Airway ?

[bigtuna]

I have been thinking about an airway case that I had several nights ago and figured I would go to the experts.

I am an upper level pulm/cc fellow at a large academic center. At the mothership, we have 24 hour anesthesia airway coverage but at 2 other hospital we work at, the pulm fellows are the last line of defense for intubations at night (with med residents and RT's the first line).

My experience:
150-200 DL's
>350 FOB intubations

Situation:
Called at 3:30AM by medicine resident in ICU for new admission. Mid 50's man with COPD, OSA, obesity (115 kg's) who presented with resp distress and bilat pulm infiltrates (prob PNA).

pCO2 stable in mid 40's on serial ABG's but oxygenation worsening. Resident says sP02 mid 90's on bipap with 100% FIO2 and she thinks he will need intubation before backup arrives around 7:30AM. Resident has done total of 2 intubations and experienced RT doesn't feel comfortable trying because he thinks the airway will be difficult. I curse my bad luck and head in.

On my arrival, obese man with RR in 50's, O2 sat 89% on bipap, altered.
Looks like MP 3 though he's not completely cooperative.
TM distance slightly less than 3 fingers.
Mild retrognathia.
NPO for > 12 hours.

Equipment at my disposal:
Miller/Mac
combitube
airtraq

No one can find a bougie. No intubating LMA. FOB will take me at least 45 min to set up if I can find someone with a key to the bronch suite.

I give propofol and versed and take a look with MAC4. Unable to visualize epiglottis.

We are easily able to maintain sats in mid 90's with bagmask vent.

I reposition and place a neck roll. I give more propofol and 50 of sux and take a look with the miller. Able to see epiglottis, airway slightly bloody. See a hole opening and closing with a bubble but no cords - take a shot, esophageal intubation -> ****.

Bagmask again, sats OK. Decide to take one more look with the miller after 50 more of sux. Able to visualize epiglottis and about 1 mm of cords - place tube successfully. Change jockeys

My question about the situation is this:
If you get a horrible view with your first DL, do you go immediately to an alternative method? I'm wondering if I should have gone to the airtraq immediately after the first DL?

Thanks.

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[Bertelman]

My question about the situation is this:
If you get a horrible view with your first DL, do you go immediately to an alternative method? I'm wondering if I should have gone to the airtraq immediately after the first DL?

Thanks.

If you aren't successful on your first view, change something. That doesn't necessarily mean climbing the airway ladder to fancy tricks. More importantly, your first attempt should be your best. You mentioned placing a neck roll. That should have been done before your first attempt. Are you familiar with the tips for intubating the very obese? At 115 kg he doesn't sound all that large, but he will need to be in proper position which may include two or more pillows, possible a shoulder roll.

Particularly in your situation, alone in a non-OR envoironment, in a relatively stable patient where you have ~30 min to optimize prior to intubating, you should have everything lined up. You didn't mention how much propofol you gave up front. Do you think he was deep enough? Why such a light dose of sux?

If you're going to tube the guy, you need to commit. You demonstrated an ability to bag him. I'm assuming his other vitals were stable. He needed at least 100 of prop and 100 of sux. If you had done that up front, my guess is you would have been successful the first time, maybe 2nd with the Miller.

 

[ssmallz]

Ramp him, get him to like 30 degrees and make sure the external accoustic meatus lines up w/the anterior of his chest. How do you not have a bougie on hand? Thats the best thing for people when you can't visualize and its cheap and easy to put into any airway cart. Also consider a MAC #3 b/c it has a better angle so you may be able to visualize more and lift the epiglottis.

 

[fastosprintini]

have a heart to heart talk with whoever is in charge of obtaining equipment , if you are the most experienced laryngoscopist in that institution (aka the buck stops here)you need to make sure that you have all the equipment that is now standard as in a difficult airway cart with all the toys...
in addition you need to be send to a difficult airway course to get proficient.
you did well, but always remember what would have happened if you get in the cannot intubate/cannot ventilate scenario in the middle of the night with a deterioriating , obese patient......
talk to people in charge and make sure things get changed, at the very least you tried to voice your concern, because one day things will go wrong and you will be asked why you attempted intubation without adequate equipment...
been there, done that
fasto

 

[Planktonmd]

In a situation like this you need to do what you do best, and obviously in your hands a FOB is your best choice.
You tried once, you were not successful, stop and don't turn a semi-elective situation into a disaster.
Don't give a muscle relaxant.
Let him wake up and tell your medical resident to keep assisting him while you find whatever that you need to find to do FOB.
Call the hospital CEO if you need to, you have plenty of time.
Once you got that, spray his airway and give some mild sedation then do what you do everyday: FOB.
You can learn other techniques and approaches later.

I have been thinking about an airway case that I had several nights ago and figured I would go to the experts.

I am an upper level pulm/cc fellow at a large academic center. At the mothership, we have 24 hour anesthesia airway coverage but at 2 other hospital we work at, the pulm fellows are the last line of defense for intubations at night (with med residents and RT's the first line).

My experience:
150-200 DL's
>350 FOB intubations

Thanks.

 

[DrRobert]

Even in a relatively controlled situation where you can mask ventilate I wouldn't try DL more than twice. Obviously you want to optimize everything on the first attempt... your best blade, positioning, induction meds, bougie, etc. On the second attempt you should change at least one variable whether it be positioning, different blade, etc.

Since a lot of people still use FOI as their backup airway device, trying DL more that twice can really cause big problems. By this time you are almost guaranteed to stir up bleeding which makes FOI nearly impossible. If your rescue device is a Glidescope or intubating LMA then you might be able to get away with some bleeding.

