Podcast appearances and mentions of rich levitan

Heartbeat: The Mind of an Airway Enthusiast We sit down with EM legend and airway guru, Dr. Rich Levitan. Dr. Levitan is a self-proclaimed airway enthusiast who has published extensively on laryngoscopes and airway management. He currently works clinically, mainly in rural, critical care access hospitals, and travels the country and the globe speaking and teaching courses on airway management.  So how does Dr. Levitan approach the “difficult airway”? It starts with mindset.   Send us your questions and continue the conversation on social media@empulsepodcast or at ucdavisem.com. Host: Dr. Sarah Medeiros, Assistant Professor of Emergency Medicine at UC Davis Guest: Dr. Rich Levitan, Emergency Physician, Adjunct Professor at Dartmouth Geisel School of Medicine, Visiting Professor at the University of Maryland School of Medicine.  Resources: AirwayCam.com ********************************************************** Ski and CME! Join us for the,UC Davis Emergency Medicine Winter Conference, March 4th-8th at the Ritz Carlton in Lake Tahoe, CA. Come play and learn with us at the Western Regional SAEM Annual Meeting, March 21-22 in beautiful Napa, CA! #WRSAEM19  Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Audio Productions for audio production services. Dr. Rich LevitanDr. Sarah MedeirosQSC mixer, Apogee converters, Shure mics, Mogami Cables, Sony headphones

Rich Levitan is an Adjunct Professor of Emergency Medicine at Dartmouth School of Medicine (New Hampshire) and visiting Professor at University of Maryland School of Medicine (Baltimore, Maryland). Professor Levitan is director of the New York City Airway Course, the Yellowstone Airway Course and the worlds largest cadaver airway course, in Baltimore (monthly for 16 years). He has given more than 350 invited international lectures on airway management and authored 42 publications and 3 textbooks on airway management. He is the inventor of the AirwayCam, which captured real-time, advanced airway skills for the first time. These resources have been used in 4000 hospitals in 26 different countries.

Dr. Rich Levitan is widely regarded as an expert in emergency airway management. He visited Brown EM as a guest lecturer in October 2017 and sat down with resident Dr Jessie Werner to discuss his career, how he became a legend in airway management, and his advice for learners in emergency medicine.

You came back for part two! In this episode Dr. Jeff Jarvis and I discuss his system's technique for pre-oxygenation, and why pre-loading your bougie can help increase your first pass success. Tip 3. NODESAT! “Nasal Oxygen During Efforts To Secure a Tube” (NODESAT) is a term coined by Rich Levitan in regards to placing a nasal cannula at high flow on a patient during the pre-ox and intubation process. This allows not only augmentation of FI02 from a NRB or BVM, but also the ability to provide apneic oxygenation during intubation. The idea is during the pre-ox period you place a NC at 15lpm, a NRB at 15lpm, and try to achieve an SP02 of 100 % for at least 3 minutes prior to intubation. Because this provides little positive pressure, it will likely not work in a patient with physiological shunting. If you HAVE to ventilate a patient due to inadequate peri-intubation ventilation, then the use of CPAP or BVM with a PEEP valve will be needed. By utilizing Henry’s law we can not only increase the surface area of alveoli by recruitment, but also apply pressure to the oxygen to assist in diffusion. Tip 4. Ditch The Stylet! I may be crucified by some for saying this, but statistics and anecdotal experience has shown you are much more likely to achieve first pass success if you utilize a bougie. Now the old way that we were taught to use the bougie required two people to perform. One person would intubate the trachea with the bougie, and the other would assist in railroading an ET tube over the bougie. A more common and efficient trick in the pre-hospital realm, is to preload the bougie with either a Kiwi grip or D grip. The cudae tip allows for easier anterior access, and the tactile feel of the bougie allows you to feel the tracheal rings upon successful placement. The bougie is commonly used as an emergency tool for difficult airways. If we are intubating a patient, it is an emergency, and we need to use everything possible to optimize our FPS. The occasional intubator recognizes the need to utilize every strategy possible to achieve their goal. A study showed providers increased their FPC success rates from 66% to 96% just by utilizing the bougie. This is a must in every pre-hospital airway kit. Sources: Comparison of the stylet and the gum elastic bougie in tracheal intubation in a simulated difficult airway Riaz Ahmed Khan*,Farah Ashraf Khan **, Muhammad Azam*** Anaesthesia, Pain & Intensive Care ISSN 1607-8322, ISSN (Online) 2220-5799

