Couldn’t intubate - when was your last one?

[AlfPropRoc]

First time for me in about 10 years.

Young dude with angioedema - pharynx looked like a bowl of jello. Luckily was able to oxygenate/ventilate with an igel and ended up intubating through said igel with a FOB later (we’re talking hours) down the track.

Horrible scary feeling though, closest I’ve come to thinking I was going to cut someone’s throat.

Looking forward to some war stories.

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[NumTacos]

Had similar a few months back. I was supervising doing locums. It was a posterior cervical fusion take back, no known airway difficulties. SRNA and CRNA both try VL, then CRNA can’t ventilate. I dropped an LMA in, barely squeaking by. They don’t have anything fancy except for fast trach, which wouldn’t seat. Had to put bougie in through LMA, take LMA out, then thread ETT, it was not easy. Able to get a 6.0 in. Suspect she retro pharyngeal edema from prior surgery. Big place, but they didn’t have igels or other intubating LMAs, only classic. In retrospect, since we did bougie blindly after FOB showed the fenestration was at the cords, would have done FOI (disposable), cut it, then threaded ETT.

 

[AlfPropRoc]

Had similar a few months back. I was supervising doing locums. It was a posterior cervical fusion take back, no known airway difficulties. SRNA and CRNA both try VL, then CRNA can’t ventilate. I dropped an LMA in, barely squeaking by. They don’t have anything fancy except for fast trach, which wouldn’t seat. Had to put bougie in through LMA, take LMA out, then thread ETT, it was not easy. Able to get a 6.0 in. Suspect she retro pharyngeal edema from prior surgery. Big place, but they didn’t have igels or other intubating LMAs, only classic. In retrospect, since we did bougie blindly after FOB showed the fenestration was at the cords, would have done FOI (disposable), cut it, then threaded ETT.

I faced a similar problem after ICU freaked about an ETT + igel in situ and wanted me to exchange to a “normal ETT” 😂 - a mere minutes after I was congratulating myself for avoiding a catastrophe.

It’s funny though - I’d never really thought about how to get the igel/lma “out” after a difficult airway scenario before and actually required a bit of thinking. Didn’t have a disposable FOB but if I did I reckon that (cutting it) would be a good way to go.

 

[NumTacos]

I faced a similar problem after ICU freaked about an ETT + igel in situ and wanted me to exchange to a “normal ETT” 😂 - a mere minutes after I was congratulating myself for avoiding a catastrophe.

It’s funny though - I’d never really thought about how to get the igel/lma “out” after a difficult airway scenario before and actually required a bit of thinking. Didn’t have a disposable FOB but if I did I reckon that (cutting it) would be a good way to go.

Yeah, I told them that this whole cluster could have been avoided if they had a modern SGA designed to accommodate an ETT, all this hassle wouldn’t have been necessary. What was scary is that even with a glide, nothing could be seen, tried FOI with glide in place, couldn’t see anything, couldn’t even advance the scope across this barrier of tissue. Very strange.

 

[pocafx]

Had a posterior tongue cancer for peg. First DL looked like yellow food, mass. Got him deeper looked again and already blood everywhere. Luckily no paralytic, bagged a bit and canceled. Next time awake foi.

 

[vector2]

First time for me in about 10 years.

Young dude with angioedema - pharynx looked like a bowl of jello. Luckily was able to oxygenate/ventilate with an igel and ended up intubating through said igel with a FOB later (we’re talking hours) down the track.

Horrible scary feeling though, closest I’ve come to thinking I was going to cut someone’s throat.

Looking forward to some war stories.

What was the sequence of events leading up to this?

 

[coffeebythelake]

First time for me in about 10 years.

Young dude with angioedema - pharynx looked like a bowl of jello. Luckily was able to oxygenate/ventilate with an igel and ended up intubating through said igel with a FOB later (we’re talking hours) down the track.

Horrible scary feeling though, closest I’ve come to thinking I was going to cut someone’s throat.

Looking forward to some war stories.

