Oral airways as bite blocks in OR

[europeman]

Do you guys/gals routinely place oral airways as bite blocks on all your tubed GA patients? They do where I'm at and I find it odd. Story goes someone bit down on tube and got negative pressure Pulm edema years ago so that's how the thing got started. Problem is they come to the ICU like that and no one removes them until I come in the next day yelling!(obviously a systems problem - but that's not the point of this post).

Thanks!

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[chocomorsel]

Nope.
Only when they are doing motors testing or when their head is cranked to the side quite a bit in a crani. I use a soft bite block most times though because the monitor techs are worried about breaking teeth on an OA. I find that hard to believe though unless their teeth were already crap to begin with. They all come out at end of case or in PACU for the OA though.

 

[pgg]

I dislike that practice. I think it's a bad idea to put a hard piece of plastic between someone's incisors as a bite block. I roll up some gauze with tape and try to stuff it between their molars.

 

[BLADEMDA]

I dislike that practice. I think it's a bad idea to put a hard piece of plastic between someone's incisors as a bite block. I roll up some gauze with tape and try to stuff it between their molars.

We agree. Tongue depressor with 4x4 gauze wrapped around it or just the gauze. This way if the patient bites down hard the gauze will protect the teeth much better than the oral airway.

 

[BLADEMDA]

 

[Arch Guillotti]

Story goes someone bit down on tube and got negative pressure Pulm edema years ago so that's how the thing got started.

I don't follow the rationale.

 

[BLADEMDA]

Negative pressure pulmonary edema: Physiology



Definition
Negative pressure pulmonary edema (NPPE) is an uncommon complication of anesthesia usually resulting from laryngospasm during extubation (approximately 0.1%). The most common risk factors are young age, male sex, and head or neck surgery. NPPE is an example of a noncardiogenic pulmonary edema. In other words, pulmonary edema develops despite the fact that the heart and lungs are working within expected norms.

The closed upper airway is the initiating event for the pathophysiology that develops. Because of the obstruction (e.g., laryngospasm), a very large, negative, intrathoracic pressure is generated by the patient’s increased effort to breath. The large, negative pressures can be upwards of -100 cmH2O. The negative pressure causes an increase in left ventricular preload and afterload. Furthermore, this pressure causes a decrease in extramural hydrostatic pressure. The hypoxia changes pulmonary vascular resistance (hypoxic pulmonary venous constriction, as opposed to elsewhere in the body). The result is right ventricle dilation, intraventricular septum shift to the left, and left ventricular diastolic dysfunction (right ventricle is in the way). All of these conditions result in increased left heart loading conditions, and thereby enhance microvascular intramural hydrostatic pressure (increased pressure). A situation has now formed (the increase in transmural pressure) where fluid can easily move from greater to lesser, and therefore out of the capillaries and into the lung interstitium. Pulmonary edema then develops.

https://www.openanesthesia.org/negative_pressure_pulmonary_edema_physiology/

 

[BLADEMDA]

Bite block has nothing to do with Negative pressure pulmonary edema. The glottis must be closed shut while the patient tries to take an inspiratory breath.
Typically, it only takes 1-2 inspiratory attempts in a young, vigorous patient to develop negative pressure pulmonary edema. I've seen it about 15-20 times in my career.

 

[Arch Guillotti]

Please post a source if you are going to do a drive by copy and paste job.

 

[Arch Guillotti]

Bite block has nothing to do with Negative pressure pulmonary edema.

Exactly.

 

[Skip2myLou]

we had a spine case in our group , usual prone position , gauze placed in mouth . initial anesthesiologist was relieved after a few hours . At end of case pt placed supine , extubated. in pacu few hours later pt developed resp failure , upon intubation wrapped up gauze was found in pharynx. nGauze removed pt recovered uneventful .

2 things happened, poor hand off and extubation anesthesiologist found a tongue depressor with no gauze around it and didn't think twice.

So now we don't use gauze for that , we use some special oral piece that sticks out and won't go in pharynx .Also strict documentation of placement and removal of bite block.

 

[BLADEMDA]

we had a spine case in our group , usual prone position , gauze placed in mouth . initial anesthesiologist was relieved after a few hours . At end of case pt placed supine , extubated. in pacu few hours later pt developed resp failure , upon intubation wrapped up gauze was found in pharynx. nGauze removed pt recovered uneventful .

2 things happened, poor hand off and extubation anesthesiologist found a tongue depressor with no gauze around it and didn't think twice.

So now we don't use gauze for that , we use some special oral piece that sticks out and won't go in pharynx .Also strict documentation of placement and removal of bite block.

Well, if you are going to use gauze in the mouth then it is necessary to remove it at the end of the case. Despite your bad experience with it I've continued to use gauze in the mouth fairly routinely but always and I mean always reminding the crna to pull all of it out prior to arriving in the pacu. This is similar to my instructing crnas to use extra tape around the ETT when doing a prone case as I've had TWO ETT tubes come out during a spine case. Never again. I lecture them repeatedly about the extra tape and removing the gauze each and every time. I really don't care what they think about these "basic points" of care because it's my arse on the line when that Tube falls out or the gauze remains in the pharynx.

Remember, you aren't their friend but their boss so take charge and hold them accountable to your standards.