When you give only after you're asked, you've waited too long. – John Mason First, learn to bag Place a towel roll under the scapulae to align oral, pharyngeal, and tracheal axes: Karsli C. Can J Anesth. 2015. Use airway adjuncts such as the oropharyngeal airway or a nasal trumpet. Use the two-hand ventilation technique whenever possible:   (See Adventures in RSI for more)     Supraglottic Airways: for difficult bag-valve-mask ventilation or a difficult airway (details in audio) LMA Classic Pros: Best studied; sizes for all ages Cons: Cannot intubate through aperture   LMA Supreme Pros: Better ergonomics with updated design; bite bloc; port for decompression Cons: Cannot pass appropriate-sized ETT through tube   King Laryngeal Tube Pros: Little training needed; high success rate; single inflation port Cons: Flexion of tube can impede ventilation or cause leaks; only sized down to 12 kg (not for infants and most toddlers)   Air-Q Pros: Easy to place; can intubate through aperture Cons: Not for neonates less than 4 kg   iGel Pros: Molds more accurately to supraglottis; no need to inflate; good seal pressures Cons: Cannot intubate through (without fiberoscopy)   Summary • If you can bag the patient, you're winning. • If you have difficulty bagging, or anticipate or encounter a difficult airway, then don't forget your friend the supraglottic airway (SGA). • Ego is the enemy of safety: SGAs are simple, fast, and reliable. • Just do it.   References Ahn EJ et al. Comparative Efficacy of the Air-Q Intubating Laryngeal Airway during General Anesthesia in Pediatric Patients: A Systematic Review and Meta-Analysis. Biomed Res Int. 2016;2016:6406391. Black AE, Flynn PE, Smith HL, Thomas ML, Wilkinson KA; Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth. 2015 Apr;25(4):346-62. Byars DV et al. Comparison of direct laryngoscopy to Pediatric King LT-D in simulated airways. Pediatr Emerg Care. 2012 Aug;28(8):750-2.  Carlson JN, Mayrose J, Wang HE. How much force is required to dislodge an alternate airway? Prehosp Emerg Care. 2010 Jan-Mar;14(1):31-5. Diggs LA, Yusuf JE, De Leo G. An update on out-of-hospital airway management practices in the United States. Resuscitation. 2014 Jul;85(7):885-92. Ehrlich PF et al. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg. 2004 Sep;39(9):1376-80. Hernandez MR, Klock PA Jr, Ovassapian A. Evolution of the extraglottic airway: a review of its history, applications, and practical tips for success. Anesth Analg. 2012 Feb;114(2):349-68.  Huang AS, Hajduk J, Jagannathan N. Advances in supraglottic airway devices for the management of difficult airways in children. Expert Rev Med Devices. 2016;13(2):157-69. Jagannathan N, Wong DT. Successful tracheal intubation through an intubating laryngeal airway in pediatric patients with airway hemorrhage. J Emerg Med. 2011 Oct;41(4):369-73.  Jagannathan N et al. Elective use of supraglottic airway devices for primary airway management in children with difficult airways. Br J Anaesth. 2014 Apr;112(4):742-8. Jagannathan N, Ramsey MA, White MC, Sohn L. An update on newer pediatric supraglottic airways with recommendations for clinical use. Paediatr Anaesth. 2015 Apr;25(4):334-45. Karsli C. Managing the challenging pediatric airway: Continuing Professional Development. Can J Anaesth. 2015 Sep;62(9):1000-16. Luce V et al. Supraglottic Airway Devices vs Tracheal Intubation in Children: A Quantitative Meta-Analysis of Respiratory Complications. Paediatr Anaesth 24 (10), 1088-1098. Nicholson A et al. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev. 2013 Sep 9;(9):CD010105. Ostermayer DG, Gausche-Hill M. Supraglottic airways: the history and current state of prehospital airway adjuncts. Prehosp Emerg Care. 2014 Jan-Mar;18(1):106-15.  Rosenberg MB, Phero JC, Becker DE. Essentials of airway management, oxygenation, and ventilation: part 2: advanced airway devices: supraglottic airways. Anesth Prog. 2014 Fall;61(3):113-8.  Schmölzer GM, Agarwal M, Kamlin CO, Davis PG. Supraglottic airway devices during neonatal resuscitation: an historical perspective, systematic review and meta-analysis of available clinical trials. Resuscitation. 2013 Jun;84(6):722-30. Sinha R, Chandralekha, Ray BR. Evaluation of air-Q™ intubating laryngeal airway as a conduit for tracheal intubation in infants--a pilot study. Paediatr Anaesth. 2012 Feb;22(2):156-60. Timmermann A. Supraglottic airways in difficult airway management: successes, failures, use and misuse. Anaesthesia. 2011 Dec;66 Suppl 2:45-56. Timmermann A, Bergner UA, Russo SG. Laryngeal mask airway indications: new frontiers for second-generation supraglottic airways. Curr Opin Anaesthesiol. 2015 Dec;28(6):717-26.   Supraglottic Airway on WikEM   This post and podcast are dedicated to Tim Leeuwenburg, MBBS FRACGP FACRRM DRANZCOG DipANAES and Rich Levitan, MD, FACEP for keeping our minds and our patients' airways -- open.  You make us better doctors.  Thank you. Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP Pediatric; Emergency Medicine; Pediatric Emergency Medicine; Podcast; Pediatric Podcast; Emergency Medicine Podcast; Horeczko; Harbor-UCLA; Presentation Skills; #FOAMed #FOAMped #MedEd