U induced and paralyzed a patient with angioedema? Without ENT at the bedside with a knife? And why the interval between SGA placement and actually securing the airway?

 

[CD125]

Had one in my last month with residency with a new attending. Patient in IR which is kind of on an island. Honestly forget the case but it was something that needed to be tubed. Skinny dude with known H&N cancer but was tubed with VL about a week prior without issue for a different surgery. Induced with paralytic, couldn’t bag so we went to take a look with VL and could see absolutely nothing. Placed LMA and couldn’t ventilate. My attending doesn’t know where anything is down in IR. I grab like 1600mg of sugammadex and the central line kit for a possible crich. Luckily patient is back breathing after the metric ton of sugammadex after only a short desat (desatted hard to like the 20-30s though). I guess the tumor had grown that rapidly in the span of one week. This is probably one of the only few situations when I might have tried to prove ventilation before paralyzing and actually went through with not paralyzing.

 

[Arch Guillotti]

U induced and paralyzed a patient with angioedema? Without ENT at the bedside with a knife? And why the interval between SGA placement and actually securing the airway?

I think I have done every one of them awake.

 

[Arch Guillotti]

Had a posterior tongue cancer for peg. First DL looked like yellow food, mass. Got him deeper looked again and already blood everywhere. Luckily no paralytic, bagged a bit and canceled. Next time awake foi.

Why not just do it awake afterwards?

 

[Arch Guillotti]

I faced a similar problem after ICU freaked about an ETT + igel in situ and wanted me to exchange to a “normal ETT” 😂 - a mere minutes after I was congratulating myself for avoiding a catastrophe.

It’s funny though - I’d never really thought about how to get the igel/lma “out” after a difficult airway scenario before and actually required a bit of thinking. Didn’t have a disposable FOB but if I did I reckon that (cutting it) would be a good way to go.

Aintree over scope, 6.0 MLT over scope, use another ETT as a “pusher”. Never really understood cutting the scope. I don’t want to thread a tube over something without structural rigidity.

 

[GassYous]

Ludwig angina
Awake fiberoptic, through the cords and see the carina 1 shot no problem
prop and roc, hook up the ventilator, no end tidal
DL, can't see anything. VL can't see anything and now there is blood and pus everywhere. No end tidal. Bag the patient. TVs 50s-100s. Try LMA, still 50s-100s. Call for ENT in the room with trach kit. Trach goes in as soon as the patient starts to desat.

Change pants and undies

 

[pgg]

Last year -

https://forums.studentdoctor.net/threads/angioedema-case.1469423/

In case you don't have access to that forum, here's the abbreviated version:

Called to help out with an angioedema intubation in the ICU. I advised that it be done awake, with topicalization. They did it their way, the patient was oversedated, and by the time they asked me to give it a try, I couldn't get the airway with either a fiberoptic scope or video laryngoscope. I was able to mask ventilate, a bit, with difficulty, but at that point we decided to cut. A surgeon was present and ready, and got a surgical airway within about two minutes. Patient did fine.

 

[Simba1711]

That sucks you got pulled into this. I reread your post and glad the surgeon was at bedside with surgical airway ready to go in case things went south.

 

[zizzer]

Ludwig angina
Awake fiberoptic, through the cords and see the carina 1 shot no problem
prop and roc, hook up the ventilator, no end tidal
DL, can't see anything. VL can't see anything and now there is blood and pus everywhere. No end tidal. Bag the patient. TVs 50s-100s. Try LMA, still 50s-100s. Call for ENT in the room with trach kit. Trach goes in as soon as the patient starts to desat.

Change pants and undies

Did it just come out in between intubating and administering propofol and rocuronium? Maybe with patient bucking or removing the scope? That sucks, but sounds well managed afterwards. Was ENT available beforehand? Usually our OMFS guys take these cases.

 

[GassYous]

I think it must have come out when I was pulling out the scope even though I was holding the tube as I did it. ENT guy was just chillin in the lounge, he came right up when we called. I was also giving nasal cannula all the way up during the whole thing

Now I will look for repeated end tidal before paralysis and have ent in the room while I'm tubing.