In academics I've seen this mistake too many times. The resident can't intubate on the first attempt... they change blades and can't intubate on the second attempt... then the attending tries and can't intubate... then the attending changes blades and still can't intubate... then they call for the fiberoptic cart and can't see shyt because of all the bleeding.

One of my favorite attendings gave me this advice:

Optimize EVERYTHING on your first attempt... blade, positioning, pre-oxygenation, adequate sedation and muscle relaxant, bougie, suction. If you are unable to intubate despite being optimized then it is time to go directly your rescue device of choice... whether it's fiberoptic, Glidescope, intubating LMA, etc.

 

[bigtuna]

Optimize EVERYTHING on your first attempt... blade, positioning, pre-oxygenation, adequate sedation and muscle relaxant, bougie, suction. If you are unable to intubate despite being optimized then it is time to go directly your rescue device of choice... whether it's fiberoptic, Glidescope, intubating LMA, etc.

Appreciate all of the great comments.

One major mistake I made was that I didn't do the above. As mentioned, the guy wasn't that obese and I didnt think it would be that difficult. I did have the head of the bed at 30 degrees but should have shoulder/neck rolled from the beginning.

I really didn't think I had the time to get the FOB out safely at the beginning of the case but I guess once sedated and we had demonstrated the ability to ventilate I could have gotten it. But this guy had a big beard and wide mandible and was taking a lot of strength to do it. I'm not sure the small female resident would have been able to successfully ventilate for a long period of time.

I agree with all of the comments that have been made about the lack of equipment availability in this situation. These issues have been brought up many times without response. Not only to have the airway backup be non-anesthesia but also at home really shows the level of idiocracy running this hospital.

 

[nutmegs]

Having the head of the bed at 30 degrees and building a "ramp" for an obese person are two totally different things. I'm defininely sold on the ramp position- for a bigger person, I'll start building them up with blankets well below their shoulders, targeting (as someone already said) ear lobe even with sternal notch.
http://bariatrictimes.com/HTML/images/thumbs/CollinsFig3Bs.jpg
This has definitely made a difference in people I was scared about.


Can't you call down to the OR and ask if you could borrow a Bougie?

 

[jwk]

I am an upper level pulm/cc fellow at a large academic center.

I agree with all of the comments that have been made about the lack of equipment availability in this situation. These issues have been brought up many times without response. Not only to have the airway backup be non-anesthesia but also at home really shows the level of idiocracy running this hospital.

I think this is a huge issue for your facility.

We are a large private hospital system with multiple operating areas. We have a fully-stocked difficult airway cart, including FOB and light source, for EVERY area - that means two separate OR areas, OB, an outpatient center, and a smaller hospital. Every one of them have identical A/W carts with all the assorted airway toys, including FOB, assorted types of LMA devices, retrograde and cric kits, etc. In addition, our main OR has a teaching FOB setup with light source, video monitor and DVD recording capabilities.

IMHO, and obviously you know this anyway, but it is inexcusable in this day and time to not have a dedicated anesthesia difficult airway cart accessible 24/7. Ours are kept in the OR hallway along with the MH and crash carts - everyone knows where they are, and if it's needed for an outlying area, it's easy enough to grab it and take it with you.

 

[Bertelman]

I think this is a huge issue for your facility.

I'm pretty sure he wasn't at the large academic center when this happened. He was at a smaller facility w/o anesthesia coverage, and clearly w/o routine anesthesia airway equipment.

I would say at a bare minimum, these facilities should be able to provide a bougie and an intubating LMA. I would make a case to your PD that if the facility is not willing to do so, your program buys you a bougie. Many docs carry these with them, especially when traveling for intubations. Furthermore, I would ask for your own key for the bronch room if they are unwilling to provide some FO source, be it a FOB or McGrath.

 

[jwk]

I'm pretty sure he wasn't at the large academic center when this happened. He was at a smaller facility w/o anesthesia coverage, and clearly w/o routine anesthesia airway equipment..

My bad - I misread the OP. Still, the cost of not having the right equipment could cost far more than the hospital sucking it up and doing the right thing.

 

[huktonfonix]

Good job. you did get lucky though. You either need to have better backup equipment or a plan for the cant ventilate cant intubate scenario. This man had a couple of risk factors for being a difficult ventilation.

 

[jennyboo]

First of all, give yourself a pat on the back for getting through a difficult situation.

Equipment at my disposal:
Miller/Mac
combitube
airtraq

No one can find a bougie. No intubating LMA. FOB will take me at least 45 min to set up if I can find someone with a key to the bronch suite.

Everyone else has already stressed the importance of preparation, so I have only a couple points to add:


1. You need to have a multi-step plan with back-up plans B,C,D,E and F, and ALL the equipment for every step, before you start.

Long before you show up to intubate any patient, you need to have a "bag of tricks and tools" that you know very well.

For example, my typical algorithm goes something like suction, mask, Mac 3, Miller 2 or Miller 3, McCoy 3, bougie, disposable LMA #4, fiberoptic bronchoscope, and a smaller tube (typically 7mm or 6.5mm) available should the bigger tube not pass. I do not necessarily use them in that order but if I am approaching an airway that I expect may be DIFFICULT I do not start without having all of these present.

If you do not have an algorithm with accompanying equipment in your head, stop now and make one up. Bring your Plan A,B,C,D,E&F algorithm with you (if not necessarily all the equipment) to EVERY airway you manage.

You need to know your algorithm as well as you know ACLS, because when the $hit hits the fan, if you don't know your next step you will flounder.