Airway management induces stress and fear in the heart of many Critical Care practitioners. In a high pressure situation, it’s easy to falter on the see-saw of demand vs. ability. Rich argues that in difficult airway management, we are hindered by: complex algorithms, anecdotal expertise and the negative perception of the task as ‘undoable’ and the downplaying of our abilities. In crisis, we need simple! Rich discusses the need to redefine the priorities of the airway (away from ‘find the vocal cords/cricothyroid membrane’), incrementalisation and consensus of method. Rich also briefly discusses the future of airway management - nasal oxygenation and the need to move past the surgical airway as a failed airway.

You’re just now coming down from your nerve block high off of SCP and Tibial block goodness, but we’ve got another for you!  It’s a block that isn’t super common, but it’s got some really nice potential in the right patient. Obviously we’ve got the nerve block man, Mike Stone, on to talk about this one.  Who else would, right?!?  At the end stay tuned to hear a special announcement about an incredible course with Scott Weingart, Haney Mallemat, Rich Levitan, Andy Sloas, Anand Swaminathan, and Rob Orman. And see you next time when we talk about DVT ultrasound and whether what we’ve been teaching for several years is total crap…… Follow us:  @ultrasoundpod Learn with us:  www.ultrasoundleadershipacademy.com Register:  Yellowstone Course, DevelopingEM Cuba Course, Atlantis CME Bahamas Course FREE Introduction to Bedside Ultrasound eBook: Volume 1 Volume 2 One Minute Ultrasound Smartphone App for iOS One Minute Ultrasound Smartphone App for Android

Canon - a general law, rule, principle, or criterion by which something is judgedNo one has changed the face of how we approach difficult airway more than Rich Levitan, MD. In this episode I review five of Rich's most important contributions to how we approach emergent intubations. These are techniques you can take to the department tomorrow to improve your view, increase your success, and save your patient's life!   Click here to follow Dr. Levitan on twitter. Ear to sternal notch positioning will not only improve your view, but save your backside and possibly your patient's life! Levitan's best bougie techniques (includes Shaka, Kiwi and Ducanto)! iTunes Link

The RAGE team are joined by many friends to recap the smaccGOLD experience: Rich Levitan (@airwaycam) Scott Weingart (@emcrit) Haney Mallemat (@CriticalCareNow) Michaela Cartner (@mjcartner) Karel Habig (@karelhabig) Chris Nickson (@precordialthump) John Hinds (@docjohnhinds) Cliff Reid (@cliffreid) Mark Wilson (@markhwilson) Oli Flower (@oliflower)