 

[narcotics999]

I think it must have come out when I was pulling out the scope even though I was holding the tube as I did it. ENT guy was just chillin in the lounge, he came right up when we called. I was also giving nasal cannula all the way up during the whole thing

Now I will look for repeated end tidal before paralysis and have ent in the room while I'm tubing.

Yes, I always hook up with the vent for etco2 before prop/roc.

 

[Simba1711]

Yeah I had an attending give paralysis once he got a view of the cords with fiberoptic. Lost the view because the airway collapsed. Ended up just intubating with dl. Luckily he was just using fiberoptic for educational purposes. Otherwise it would have been a total ****show.

 

[Arch Guillotti]

Always check for end tidal. No exceptions.

 

[repititionition]

Aintree over scope, 6.0 MLT over scope, use another ETT as a “pusher”. Never really understood cutting the scope. I don’t want to thread a tube over something without structural rigidity.

can also use plunger end of 3cc syringe as a pusher

 

[GassYous]

Yes, I always hook up with the vent for etco2 before prop/roc.

I think I saw end tidal after bagging but then when I switched to the vent didn't see anything.
I dunno, I try to block out the memory it was a dark time

 

[coffeebythelake]

Yeah I had an attending give paralysis once he got a view of the cords with fiberoptic. Lost the view because the airway collapsed. Ended up just intubating with dl. Luckily he was just using fiberoptic for educational purposes. Otherwise it would have been a total ****show.

Awake fiberoptic. Got a view. Intubated. Confirmed ETCO2. Gave propofol and paralytic but then patient proceeds to retch and coughed the ETT out. That was fun times.

 

[DrOwnage]

Awake fiberoptic. Got a view. Intubated. Confirmed ETCO2. Gave propofol and paralytic but then patient proceeds to retch and coughed the ETT out. That was fun times.

Every time I've done an awake fiber I get 2 people on either side to hold their arms down especially once I'm driving the tube. Coughing it out is unfortunate lol

 

[narcusprince]

I think I have done every one of them awake.

Same…. Never asleep….

 

[Simba1711]

I had to do one asleep. I don’t recommend it and probably a slam dunk malpractice suit if things went south. I had the patient in the or and neck prepped by the general surgeons who are on standby. Tried to do awake but patient started refusing despite me explaining risks beforehand. Decision made to do it asleep. Idiot partner that nurse asked to assist me tried to push medications without giving me chance to preoxygenate. Some anesthesiologists are so ******ed. Preoxygenated and easy view with glide. I got lucky these airways can be terrible. In hindsight probably should have people holding his arms down.

I never saw an angioedema in residency. I’ve already seen 3 less than 5 years as an attending

 

[Angus Avagadro]

Had a patient with tight LMain for Cabg. Unremarkable airway exam. This was long ago when intubating with Pancuronium was de rigueur. A
Cardiac Fellow looked once DL, could not see anything. Senior CRNA looked and saw nothing. I called for airway cart when CRNA announces " I can't get any air in". No airway maneuvers can relieve obstruction. Sats in the basement. Pi$$ed off surgeon does trach and case canceled. Cardiologists are baffled as to why we didn't kill this man. So they cathed him AGAIN! Turns out that tight LMain was just the tip of that pesky 'ole angio catheter and NOT a LMain plaque. The patient tolerated the events well. I spoke with him later and he was ecstatic that he didn't need surgery and was very happy to go home with my difficult airway letter for future surgeries. Go figure.

 

[coffeebythelake]

Had a patient with tight LMain for Cabg. Unremarkable airway exam. This was long ago when intubating with Pancuronium was de rigueur. A
Cardiac Fellow looked once DL, could not see anything. Senior CRNA looked and saw nothing. I called for airway cart when CRNA announces " I can't get any air in". No airway maneuvers can relieve obstruction. Sats in the basement. Pi$$ed off surgeon does trach and case canceled. Cardiologists are baffled as to why we didn't kill this man. So they cathed him AGAIN! Turns out that tight LMain was just the tip of that pesky 'ole angio catheter and NOT a LMain plaque. The patient tolerated the events well. I spoke with him later and he was ecstatic that he didn't need surgery and was very happy to go home with my difficult airway letter for future surgeries. Go figure.

wow. what a weird set of circumstances. glad everything ultimately worked out well for the patient!!