2. Do not start, and especially do not sedate or paralyze, until you have ALL the equipment for every step, before you start.

For an anticipated difficult airway, this means getting someone to unlock the room for the bronchoscope before you start. Better to wait 45 minutes while the patient breathes on his own, even if it's crappy breathing, than to give drugs and have him obstruct or be paralyzed while you can't intubate and can't ventilate him!

Another point of great concern to me is that you did not have an LMA. Look at the flowchart on p1273 of the ASA Difficult Airway algorithm at http://www.asahq.org/publicationsAndServices/Difficult Airway.pdf . Note that LMA has been included very specifically in the algorithm. This means that LMA is now part of the standard of care. Your other devices (Airtraq, Combitube) are mentioned further down in the algorithm as options, with much less emphasis. Airtraq and Combitube are not in the anesthesia bag we carry to floor intubations and codes in our hospital, but I have NEVER gone to any intubation without an LMA. I believe that you also should never intubate without having an LMA around. (Note: You don't need an intubating LMA -- any LMA would be okay in my opinion. Others may differ on this point, but my point is, you should not have done this without an LMA.)

 

[jennyboo]

One last thing:

I really didn't think I had the time to get the FOB out

This is something I see very commonly. Pulmonary-MICU folks take much longer to make the decision to intubate, typically checking blood gases and bipap-ing for hours or even a couple of days. Anesthesia-SICU folks typically bipap for a couple hours and if the gas doesn't improve or the patient clinically doesn't look more comfortable, we intubate. So in my experience our patients get intubated much earlier than yours do, especially when your patients have been sitting on the floor bipap-ing for hours even before they get admitted to an ICU.

You had time to get the bronchoscope. In fact, you had hours of time while this guy was sitting on bipap spiraling down the drain. You did not know the patient was coming to you and you did not know the patient needed to be intubated until you were called by the resident. But in the big picture, anyone could've seen where this was going hours ago.

This is another thing I see very commonly. You get there and the patient is going into respiratory failure, tachypneic, has low sats, etc. You think you need to secure the airway instantaneously. Wrong -- this is not a code, the patient is currently maintaining his own airway and if he is still breathing he is probably okay for longer than the five minutes you think you have. This is still semi-elective, meaning that you still have options:
- You can take 15 minutes to gather enough equipment (which you didn't have).
- You can wait 20 minutes or 45 minutes to get the bronchoscope out.
- You can transfer the patient to a hospital where they have real equipment.

You have more time than you think.

 

[Idiopathic]

>350 FOB intubations...really?

So, if you are going to be doing intubations as routinely as you seem to be doing them (100 or so a year?) maybe you should do more direct laryngoscopies? at least during elective situations or in the daytime.

 

[bigtuna]

One last thing:



This is something I see very commonly. Pulmonary-MICU folks take much longer to make the decision to intubate, typically checking blood gases and bipap-ing for hours or even a couple of days. Anesthesia-SICU folks typically bipap for a couple hours and if the gas doesn't improve or the patient clinically doesn't look more comfortable, we intubate. So in my experience our patients get intubated much earlier than yours do, especially when your patients have been sitting on the floor bipap-ing for hours even before they get admitted to an ICU.

You had time to get the bronchoscope. In fact, you had hours of time while this guy was sitting on bipap spiraling down the drain. You did not know the patient was coming to you and you did not know the patient needed to be intubated until you were called by the resident. But in the big picture, anyone could've seen where this was going hours ago.

This is another thing I see very commonly. You get there and the patient is going into respiratory failure, tachypneic, has low sats, etc. You think you need to secure the airway instantaneously. Wrong -- this is not a code, the patient is currently maintaining his own airway and if he is still breathing he is probably okay for longer than the five minutes you think you have. This is still semi-elective, meaning that you still have options:
- You can take 15 minutes to gather enough equipment (which you didn't have).
- You can wait 20 minutes or 45 minutes to get the bronchoscope out.
- You can transfer the patient to a hospital where they have real equipment.

You have more time than you think.

I appreciate your response but some of this is ridiculous.

First of all, as I mentioned, this is not in house call nor do I get called with new admissions. I heard about this 5 minutes before I left my house.

Second of all, in my program I spend just as many months in SICU, CTICU, NICU with predominantly anesthesia attendings as I do in a MICU and I can pretty much guarantee that I have seen more patients with advanced lung disease and impending respiratory failure than most of the anesthesia residents on this board. In fact I spend a significant amount of time supervising CA1,2 in these units.

Thirdly, let me more carefully explain why I didn't get the bronchoscope. We do a consult rotation at this hospital as 1st year fellows and then never go back. This year I am on home call 1 day a month at this hospital which is usually very quiet after hours/nights. I have not stepped into this place for 10 months. I don't know where the equipment is kept in the bronch suite any longer and don't have a key. I do remember that the equipment is not set up to be very portable. There is really no telling how long it would have taken me to get that set up correctly.


I know a lot of you are used to getting called to the MICU and arriving with a pulmonary fellow holding a blood covered laryngoscope but that is not how I operate. I have a lot of respect for anesthesiologists and I think that the ones I have worked at have respect for me as well.

In your earlier post you mentioned that you wouldnt try intubating without an LMA. How much more successful is an LMA in ventilating a difficult to mask patient than a combitube? Just curious.

 

[bigtuna]

>350 FOB intubations...really?

So, if you are going to be doing intubations as routinely as you seem to be doing them (100 or so a year?) maybe you should do more direct laryngoscopies? at least during elective situations or in the daytime.

The reason I have so many is that we intubate about 90% of patients having bronchoscopy over the scope during the procedure. This is not common everywhere but traditionally done at my program because of the very sick patient population we deal with.