There is a really smart anesthesiologist out there called Nicholas Chrimes. He along with his mate Peter Fritz invented the Vortex Approach to Airway Management. He also runs a blog called Clinical CrEd. He did a post advocating the Mapleson B Circuit as the Ultimate Preox Device What is the Mapleson B? The Mapleson circuits were used for anesthetics in the good old days. At least in the US, we have move to bigger, and arguably better designs for our operative patients. Many would have thought this device would have been consigned to the trash heap, but seemingly not. from anesthesia 2000 My Recommended Approaches I recommend two approaches to preox: standard and shunt physiology strategies. I outlines these strategies in the paper Rich Levitan and I wrote. Standard: NRB @ >=15 lpm and NC @ 10-15 lpm for 3 minutes Shunt Physio: Choose 1 BVM with PEEP Valve & NC @ 10-15 lpm NIPPV Ventilator with NIPPV Mask or BVM Mask & NC @ 10-15 lpm Nick makes a number of arguments as to the superiority of the Mapleson circuit over these standard techniques. His points are excellent, but I disagree with pretty much all of them--I think it becomes a question of perspective. Automatic Checking Yes, using the same device for reox and preox makes sure the reox device is there and hooked up, but this for me is an inadequate argument to dispense with NRB/NC set-up. Multiple BVM Masks We don't have these readily available in any ED or ICU I've worked in. We have neonate, peds, and adult. Our masks also are not inflatable. PEEP PEEP is good, Mapleson may or may not be a good way to provide this for the reasons I've mentioned in the wee, but a BVM with a PEEP valve or a vent are at least as good. ApOx Mapleson may provide this better than BVM, but not as well as a NC, which should be on during any intubation. ETCO2 No advantage of Mapleson Low resistance Maybe this matters, as soon as you put on the PEEP, I can't imagine this difference persisting Room Air Entrainment Release your seal for even one breath and you have blown denitrogenation. Always, always use a strapped system if possible=NRB/NC, NIV mask, or BVM mask with OR straps. Troubleshooting Leaks This is the real area in which Nick and I differ. Nick makes the point that a good seal in preox guarantees a good seal in reox--this may be true, but it is unimportant. What I care about is does a bad, one-handed seal in preox mean I won't be able to reox with the BVM--this is entirely untrue. If I did to an awake patient what I will do to them when asleep and desaturating, they would, quite rightfully, punch me in the face. Anesthesiologists should use Mapleson B/C; ED/ICU should only use BVM +/- PEEP Valve with two hands and oral airway and a rocking triple maneuver (that no pt should experience if they are conscious) otherwise they should be NIV mask with straps or (BVM mask with straps). This is the same reason I tell my residents to just train with Macintosh blades. Primary and secondary leaks are the main thrust of Nick's love for the old-timey circuits. But all of us have appreciated this easily by squeezing the bag-valve-mask: Easy-squeezy or Hard Squeezy ETCO2 with a monitor you can see Is he holding or squeezing? I can feel compliance with a BVM if I squeezed it, but I don't unless the pt needs it during reox. But are they squeezing the Mapleson? If they are, they may be doing damage. This study (Anesthesiology 2014;120:326) talks about the myths of Gentle Facemask Ventilation: >15 cmH20 may be entraining gas into the stomach via the LES (in some patients, even 10 cmH20 may be a problem) UES will withstand at least 20 cmH20 until NMB at which point again 15 seems to be the number (The latter is why we don't bag during apnea unless we have to) Two hands ALWAYS on the mask Recently, I spent 2 weeks intubating 10-15 patients per day. One hand mask skills got better and better--all for naught.

Rich Levitan on Surgical Airway from EMCrit/ISMMS 2014 Conference

Rich Levitan is one of the best teachers on the skills of airway management and laryngoscopy--or as he would probably put it, epiglottoscopy. Here is an hour long lecture he delivered last month at Mount Sinai School of Medicine.