 

[TxGasserMD]

I’ve had two about 2 years ago…one patient had a goiter with significant tracheal deviation and peri-glottic edema. We tried an awake FOI and were unsuccessful. Luckily transferred to a tertiary center and hour away and they did awake trach + total thyroidectomy. The other was more unplanned ….a bipolar hip on a weekend, patient h/o tracheostomy 20 years prior. We were unable to pass any tube to a 5.5. I was able to a quick bronch which showed subglottic stenosis. We abandoned the procedure then.

 

[ERRES2288]

Back in residency 6 months into CA-1 year. Middle of night, I’m covering OB. CA-3 is “supervising” OB and OR cases.

Known “impossible to intubate” patient with severe difficulty with awake fiberoptics in past prior to pregnancy. Congenital stuff, TMJ, tiny mouth opening. Patient laboring with epidural, good level.

You know the rest. Crash section called. Chlorprocaine, splash, drapes, patient feeling the test clamps. CA-3 announces we are going to sleep. Pushes prop, succ. Im calling attending. Looks with VL, nothing. Techs roll in with fiberoptic cause I called them in case. He can’t see anything with fiberoptic. OB asking to cut, he’s telling them no. Multiple attempts. Patient desating bad, can’t ventilate. Attending walks in, tells them to cut. Gets smalls LMA in can move enough air to keep sats up. Tells OB to make this the fastest section you’ve ever done. Do entire case with LMA. Patient woke up completely numb. Probably needed another 1 minute.

Think of this case often and how dangerous hubris can be.

 

[jwk]

Had a patient with tight LMain for Cabg. Unremarkable airway exam. This was long ago when intubating with Pancuronium was de rigueur. A
Cardiac Fellow looked once DL, could not see anything. Senior CRNA looked and saw nothing. I called for airway cart when CRNA announces " I can't get any air in". No airway maneuvers can relieve obstruction. Sats in the basement. Pi$$ed off surgeon does trach and case canceled. Cardiologists are baffled as to why we didn't kill this man. So they cathed him AGAIN! Turns out that tight LMain was just the tip of that pesky 'ole angio catheter and NOT a LMain plaque. The patient tolerated the events well. I spoke with him later and he was ecstatic that he didn't need surgery and was very happy to go home with my difficult airway letter for future surgeries. Go figure.

Wait, you're older than me??? We were pretty much always DTC/Sux. I can't ever remember intubating just on panc, although I do remember trying high dose DTC, maybe 30mg - once Talk about some histamine release! Just like red-man syndrome but no vanco.

 

[Arch Guillotti]

I’ve had two about 2 years ago…one patient had a goiter with significant tracheal deviation and peri-glottic edema. We tried an awake FOI and were unsuccessful. Luckily transferred to a tertiary center and hour away and they did awake trach + total thyroidectomy.

Should have done ECMO.

 

[coffeebythelake]

Back in residency 6 months into CA-1 year. Middle of night, I’m covering OB. CA-3 is “supervising” OB and OR cases.

Known “impossible to intubate” patient with severe difficulty with awake fiberoptics in past prior to pregnancy. Congenital stuff, TMJ, tiny mouth opening. Patient laboring with epidural, good level.

You know the rest. Crash section called. Chlorprocaine, splash, drapes, patient feeling the test clamps. CA-3 announces we are going to sleep. Pushes prop, succ. Im calling attending. Looks with VL, nothing. Techs roll in with fiberoptic cause I called them in case. He can’t see anything with fiberoptic. OB asking to cut, he’s telling them no. Multiple attempts. Patient desating bad, can’t ventilate. Attending walks in, tells them to cut. Gets smalls LMA in can move enough air to keep sats up. Tells OB to make this the fastest section you’ve ever done. Do entire case with LMA. Patient woke up completely numb. Probably needed another 1 minute.