This is done under light sedation with fent/versed and topical but we don't sedate deeply enough for them to tolerate DL.

I know this is not the same as doing a fiberoptic intubation on a crashing patient with a bloody airway but I'm pretty darn efficient at finding the cords at this point

 

[huktonfonix]

The reason I have so many is that we intubate about 90% of patients having bronchoscopy over the scope during the procedure. This is not common everywhere but traditionally done at my program because of the very sick patient population we deal with.

This is done under light sedation with fent/versed and topical but we don't sedate deeply enough for them to tolerate DL.

I know this is not the same as doing a fiberoptic intubation on a crashing patient with a bloody airway but I'm pretty darn efficient at finding the cords at this point

you guys are also probably talking about different scopes. The pulmonary/ENT bronchoscopes at our place allowed much better control than the typical fiberoptic scopes. The fiberoptic we're used to using takes 1 minute to grab, pop on a lightsource, and look in the scope. They also dont allow as good control as the "better" bronchoscopes. It also doesnt require the whole bronchoscope cart. Im actually not sure if the bigger bronchoscopes can use the portable lightsources.

 

[aredoubleyou]

One last thing:



This is something I see very commonly. Pulmonary-MICU folks take much longer to make the decision to intubate, typically checking blood gases and bipap-ing for hours or even a couple of days. Anesthesia-SICU folks typically bipap for a couple hours and if the gas doesn't improve or the patient clinically doesn't look more comfortable, we intubate. So in my experience our patients get intubated much earlier than yours do, especially when your patients have been sitting on the floor bipap-ing for hours even before they get admitted to an ICU.
.

I'd agree with your observation, but would say that these are often very different pt populations - with the MICU pts being way sicker, often with end stage COPD - and the last thing you want to do is intubate them if you can avoid it -- extubating someone who does not meet extubation criteria even on their best day before they were intubated can be a distaster as you cant get them off the vent and are very prone to develop pneumonias(immunosupressed, sludgy COPD lungs, etc, etc) and sepsis

 

[Jeff05]

problem list:

1. why did you need to intubate this patient emergently? patient had stable pco2 and po2 - so not impending failure. erroneously, you believed that the benefit of intubating this patient was worth the risk of having you (as far as airway experience is concerned - yours qualifies as BEGINNER.) manage the airway. not just any airway. an airway with MULTIPLE predictors of difficult intubation AND difficult ventilation. plus, pulmonary physiology that would be unforgiving (atelectasis, pna, low frc) to apnea.

so at this point, anyone who has an real experience managing an airway would have assessed the situation as "serious"

2. you have NO advanced airway equipment. you have NO plan B.

3. so, a novice, with a difficult airway, with no help, without any advanced airway devices in a non-emergent situation. clearly the only logical thing is to induce and paralyze and take "a look." an icu and ED classic move.

no offense, but YOU ARE that icu fellow that stands there with a bloody laryngoscope when we arrive...

 

[bigtuna]

problem list:

1. why did you need to intubate this patient emergently? patient had stable pco2 and po2 - so not impending failure. erroneously, you believed that the benefit of intubating this patient was worth the risk of having you (as far as airway experience is concerned - yours qualifies as BEGINNER.) manage the airway. not just any airway. an airway with MULTIPLE predictors of difficult intubation AND difficult ventilation. plus, pulmonary physiology that would be unforgiving (atelectasis, pna, low frc) to apnea.

so at this point, anyone who has an real experience managing an airway would have assessed the situation as "serious"

2. you have NO advanced airway equipment. you have NO plan B.

3. so, a novice, with a difficult airway, with no help, without any advanced airway devices in a non-emergent situation. clearly the only logical thing is to induce and paralyze and take "a look." an icu and ED classic move.

no offense, but YOU ARE that icu fellow that stands there with a bloody laryngoscope when we arrive...

I didn't go into as much detail as I probably should have initially because I didn't know that this would turn into a discussion about how long the guy would last without being intubated.

I did say that the PCO2 was stable on serial abg's but the most recent gas by the time I arrived was about 4 hours old.

Since the prior gas, FIO2 increased from 60% to 100% while sPO2 dropped from mid 90's to upper 80's. Also mental status has changed from relatively alert to somnolent.

So when I see him for the first time, i see basically an unarousable patient with an SPO2 of 89% on bipap with 100% FIO2 and guppy breathing with a RR>50. I guarantee at that point that this ABG was no longer "stable".

So while he may have gone on for a while longer, i personally don't think he would have lasted very long. And like I said, there is no anesthesia or ER attending ( or resident for that matter) available. I have attending backup but trust me...it wouldn't have been much help.

So your suggestion is what exactly? Wait for code and the bag for several hours.

And i wouldn't say there was no plan B (though admittedly suboptimal)....there was the combitube and the airtraq still to go.

 

[Jeff05]

set up.
get an LMA ready.
get your fiberoptic - since it is the device with which you have the most experience.
if the patient needs bagging - call a respiratory tech and have him bag while you get ready.
give him glyco to dry him out.

as far as YOU are concerned, this patient needs to be intubated awake if possible. sit him up. open him up by bagging aggressively. spray some local in the back of throat. and intubate fiberoptically.

i'm just telling you that if you lost this airway you would lose your license.

I didn't go into as much detail as I probably should have initially because I didn't know that this would turn into a discussion about how long the guy would last without being intubated.

I did say that the PCO2 was stable on serial abg's but the most recent gas by the time I arrived was about 4 hours old.

