Exchanging a King Airway for an ETT over a Bougie

5 Sep
EM Faculty at Medical College of Wisconsin attempted to convert a King to an ETT over a gum elastic bougie in an airway skill session
 
The bougie could not be passed into the trachea using an artifical airway model on several attempts. It wouldeithermeet resistance from the esophageal balloon, or get hung up on lateral structures of the airway
 
In the cadaver model, the bougie was thought to have passed into the trachea, but on direct laryngoscopy after removal of the King airway, it was found to have penetrated the right aryepiglottic fold
 
Subsequent attempts at the same technique also failed to intubate the trachea
 
A second paper followed 26 patients with a King airway placed by an air medical crew.
 
21 survived to hospital care, 10 of these had followup information available
 
4 of these 10 had the King airway exchanged in the ED. 1 of these 4 by the ED physician for a different sized King airway, which was subsequently exchanged for an ETT in the OR by anesthesia. 3 of these 4 were changed out by anesthesia and replaced with an ETT, one using a bougie and one using a fiberoptic scope.
 
6 of these 10 had a definitive airway placed in the OR, 4 requiring emergent tracheostomy
 
[editor’s note/anecdotal “n of 1”: the opening where the bougie would come through is angled up, and the angled tip of the bougie as it comes out seems to hit the anterior trachea and not thread smoothly. personally, if it’s working, i’d leave it alone; if there’s a question if its working, then needs to be changed, i’d just have my adjuncts handy (bougie, video, scalpel) and take the King out completely, then go in fresh.
 
one thing i haven’t tried but might (based on previous difficult airways), is deflate the King but leave it in (in the esophagus) and then slide a bougie in anteriorly over-top the King. not sure if there’s enough real-estate in the oral cavity for this.  the more universal tip here is that if you happen to intubate the esophagus, leave it in and intubate around it. much harder to intubate the esophagus twice in a row if there’s something already in it.]
 
Submitted by M. Smith.
 
References: Guyette Fx, Wang H, Cole JS. King airway used by air medical providers. Prehosp Emerg Care, 11 (2007), pp. 473–476; Lutes M, Worman DJ. An unanticipated complication of a novel approach to airway management.  J Emerg Med. 2010 Feb;38(2):222-4. Epub 2009 Jan 15.; picture; picture 2
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