Think of this case often and how dangerous hubris can be.

I hope that resident got a lot of feedback on case debrief. Absolutely could have been deadly.

 

[narcusprince]

I will say this having been in private practice. The mcgrath is superior to the glidescope. I have seen minimal failures with the mcgrath. In the military their were at least 1-2 failures a year with the glidescope.

 

[Arch Guillotti]

I will say this having been in private practice. The mcgrath is superior to the glidescope. I have seen minimal failures with the mcgrath. In the military their were at least 1-2 failures a year with the glidescope.

Disagree 100%, glidescope optics are superior.

 

[Angus Avagadro]

Wait, you're older than me??? We were pretty much always DTC/Sux. I can't ever remember intubating just on panc, although I do remember trying high dose DTC, maybe 30mg - once Talk about some histamine release! Just like red-man syndrome but no vanco.

Yep. I'm older than you. Pretty sure.

 

[medicine2wallstreet]

Disagree 100%, glidescope optics are superior.

Dinosaur.

 

[GassYous]

Glide is terrible. The blade is huge and unwieldy. You need a tower. Mcgrath is the perfect blade

 

[Volatile]

Haven’t had one yet but I definitely have had patients that weren’t easy. Over the years I’ve found obese patients don’t worry me anymore, but any kind of airway/neck mass, radiation, and occasionally little old ladies w/ recessed chins can make things tough. Stay humble out there

 

[DocMcCoy]

Glide is terrible. The blade is huge and unwieldy. You need a tower. Mcgrath is the perfect blade

Glidescope Lo pro blades 💯. The old school bricks suck

 

[repititionition]

Glidescope Lo pro blades 💯. The old school bricks suck

this exactly. It’s a blade issue, not a tech issue. Glide lo pro and McGrath are roughly same angulation.

The only times I’ve ever truly needed a hyperangulated VL blade are the near-impossible FOIs which getter better with VL assist... the hyperangulated blade tends to provide better tissue displacement to open an aperture to the cords. Otherwise it’s often more a hinderance than help.

 

[coffeebythelake]

+1 for glide.

 

[Maverikk]

+1 for awake always with angioedema, when I receive the ER call I know to get enough info (ie do I need to come running) to tell them to stop hook then up to CPAP and 100% and stop giving drugs till I get there

A bad one I’ve had is mitochondrial disorder person, didn’t look bad, I was a resident, very good attending said have the fiber optic primed and ready. Induced with remi, ketamine, spontaneous the whole time. Nothing on glidescope, had to do a lot of maneuvering with the fiber to get it in, puffy weird tissue. Preparation and low threshold is key to avoiding disaster.
Absolute worst: very bad cirrhotic, drunk fall with femur fracture, ED attempts to intubate bc patient is going wild, apparently started bleeding during attempt, probably ruptured varices, blood like a faucet and ED is sticking the glidescope in and out. I ask to call trauma surgeon overhead and get trach kit. Then do what another good attending taught (his phrase ‘always do something in a bad situation even if you’ve got nothing’), suction catheter jammed down, DL, see nothing but blood, pass it blindly feeling on the neck, got it in. Patient did not do ok. That same attending liked us to try to intubate by feel, would have us take a look in healthy patients after pre-oxygenating, then have me go super slow, get a feel if you’re in the arytenoids, check your depth, feel if your on tracheal cartilage, always thought it was odd until I had that happen.

 

[Beeftenderloin]

The glidescope lopro titanium was BAE. I haven’t seen one since pre-covid though. Now it’s just the big clunky re-usable plastic sleeves. They get the job done, but take up a lot of space in the mouth.

 

[PpfSuxTube]

Disagree 100%, glidescope optics are superior.

Agreed. The new version glidescope that can do simultaneous bronch and VL with the titanium blade in a split screen is so good it's actually cheating.