Since the prior gas, FIO2 increased from 60% to 100% while sPO2 dropped from mid 90's to upper 80's. Also mental status has changed from relatively alert to somnolent.

So when I see him for the first time, i see basically an unarousable patient with an SPO2 of 89% on bipap with 100% FIO2 and guppy breathing with a RR>50. I guarantee at that point that this ABG was no longer "stable".

So while he may have gone on for a while longer, i personally don't think he would have lasted very long. And like I said, there is no anesthesia or ER attending ( or resident for that matter) available. I have attending backup but trust me...it wouldn't have been much help.

So your suggestion is what exactly? Wait for code and the bag for several hours.

 

[OB1🤙]

bigtuna- you asked about ventilating through the LMA vs. combitube- keep in mind that you can intubate fiberoptically through an LMA. Huge advantage over the combi. You can also potentially intubate blindly through an intubating LMA. The LMA is leaps and bounds better than the combitube as a temporizing device.

As has been said, if you are the last line of airway defense in this hospital, it would greatly behoove you and your patients to become familiar with the use of the LMA and its well-defined role in difficult airway management.

 

[bigtuna]

set up.
get an LMA ready.
get your fiberoptic - since it is the device with which you have the most experience.
if the patient needs bagging - call a respiratory tech and have him bag while you get ready.
give him glyco to dry him out.

as far as YOU are concerned, this patient needs to be intubated awake if possible. sit him up. open him up by bagging aggressively. spray some local in the back of throat. and intubate fiberoptically.

i'm just telling you that if you lost this airway you would lose your license.

Fair enough.

There has been some conflicting opinions given on this thread.

*Dont paralyze vs didn't give enough sux
*MICU waits too long to intubate vs this patient didn't need to be intubated, keep waiting

One recurring theme is that I should have gotten the fiberoptic as my backup since I am most proficient with it. I guess in this case it was a judgement call as to whether or not I had time. As I mentioned earlier, my minimum estimate for getting it set up is 45 minutes after I located a key to the room. Maybe next time I will reconsider.

Thanks for the answer about the combitube. I am familiar with using an LMA. This particular hospital has decided to place combitubes rather than LMA's on the airway cart....i don't know why. I am sure they have LMA's in the OR but again i didnt have easy access. When you say that the LMA is leaps and bounds better than the combitube as a temporizing device, do you mean because of the easier method of intubating with it or because it is better at ventilating?

In any event, I appreciate all of the insight.
I know that I don't have the airway training of an anesthesiologist.
But, as many on this board know...it is not all that unusual for smaller hospitals to have an intensivist covering the emergency airways overnight so we need to practice these situations and learn from experiences like this.

 

[huktonfonix]

Fair enough.

There has been some conflicting opinions given on this thread.

*Dont paralyze vs didn't give enough sux
*MICU waits too long to intubate vs this patient didn't need to be intubated, keep waiting

One recurring theme is that I should have gotten the fiberoptic as my backup since I am most proficient with it. I guess in this case it was a judgement call as to whether or not I had time. As I mentioned earlier, my minimum estimate for getting it set up is 45 minutes after I located a key to the room. Maybe next time I will reconsider.

Thanks for the answer about the combitube. I am familiar with using an LMA. This particular hospital has decided to place combitubes rather than LMA's on the airway cart....i don't know why. I am sure they have LMA's in the OR but again i didnt have easy access. When you say that the LMA is leaps and bounds better than the combitube as a temporizing device, do you mean because of the easier method of intubating with it or because it is better at ventilating?

In any event, I appreciate all of the insight.
I know that I don't have the airway training of an anesthesiologist.
But, as many on this board know...it is not all that unusual for smaller hospitals to have an intensivist covering the emergency airways overnight so we need to practice these situations and learn from experiences like this.

People will have different opinions in these situations. The paralytic issue was 2 separate things. The first being that you may not have given enough succ to optimize your view for the first DL. The second issue is whether or not you should have given succ in the first place.

The LMA is in general, easier to use than a combitube and you can guarantee yourself of a secure airway if you intubate through it, since the combitube may still be a supraglottic airway.

Lastly, if you are using the same fiberoptic scopes we do, then it should take all of 30 seconds or less to set up. I assume you are using the scopes that need the cart and appropriate equipment to go with it. Are you able to directly visualize or use a portable lightsource with your scope?

 

[OB1🤙]

Advantages of LMA over combi IMO,

1- Ease of use. Slide it in. Ventilate. With the combi there are more variables- where is the tube, which port do I use, which cuff do I use, etc. Less moving parts= better in an urgent situation.

2- Given that the LMA seats directly over the glottis whereas the combi does not, I do think the LMA is probably going to easier to ventilate through most of the time. I don't know of any data out there that definitively compares the two devices to prove this, but especially with LMA supremes and proseals, there is minimal leak when ventilating through them when properly placed, and there's no insufflation of air into the stomach.

3- Intubation possible through LMA, which is the major advantage IMO.

 

[rsgillmd]

....
Situation:
Called at 3:30AM by medicine resident in ICU for new admission. Mid 50's man with COPD, OSA, obesity (115 kg's) who presented with resp distress and bilat pulm infiltrates (prob PNA).

pCO2 stable in mid 40's on serial ABG's but oxygenation worsening. Resident says sP02 mid 90's on bipap with 100% FIO2 and she thinks he will need intubation before backup arrives around 7:30AM. Resident has done total of 2 intubations and experienced RT doesn't feel comfortable trying because he thinks the airway will be difficult. I curse my bad luck and head in.

