A Whole New World

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    A Whole New World

    We all love FOAM, and we all love airway. Today’s pearl will introduce you to a corner of FOAM you may not have come across, as well as a corner of airway management you might not know about.

    I’m a big fan of Jed Wolpaw’s Anesthesia and Critical Care Reviews and Commentary podcast. Many of the episodes overlap with emergency medicine topics, and it’s a great source of pearls from another perspective. One of these pearls is the paraglossal approach to intubation using direct laryngoscopy with a straight blade.

    While many of us are most comfortable reaching for a curved Macintosh blade, or a hyperangulated VL blade of some sort, our airway boxes stock Miller 2s and 3s at both sites. While anecdotally, most of us don’t use a straight blade routinely, I think we are all familiar with their use. If not, get back to the books, and then hit the ORs for some practice.

    But did you know there’s a whole other way of using these things? Behold, the paraglossal approach:

    Typically, the straight blade uses a midline approach to visualize and then directly lift the epiglottis. In the video above Dr. Levitan (also of FOAM fame) demonstrates the alternative paraglossal approach. The basic steps are:

    • With straight blade, enter the mouth as far to the patient’s right as you can
    • Keep advancing, hugging the right side of the mouth
    • You will eventually just….see cords

    In the first clip above you’ll see Dr. Levitan briefly gets a view before having to do some epiglottis manipulation, but in the second, the epiglottis is totally bypassed. Dr Wolpaw goes in to more detail about this technique in this episode of his podcast.

    I am definitely not advocating that you go out at try this on your next sick ED intubation. But on your next trip through the operating room, consider giving a shot. I’ve talked to several anesthesiology attendings about this technique, and each one I’ve spoken to has at least one war story that comes to mind where this was the thing that saved their bacon on hairy airway. It’s one more tool to put in your armamentarium.

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