I believe it's called the glidescope 'core'. It has replaced the difficult airway cart for me... I do more cardiac than anything else and we don't get the horrendous airways you do but I've intubated 6mm airways recently with large glottic tumors no big deal...

McGrath is a nice tool and I used to believe it better but I'm 💯 converted now

 

[Arch Guillotti]

Agreed. The new version glidescope that can do simultaneous bronch and VL with the titanium blade in a split screen is so good it's actually cheating.

I believe it's called the glidescope 'core'. It has replaced the difficult airway cart for me... I do more cardiac than anything else and we don't get the horrendous airways you do but I've intubated 6mm airways recently with large glottic tumors no big deal...

McGrath is a nice tool and I used to believe it better but I'm 💯 converted now

yes, I was referring to the large screen scope that can split the screen with the fiberoptic.

 

[Maz777]

Tracheostomy revision. ENT wanted us to intubate from above

Had a patient with tight LMain for Cabg. Unremarkable airway exam. This was long ago when intubating with Pancuronium was de rigueur. A
Cardiac Fellow looked once DL, could not see anything. Senior CRNA looked and saw nothing. I called for airway cart when CRNA announces " I can't get any air in". No airway maneuvers can relieve obstruction. Sats in the basement. Pi$$ed off surgeon does trach and case canceled. Cardiologists are baffled as to why we didn't kill this man. So they cathed him AGAIN! Turns out that tight LMain was just the tip of that pesky 'ole angio catheter and NOT a LMain plaque. The patient tolerated the events well. I spoke with him later and he was ecstatic that he didn't need surgery and was very happy to go home with my difficult airway letter for future surgeries. Go figure.

Dude. Why would anyone allow a CRNA to intubate after a fellow couldn’t get a view?!

 

[Maz777]

The glidescope lopro titanium was BAE. I haven’t seen one since pre-covid though. Now it’s just the big clunky re-usable plastic sleeves. They get the job done, but take up a lot of space in the mouth.

If someone brings me one of those garbage plastic Glidescope disposable blades, I have them wheel that trash out of the door. I’ll just DL. They are useless. Titanium blades are useful.

 

[Angus Avagadro]

Tracheostomy revision. ENT wanted us to intubate from above

Dude. Why would anyone allow a CRNA to intubate after a fellow couldn’t get a view?!

The dude had 20 + yrs experience and I had worked with him for several years. He was quite capable. I saw no need for continued airway manipulation if he could not visualize the larynx. I don't consider a trainee with a couple yrs of experience to be more skillful at laryngoscopy than he was. No disrespect intended.

 

[Gator7]

I really appreciate this thread. Nice knowing I’m not the only one getting hit with this BS.

Called in at 3AM for some ENT mess take back. Apparently radical neck with tongue base work as well. When I get there patient is being wheeled into OR directly. Patient is huge, neck is massive and purple from hematoma. Tongue is swollen, patient cannot open his mouth and is gasping for air. ENT is yelling “just rapid sequence there’s no time for FOI.” After I politely tell them that I will not intentionally murder the patient I tell them to get ready to trach while I take one shot at nasal fiber optic. Absolutely nothing but ground beef to be seen and patient stops breathing and is not responding. I jam a LMA in some how and tell them they have to cut or he’s going to die. They finally do and somehow this guy lived. Years taken off my life for this one.

 

[Maz777]

The dude had 20 + yrs experience and I had worked with him for several years. He was quite capable. I saw no need for continued airway manipulation if he could not visualize the larynx. I don't consider a trainee with a couple yrs of experience to be more skillful at laryngoscopy than he was. No disrespect intended.

I would never allow a CRNA to attempt an intubation if a board eligible or certified anesthesiologist could not (and another one is in the room i.e. myself). Dude, that is so embarrassing. I would take over. I have rescued airways from countless "experienced" CRNAs. That 2nd attempt should be done by the best person in the room otherwise the anatomy is going to get even more jacked up. I would never occur to me to have some "experienced" CRNA rescue my own airway. I might as well stop practicing at that point.