On my arrival, obese man with RR in 50's, O2 sat 89% on bipap, altered.
Looks like MP 3 though he's not completely cooperative.
TM distance slightly less than 3 fingers.
Mild retrognathia.
NPO for > 12 hours

I'm assuming you were at the hospital where there is no anesthesia backup. Most others have already mentioned my thoughts. My quick read impression is you have a tough situation in a patient with a likely anterior larynx.

Equipment at my disposal:
Miller/Mac
combitube
airtraq

No one can find a bougie. No intubating LMA. FOB will take me at least 45 min to set up if I can find someone with a key to the bronch suite.

I give propofol and versed and take a look with MAC4. Unable to visualize epiglottis.

We are easily able to maintain sats in mid 90's with bagmask vent.

I reposition and place a neck roll. I give more propofol and 50 of sux and take a look with the miller. Able to see epiglottis, airway slightly bloody. See a hole opening and closing with a bubble but no cords - take a shot, esophageal intubation -> ****.

Bagmask again, sats OK. Decide to take one more look with the miller after 50 more of sux. Able to visualize epiglottis and about 1 mm of cords - place tube successfully. Change jockeys ......
Thanks.

It sucks about your equipment available (or lack thereof). Given what you had I would have ramped the patient, and used a Miller for my first look because I expect him to be anterior. I'll leave the dosages of the drugs to your judgement since you were there and I was not. If I saw cords I would try to slip tube in. If I saw cords and moving too fast to slip in, I would give Sux at that point to weaken (40 mg usually does the trick). I find I can do most intubations without Sux. If you were more experienced with DLs and had better rescue equipment available, you could very easily argue for a proper dose of Sux up front to optimize your intubating conditions. Otherwise going with what you did, I would have gone to Airtraq after you saw a little bit of blood.

Will finish this post later. Have to go deal with a OB disaster.

 

[Bertelman]

People will have different opinions in these situations. The paralytic issue was 2 separate things. The first being that you may not have given enough succ to optimize your view for the first DL.

That was my point. If you're going to give the drug, you've got to give enough to work. I don't think you did anything magical on the third DL, I think you had just finally given enough drug to ease your laryngoscopy, whether that was sux or propofol.

And it appears as though this person was in extremis when you arrived, approaching code status. I don't believe you would have lost your license. I'm not even sure why that statement was made.

 

[bigtuna]

Lastly, if you are using the same fiberoptic scopes we do, then it should take all of 30 seconds or less to set up. I assume you are using the scopes that need the cart and appropriate equipment to go with it. Are you able to directly visualize or use a portable lightsource with your scope?

Correct. The scope at this hospital is not "portable". It requires a huge cart with a monitor and large light source and doesnt allow direct visualization.

 

[Jeff05]

inducing and paralyzing a difficult intubation/ventilation airway without the experience to control it - that's why he would have lost his license. best case scenario massive lawsuit (check out closed claims). also see:

Nonoperating-room anesthesia claims had a higher severity of injury and more substandard care than operating room claims. Inadequate oxygenation/ventilation was the most common mechanism of injury. Maintenance of minimum monitoring standards and airway management training is required for staff involved in patient sedation.
Curr Opin Anaesthesiol. 2006 Aug;19(4):436-42.

a tube is NOT magic.

if the patient was in "extremis" when he got there - he could have placed an oral airway and mask/bag with a PEEP valve and ventilated the patient - this would provide adequate ventilation and oxygenation. the AMS is likely secondary to hypercarbia - so blow off that CO2 for him, he would likely regain his mental status and airway tone to cooperate with BiPAP and that buys even more time. i've done many months of SICU and PACU and these patients are a dime a dozen. nothing extreme here.

the biggest lesson here is that he got lucky. the right thing to do and not just cause it's academic dogma is not to induce a difficult intubation/ventilation.
awake fiberoptic is the first choice. if you chose to take away this patient's remaining ability to ox/vent you must have adequate airway experience coupled with a good plan that has several well rehearsed options. anyone dealing with airways MUST be proficient with LMA use as it appears in multiple places in the ASA difficult airway algorithm.

That was my point. If you're going to give the drug, you've got to give enough to work. I don't think you did anything magical on the third DL, I think you had just finally given enough drug to ease your laryngoscopy, whether that was sux or propofol.

And it appears as though this person was in extremis when you arrived, approaching code status. I don't believe you would have lost your license. I'm not even sure why that statement was made.

 

[Bertelman]

...We are easily able to maintain sats in mid 90's with bagmask vent...

...Bagmask again, sats OK. Decide to take one more look with the miller after 50 more of sux. Able to visualize epiglottis and about 1 mm of cords - place tube successfully. Change jockeys

It appears as though he demonstrated the ability to bag/mask and maintain sats.

inducing and paralyzing a difficult intubation/ventilation airway without the experience to control it - that's why he would have lost his license. best case scenario massive lawsuit (check out closed claims). also see:

Nonoperating-room anesthesia claims had a higher severity of injury and more substandard care than operating room claims. Inadequate oxygenation/ventilation was the most common mechanism of injury. Maintenance of minimum monitoring standards and airway management training is required for staff involved in patient sedation.
Curr Opin Anaesthesiol. 2006 Aug;19(4):436-42.

a tube is NOT magic.

if the patient was in "extremis" when he got there - he could have placed an oral airway and mask/bag with a PEEP valve and ventilated the patient - this would provide adequate ventilation and oxygenation. the AMS is likely secondary to hypercarbia - so blow off that CO2 for him, he would likely regain his mental status and airway tone to cooperate with BiPAP and that buys even more time. i've done many months of SICU and PACU and these patients are a dime a dozen. nothing extreme here.

the biggest lesson here is that he got lucky. the right thing to do and not just cause it's academic dogma is not to induce a difficult intubation/ventilation.
awake fiberoptic is the first choice. if you chose to take away this patient's remaining ability to ox/vent you must have adequate airway experience coupled with a good plan that has several well rehearsed options. anyone dealing with airways MUST be proficient with LMA use as it appears in multiple places in the ASA difficult airway algorithm.

