PulmCrit: Large-bore suction for intubation: strategies & devices
September 25, 2017 by Dr Josh Farkas of Pulmcrit:
The Yankauer fails to manage large-volume regurgitation. The flow rate is proven to be lower than large-bore suction catheters (Andreae 2016). The small holes of the Yankauer are easily clogged with debris (Kei 2017). The ideal suction tool for intubations is debatable, but it seems clear that the Yankauer is a poor choice. Persistent use of the Yankauer suction catheter for airway management represents a profession-wide failure in our ability to manage large-volume regurgitation.
Requisite features of any suction device used for intubation
An ideal suction tool for intubation should have the following features:
- Appropriate geometry for deployment during direct or indirect laryngoscopy.
- Large internal diameter and hole size, which largely eliminates clogging by particulate matter.
- Ability to pass a bougie or airway exchange catheter through the suction device (more on this below).
The Yankauer has feature #1, but lacks #2-3. The large-bore suction devices discussed below satisfy all three of these criteria.
Endotracheal tube suction using a meconium aspirator
Many hospitals lack commercial large-bore suction devices, which has led to the creation of a variety of work-arounds. This was first proposed by Scott Weingart, who described how to create a large-bore suction device using an endotracheal tube connected to a meconium aspirator (figure below). The stylet can be shaped into any configuration desired, to accommodate either a straight-to-cuff geometry (for direct laryngoscopy) or a more gradual curve (for hyperangulated videolaryngoscopy). This is elegant, but it does have the drawback of requiring a swivel adaptor and meconium aspirator.
Summary: The Bullets
- Yankauer suction wasn’t developed for intubation, nor does it work well for this situation. Persistent use of the Yankauer for airway management represents a system-wide failing of modern medicine to manage regurgitation.
- Large-bore suction catheters are less likely to be clogged by vomitus and may allow for securing the airway directly using a Seldinger maneuver.
- Commercial large-bore suction catheters are only trivially more expensive than Yankauer catheters and should replace Yankauer suction devices for routine use in airway management (because it’s impossible to predict regurgitation with 100% certainty).
- For practitioners who lack access to commercial large-bore suction devices, there are various ways to MacGyver a large-bore suction device. This may be reasonable for selected situations where a patient is at higher risk for large-volume regurgitation.