowledge.
Airway Management Adventures: Case Three
Okay, now let’s talk about Airway Adventures case number three. As I mentioned earlier, this was a case that happened to one of my senior nurse anesthesia students at the program I teach at in Southern California. This was the email I got “We had a recent difficult airway!” Alright, I don’t know whether this is good or bad, but I actually love getting these emails because now I get to talk about airway cases.
This is the case that he described: He had a middle aged incarcerated male with no other major medical history who was transferred to us for removal of a rapidly growing tracheal mass by the ENT surgeon. The mass was not only causing a tracheal shift but also impinging on his vagus nerve. They suspected that because he was bradycardic with sustained heart rates in the thirties to forties preoperatively.
This was the preoperative assessment that he described: “My CRNA and I talked about the importance of keeping him spontaneously breathing until we could assess how bad this impingement was and what we were dealing with. We were going to have a glide scope as our primary tool and a fiber optic (flexible scope is the recent terminology) on standby. The goal was to sedate him and numb his airway enough to allow us to take a look with the GlideScope, then determine from there if we could intubate him like that or escalate.”
Alright, there’s a lot to unpack here, so let’s do this. Number one, they get a patient, he’s middle aged. He’s got a tracheal mass. It’s impinging on the airway. That’s not good. It’s also potentially compressing the vagus nerve causing bradycardia. Wow. One problem is now exacerbated by another problem.
Awake Intubation for Difficult Airway Management
What did they decide to do? They decided to keep this patient spontaneously ventilating, which is absolutely the right choice here. They decided to do an awake intubation. That’s the terminology, awake intubation. Anytime you have an identified difficult airway, awake intubation should be at the top of your list for airway management.
In order to do an awake intubation, you have to numb up the airway. It’s not possible to stick an endotracheal tube in the trachea unless that airway is numbed up. There are various ways to do that. I’ll talk about one in just a moment. Let’s see what happened from here. Once it was go time, they anesthetized the airway using nebulized lidocaine for a good 10 minutes with like 4% lidocaine or some super high concentration, 4% lidocaine is one of the highest concentrations you can get in the hospital.
They decided to avoid midaz and fentanyl. That’s midazolam, versed and fentanyl, which is a good idea. In an awake intubation situation, you absolutely want to avoid any potential respiratory depression and uncooperative behavior, which both of these medications can lead to. We can get ventilation, depression from fentanyl, and if the patient is too sedated from something like Midazolam, they could be uncooperative.
They did decide to treat the patient’s heart rate with 0.4 milligrams of Glycopyrrolate IV. Apparently they had to do it twice because on the initial dose the patient was not super responsive and then they decided to give 100 milligrams of ketamine IV. This is something we’ll talk about. So earlier when I was talking about midazolam, we talked about an uncooperative patient.
100 hundred milligrams of ketamine IV can lead to an uncooperative patient, it can sedate them, and the great thing about ketamine is it preserves spontaneous ventilation, but if you give that much ketamine, you’re going to end up with a patient who is very, very sedative and potentially uncooperative, which here we see it.
Initially he was clenching his jaw pretty hard, but eventually he relaxed it enough for them to take a look with the GlideScope, thank goodness. Now, once they had the GlideScope in place, they were able to see the laryngeal structures and they determined that the oral and hypopharynx actually looked pretty good. They said not too shabby, and they decided to do an induction of anesthesia with paralysis. So they induced with propofol and succinylcholine, then went straight for the intubation with no issues and that is totally appropriate. They had success.
Airway Management Adventures: Anytime you have an identified difficult airway, awake intubation should be at the top of your list for airway management.
Alright, so a couple of things to unpack here. Number one, if you’ve got a tracheal mass impinging on the trachea, one thing to be aware of is that there might be subglottic stenosis, so a narrow trachea below the vocal cords. What can happen is, if you don’t understand that this is happening, you can try to pass a regular size endotracheal tube and get it through the vocal cords and then it might stop. There might be an obstruction, so sizing down one to two sizes may help to get around that obstruction and pass the endotracheal tube into the trachea.
Another option is passing a stylet such as a bougie stylet through the glottic opening down into the trachea until you get hangup, and then railroading a smaller sized endotracheal tube over the top of that. The next thing that I would talk about if we’re going to evaluate this case is awake intubation. This is something that we do not do very often. It’s a rare anesthesia airway management technique, but something that we do have to have in our airway plans. We have to understand it and we should use it when it’s appropriate, when there’s an identified difficult airway.
Awake Intubation Techniques
Now, here’s the issue. Not all awake intubation techniques are standardized. There is no standardized technique for awake intubation. What I’ve done is I’ve come up with something that kind of helps people standardize this technique and it’s a technique for awake intubation that’s an amalgamation of several awake intubation techniques that I’ve read about. I’ve studied, I’ve looked at airway experts and I’ve put it into practice- guys and ladies, I’m telling you, it is super effective.
I had the opportunity of talking about this particular airway technique at the 2023 AANA Annual Congress in Seattle, and I call it Topical Thunder. It is an awake intubation technique that utilizes high percentage lidocaine to anesthetize the airway in a topical fashion. There are three steps to this technique. I’m not going to go into it today because we simply don’t have the time, but look for a podcast in the future on The Nurse Anesthesia podcast and also check us out thenurseanesthesia.com. I’m going to talk about it there. I’m going to talk about it at future anesthesia conferences. This is one of my favorite anesthesia concepts to talk about.
That does it for this edition of Airway Management Adventures. Thank you so much for hanging out with me as we discussed some pretty high acuity airway cases. So for those of you who have not yet managed an airway as an anesthesia provider or an airway expert, don’t worry. Hopefully this motivates you. Hopefully you have something to look forward to because you will get there when you’re in CRNA school.
There is so much to learn when you’re in anesthesia practice. There is so much to learn and you will get there. So hopefully this is some motivation for you. Before I go, I want to put one more plug in for The Nurse Anesthesia. I mentioned we have a podcast, The Nurse Anesthesia Podcast. Sass, Mark and I formed The Nurse Anesthesia. We’re all about learning. We’re educators. We’ve been educating nurse anesthesia students and CRNAs for decades, and we want to build this community of learning.
Currently we have a crisis management series that’s available for you. You can go to our website at www.thenurseanesthesia.com and check it out. It’s a nominal fee and it is power packed with videos that explain how to manage anesthesia and ICU crises. Check us out. You won’t be disappointed. Again, our mission is to build a community of learning in anesthesia and critical care. We’re trying to do that through the podcast. We’re doing it through our website and the products we’re offering. We have our Crisis Management series currently available. There’ll be more in the future, so check us out at thenurseanesthesia.com. My name is Jeremy Heiner and we are The Nurse Anesthesia.
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