Dual-Mode Airway Techniques in Medicine

Hello, everyone, and welcome to the June twenty twenty-six

Airway of the Month.

I'm Andrew Perrotte. I'll be your host.

I'm an emergency medicine physician at the University of Kansas Health System and

Medical Center. I'm joined by my colleagues, Dr.

Kyle Brown, also here at KU, Dr. Reeba Hodge at Prisma

EM Critical Care in South Carolina, and Dr.

Kristin Grabenbauer at Emory EM.

Uh, we're going a little bit, uh, back to old school Airway of the Month,

um, as

we sort out some behind-the-scenes, um,

processing and production. So all you get today is

essentially my head and the, uh, screen that we'll go through with, uh,

the mouse icon. This is how we used to do it. It's all good.

We want to keep, keep the content flowing as we sort out

the background.

Um, so today is a dual-mode airway.

For those of us who are new or those of you who are new, uh,

dual mode is

a video laryngoscope and a bronchoscope, uh, combined, so you get to

split screen on the GlideScope. Um, I am on the medical advisory board for

Verathon as a conflict of interest, but, uh, there's a variety of

ways you can do this, but essentially augmenting video

laryngoscopy with

bronchoscopy. Um, so let's take a look at this.

So you see on the left side of the screen, a pretty good view, grade two A.

You know, you have a good view of the arytenoids,

the epiglottis, and the

vocal cords. Anterior commissure is not evident. This

is the interarytenoid notch.

But the power of this is on the left side, what we're all used to is seeing this,

uh, laryngoscopy view, which is nice.

Then we'll see on the right side, you come in with a bronchoscope.

The whole idea of a dual mode or bimodal, um, is that you're

not only seeing with the laryngoscope, you're also seeing with the bronc, which

serves as an articulating bougie with suction.

The lighted camera, it's a really powerful way to intubate.

A good colleague of mine says if they're intubatable from above,

you can do it with

dual mode, which I agree with. This is actually a fairly straightforward

airway,

but, um, a good example of this pathway, which we'll show you.

So coming in here, the key on the bronchoscopy side of

things, so

the laryngoscope is standing here or holding here.

The, the provider or clinician who initially

performs

laryngoscopy takes precedent at the head of the bed, and then they step to the

side, and they hold from the side with the

laryngoscope.

Then the bronchoscopist comes in and stands head of the bed.

The key when you're driving the bronchoscope is to stay high rather than

diving

backwards into the posterior oropharynx into the soft tissue.

You want to translate the bronchoscope through the potential space and

really not engage soft tissue at all.

And you can see providers do a fairly good job here with that.

So this is a great view. So you have the laryngoscope confirming

the bronchoscope

is in a great place. The bronchoscope, you have this really close-up view of the

vocal cords. The trick here is a little bit of flexion with your

thumb, which causes flexion of the bronchoscope

tip, and then you

place the body of the bronchoscope against the interarytenoid notch.

And then as you're moving into the-- into place, when

your camera would start to engage the anterior trachea,

you then extend your thumb,

drop the camera down into the trachea.

So you'll see the providers do that, so watch that one more time.

So flexion up into the interarytenoid notch and extension down to the trachea.

When you're in the trachea, you still want to drive.

You don't want to just rake it along the soft tissue.

So you drive into that potential space down the tunnel of

the trachea and then

hold up above the carina. We are working on a project that is gonna be

comparing, uh, depth of bronchoscopy to endotracheal

tube placement rather than waiting for the chest X-ray. More to come there.

Little bit of a hold up on the arytenoids here.

Remember, there's no magic to the bronchoscope.

It's still-- It's just a bougie at this point,

essentially, or i-introducing

stylet. So you can still hang up on the sty--

or the arytenoids. Like Dr.

Levitan says, "Rotation is the key." So you come

down--

Endotracheal tube comes down, it hangs up in the arytenoids.

Larynx left, rings right. That's Dr. Levitan's line.

So rotation left or counterclockwise, clear the

bevel from the arytenoids if you're hanging up on the anterior

trachea.

Rings right, rotation clockwise.

So you'll see this little rotation, and endotracheal tube comes

in.

Some attention to the right side of the screen.

You, you'll see after you pass, almost everybody

then, at least at the beginning, continues to go deep as the endotracheal

tube

comes in. You'll see that kind of procedural ten-tendency.

So the bronch is trying to kind of go down to the right mainstem bronchus, and the

providers do a nice job of keeping it high, so they keep it above the carina.

You'll see the endotracheal tube then passes the bronch, and you're like,

"I know

exactly where I'm at." So I'm right above the carina, hovering, watching the

endotracheal tube pass on the video laryngoscope, left screen.

See the endotracheal tube go just distal to the bronchoscope on the bronc screen.

You see carina right there. You're in excellent position.

One hundred percent I'm in and I-- where, where I wanna be.

This is a really nice job. So okay, more to follow.

Great talking with you all. Keep pushing. See you guys. Bye.