I never said the situation was extreme. I've done one month of critical care and I've seen a few of these situations. I said the patient was in extremis, as in rapidly approaching a critical juncture in his livelihood.

What if there are no LMAs? Is it now the covering physician's responsibility to provide this tool?

I think the biggest lesson is to optimize your conditions the very first look. After optimizing the intubating conditions, this doc got the tube in the hole. I think he would have done so on the first or second attempt if he had used the right blade, the right patient position, and the right drugs.

I still don't see a scenario in which a fellow would lose his license. That's just hyperbole.

 

[Jeff05]

i got your in extermis comment. which, by the way, means "at the point of death" and not approaching that point.

that's the issue here. the patient was NOT in extremis, not even close. after inducing (which he shouldn't have done) they found that they could easily ventilate and maintain the patient with a mask/bag.

you suppose that if he started with the "right" position he would have gotten the tube in. certainly, it would help. but you don't know that he would have. i don't know that he wouldn't. that's the truth.

there are a million ways do do things. i mean we could put to sleep all of our difficult airways and get rid of awake FO altogether. likely, most will be just fine with an asleep intubation. but, very very few won't. medicine is a game of numbers. it's not IF the horrible complication will happen, but when. you can practice in a way that makes those complications less likely or you can keep putting difficult airways to sleep and seeing what happens. good luck with that.

the glaring error here is that there was NO backup plan.
what if he put this guy to sleep and paralyzed him and he COULDN'T mask him all of a sudden? he had NO WAY of knowing that he would be easy to mask after induction.

i discussed this case with some of my attendings today, one who is an expert witness and had participated in some airway disaster cases. if there was an airway related mortality in this case he said that his testimony would not have been sympathetic.

 

[Bertelman]

i got your in extermis comment. which, by the way, means "at the point of death" and not approaching that point.

that's the issue here. the patient was NOT in extremis, not even close. after inducing (which he shouldn't have done) they found that they could easily ventilate and maintain the patient with a mask/bag.

you suppose that if he started with the "right" position he would have gotten the tube in. certainly, it would help. but you don't know that he would have. i don't know that he wouldn't. that's the truth.

there are a million ways do do things. i mean we could put to sleep all of our difficult airways and get rid of awake FO altogether. likely, most will be just fine with an asleep intubation. but, very very few won't. medicine is a game of numbers. it's not IF the horrible complication will happen, but when. you can practice in a way that makes those complications less likely or you can keep putting difficult airways to sleep and seeing what happens. good luck with that.

the glaring error here is that there was NO backup plan.
what if he put this guy to sleep and paralyzed him and he COULDN'T mask him all of a sudden? he had NO WAY of knowing that he would be easy to mask after induction.

i discussed this case with some of my attendings today, one who is an expert witness and had participated in some airway disaster cases. if there was an airway related mortality in this case he said that his testimony would not have been sympathetic.

I would argue he wasn't far from extremis, likely less than 12 hrs without intervention, but who cares. Neither of us were there, and death was not the outcome, so neither of us can make that distinction. The MD sharing the case thought he wouldn't last a couple hours. That's close enough to death for me.

It seems to me the fellow had at least two backup plans. What would your recommendation be if the FOB weren't available? Do you consider all patients with OSA and borderline morbid obesity "difficult airways"?

Did your airway expert suspect this guy would lose his license? I am personally aware of an anesthesiologist who tubed the goose on a CABG, then proceeded to place lines. Some time later, he recognized the error. Tried to blame it on support staff. You can imagine the outcome. Here is an "airway expert" who didn't even confirm placement of an ETT before spending the next several minutes ignoring the device. This was in the era of SpO2. Settled out of court. Soon found another job, small market in a neighboring state.

 

[Tenesma]

Bigtuna --- thank you for posting on this forum... a few thoughts

1) the concept that you HAD to intubate is flawed... 89% Sats for a patient who is tachypneic on 100% FIO2 does not EQUAL emergency... one trick, in a patient who is "somnolent" is to bag mask the patient and over-drive their breathing a bit (helps slow them down a bit) and will likely increase sPO2 a bit... this would have bought you time to get FOB to the bedside

2) forward thinking: if an RT thinks the patient is going to be a difficult intubation, and the patient looks tough to you, then you need a plan B... and that plan B MAY include transporting patient to the OR for anesthesia intubation with gen. surg. or ENT on stand-by for trach/cric... JUST because you are the SENIOR pulm fellow, doesn't mean you are alone --- you CAN get help if you ask for it... there is nothing wrong with calling for help, and then not needing it...

3) and lose the habit of relying on SUX for your airway management... as a resident who did TONS of emergency airways during my training, INCLUDING in the ER, I NEVER, EVER USED SUX...

4) in fact, by the end of my training i did most of my non-code intubations on the floors/units with a Miller 3, Hurricane spray, a touch of fentanyl and that is it... most of these patients, who are in the same shape as the guy you posted about, are actually EAGER to get a tube down their throat...

 

[OB1🤙]

I think if you talk to 100 anesthesiologists/residents/CRNAs, you'd get 100 differing opinions on which induction agents and relaxants to use for floor intubations and how they should be dosed.

