5. Not every difficult airway needs to be intubated. There's
no tool that's a panacea for intubating all difficult airways. Given the
potential trauma intubation can cause to the airway, avoid making an
autopilot decision.
"Many people will default to the endotracheal tube as the safest
option," says Michael Jopling, MD, medical director and chief of anes-
thesiology for Springfield Regional Medical Center in Springfield,
Ohio. "They think: 'If I run into trouble, I don't want to have to switch
a supraglottic airway to an endotracheal tube in the midst of an emer-
gency.' I understand that argument, but if you can ventilate the patient
with a supraglottic airway — while maintaining a backup plan — you
may avoid trauma. I've seen bad outcomes from those who didn't try
to ventilate the patient first."
6. You may not be inflating your LMA correctly. Studies show
that laryngeal mask airways are often over-inflated, which can lead to
ischemia and reduced tracheal mucosal blood flow. One such study
found no correlation between the experience of the anesthesia
provider and his ability to inflate to a proper level. Confusing instruc-
tions may be to blame. The maximum volume vendors suggest is
often for the safety of the cuff, not the patient. To avoid problems,
don't inflate the cuff until after it's been inserted — even if it comes
out of the package this way. And if your LMA doesn't come with a
built-in manometer for measuring pressure, consider getting one.
Finally, don't underinflate because that, too, can lead to a lack of ven-
tilation. You can avoid inflation altogether by using a supraglottic air-
way that doesn't require inflation.
7. Innovate around your equipment. Don't be straitjacketed by
the limitations of your tools. For example, if the suction channel on
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