Some people paralyze, some don't. Some give a stick of sux, some give one or two ccs. Some never use sux and always use roc if they give anything. All camps have very defensible rationales, and ultimately, which camp we fall into derives from our individual experiences.

So I don't think it's very useful to give advice to a pulm/cc fellow on which meds to use given how variable we are within the specialty- he should use what he's comfortable with and what he knows.

 

[Tenesma]

Hawaiian Bruin --- just because many people have different "styles", doesn't mean that a chaotic approach is therefore appropriate.

Please show me where in the difficult airway algorithm they mention the use of a muscle relaxant?

and based on your thoughts that the pulm/cc fellow should do what he is comfortable with, then how is he going to learn/mature as an airway manager???

and not all camps have defensible rationale... HOW do you defend turning a difficult airway into NO airway because somebody is now paralyzed?

I'd rather have somebody struggle with an airway while the patient still is generating bubbles/air movement...

don't you realize this patient has a sat of 89% on 100% with minimal to NO reserve... you paralyze him, and miss the intubation and screw up the bag-mask, this patient could be toast...

 

[OB1🤙]

<oddly indignant commentary...>

Time out. We're not ON the can't ventilate/can't intubate algorithm, because prior to giving any relaxant, the OP showed he could bag. We're not talking about a bona fide airway emergency, just a suboptimal situation. The OP recognized that the management was probably suboptimal and appropriately came into this forum asking for advice on how to improve for the future.

And let's give him some credit- he has managed about 500 airways. Does that make him an airway expert? Not at all. Is he a rank beginner? Not at all. Has he developed some feel for the meds involved in a floor intubation? Of course. Should you automatically assume he doesn't know how to effectively bag a patient? I don't think so. He says he can bag this patient, I believe him.

There are two main issues here- the optimization of his initial DL, and his backup plans should that have proved difficult. He eventually got a grade 2 view with better positioning, and the take home message there is to optimize your positioning on an obese patient prior to induction, usually with a ramp. We've beat the LMA horse to within an inch of its life, and I think he understands now that we believe he needs to do everything in his power to make the presence of an LMA standard at every intubation. We've also said that we really really want the fiberoptic in the room, he says it couldn't happen and that was the hand he was dealt.

I don't think there's any controversy with any of these points.

So the sux issue is an aside. You say "I'd rather have somebody struggle with an airway while the patient still is generating bubbles/air movement." Others might counter that you should make your first look your best look, and the way to optimize that look is with some relaxant. They might say that if you're producing apnea with propofol alone, you're just as screwed if you can't ventilate a patient with no pulmonary reserve as you are if you gave sux with the propofol, so you may as well give both and give yourself and the patient the best shot of success right off the bat. They might also say that the duration of action of propofol and sux are about the same, so as long as you give them at the same time, what's the difference?

Now I'm not necessarily saying that I personally espouse any of these points of view. I have many many more floor intubations to go before I decide what my personal preference will be. I'm saying that reasonable people can argue both sides of the issue. You can state that your opinion, borne of your own extensive experience, is that sux should NEVER be given on a floor intubation, but just because it's your opinion doesn't make it the standard of care.

Bonus link: http://forums.studentdoctor.net/showthread.php?t=226462

 

[Tenesma]

i am just glad everything turned out ok... but this has all the ingredients of a typical floor/unit airway disaster...

 

[bigtuna]

Tenesma,

Thanks a lot for your comments. I agree with a lot of what you said, especially in reference to the paralytics which I dont' use as a matter of course.

One interesting thing about this case to me is that we don't often see the natural course of respiratory failure. I can't think of a similar case where nothing has been done and one actually sees how long a patient will last. The only similar situation I can think of is watching a DNR patient go out but they almost universally receive opiates.

My impression of this patient's situation is the following:
-He had severe hypoxemia from PNA but as you pointed out this is not an emergency. Who cares if his sats are 89, 85, 80? He is not going to code from this.

-More concerning to me is that his RR has increased from around 30 to >50 in less that 1 hour and he is taking extremely shallow breaths. This indicates to me that he is rapidly developing respiratory muscle fatigue. You don't start to get somnolent until pCO2 is > 70 typically. I suspect his ABG would have been somewhere in the neighborhood of pH7.1, pCO2 80s but could have been worse as well.

It seems to me like bagging him in this situation could be risky as well. What if he aspirates and then you cant intubate or ventilate while he codes? This type of situation can go downhill fast. One of the main points here is that this guy has some risk factors for being a difficult bag-mask as well

Anyway, your points are well taken. If he had surgery 2 weeks prior and required a fiberoptic intubation, I probably would have gone the route you suggested. I think my main mistake was overreliance on the combitube as a backup ventilation method.

 

[Tenesma]

well the risk always exists for aspiration --- in fact, he could aspirate after the sux, he could aspirate after the DL, he could aspirate at any point of this... the skill with bag mask is to "Assist" the ventilations, and by giving them that extra support you will likely notice that the respiratory rate will go down as well...

however, if you don't feel comfortable with creating a good seal AND providing good control over ventilation, then there is a good chance to fill up the belly with air --- also not very helpful...

 

[europeman]

I know this is an old post - but boy it's a great one. One thing I would add is..... in addition to the fact that ALL your airway supplies should have been there - be mentally prepared and have a knife/supplies ready for Cric in the event you did lose the airway.

 

[abolt18]

I know this is an old post - but boy it's a great one. One thing I would add is..... in addition to the fact that ALL your airway supplies should have been there - be mentally prepared and have a knife/supplies ready for Cric in the event you did lose the airway.

I appreciate the bump. I thought it was a good read!

 

[ranvier]

Agreed, good read.