 

[Arch Guillotti]

This is similar to my instructing crnas to use extra tape around the ETT when doing a prone case as I've had TWO ETT tubes come out during a spine case.

So what did you do each time?

 

[BLADEMDA]

So what did you do each time?

Crawled under the OR table and placed an LMA. LMA was held in place while surgeon draped over the incision and patient was turned supine. Fortunately, this strategy worked to maintain the saturation during the "event" which should never have occurred in the first place.

 

[BLADEMDA]

Do you tape the eyes closed? Well, I've had 4 patients (all very elderly) where the crnas literally ripped the skin off the patients' eyelids. I've now added that "please be extra careful when removing the paper tape from little old Mabel" line to my routine along with extra tape for the ETT and gauze removal.

 

[WholeLottaGame7]

Bite block has nothing to do with Negative pressure pulmonary edema. The glottis must be closed shut while the patient tries to take an inspiratory breath.
Typically, it only takes 1-2 inspiratory attempts in a young, vigorous patient to develop negative pressure pulmonary edema. I've seen it about 15-20 times in my career.

I took it to mean the patient developed pulmonary edema after biting down on a tube without a bite block, so they started placing OPAs so that the patient couldn't occlude the tube if they bit down.

 

[BLADEMDA]

I took it to mean the patient developed pulmonary edema after biting down on a tube without a bite block, so they started placing OPAs so that the patient couldn't occlude the tube if they bit down.

http://www.ncbi.nlm.nih.gov/pubmed/10402898

Typically, a patient only partially obstructs the ETT when biting down on it. That said, case reports clearly show biting down as a cause and I have had 1-2 cases myself. The soft gauze will eliminate ETT obstruction as a cause of negative pressure pulmonary edema.

 

[Arch Guillotti]

I took it to mean the patient developed pulmonary edema after biting down on a tube without a bite block, so they started placing OPAs so that the patient couldn't occlude the tube if they bit down.

Makes sense.

 

[Planktonmd]

The oral airway is necessary on emergence especially if the patient is young and strong because if you extubate and they decide to clamp their jaws and try to breath at the same time against obstructed airway they will develop negative pressure pulmonary edema very quickly.
The gauze thing can prevent biting the tube but after extubation it will make mask ventilation more difficult if needed, especially in patients with redundant soft tissue and OSA.
If the case is going to be done by a CRNA I have a very low threshold to tell them to keep the oral airway in throughout the case, because you never know when the patient might get light during the case, and because you can't count on them remembering to insert an oral airway before extubation.

 

[pgg]

The oral airway is necessary on emergence especially if the patient is young and strong

I don't agree with that at all.

A bite block of some variety is important if you're going to extubate awake, because of the NPPE risk. See upthread for my dim view of oropharyngeal airways as bite blocks.

If I think a patient might obstruct after extubation, I use nasopharyngeal airways. I don't think OPAs have a good role peri-extubation.

 

[IlDestriero]

Well, if you are going to use gauze in the mouth then it is necessary to remove it at the end of the case. Despite your bad experience with it I've continued to use gauze in the mouth fairly routinely but always and I mean always reminding the crna to pull all of it out prior to arriving in the pacu. This is similar to my instructing crnas to use extra tape around the ETT when doing a prone case as I've had TWO ETT tubes come out during a spine case. Never again. I lecture them repeatedly about the extra tape and removing the gauze each and every time. I really don't care what they think about these "basic points" of care because it's my arse on the line when that Tube falls out or the gauze remains in the pharynx.

Remember, you aren't their friend but their boss so take charge and hold them accountable to your standards.

After supervising for around a decade now, I've come to the conclusion that even with experienced CRNAs and fairly benign cases, you really do have to watch what's going on fairly closely as I've seen them (completely) ignore things that I found ominous. Situations that, when discovered, I acted on quickly.
It's just a matter of time, and to be honest it scares me quite a bit, and I often long for the days doing all my own cases where I know I can provide the outstanding care the patient deserves. When I'm tied up with a complex start up in one room, my mind often wanders to what is going on in the other room. We have the technology to remote view the record and/or monitors, in all the ORs and I use it to peek in from time to time, but maybe I should make that a routine part of my practice.

 

[Skip2myLou]

Well, if you are going to use gauze in the mouth then it is necessary to remove it at the end of the case. Despite your bad experience with it I've continued to use gauze in the mouth fairly routinely but always and I mean always reminding the crna to pull all of it out prior to arriving in the pacu. This is similar to my instructing crnas to use extra tape around the ETT when doing a prone case as I've had TWO ETT tubes come out during a spine case. Never again. I lecture them repeatedly about the extra tape and removing the gauze each and every time. I really don't care what they think about these "basic points" of care because it's my arse on the line when that Tube falls out or the gauze remains in the pharynx.

Remember, you aren't their friend but their boss so take charge and hold them accountable to your standards.

well it seems obvious to remove the gauze but clearly it was a mistake. The gauze was not in the mouth but rather in the hypo pharynx. So the gauze was never noticed on extubation .

 

[pgg]

If the case is going to be done by a CRNA I have a very low threshold to tell them to keep the oral airway in throughout the case,

There's another reason I don't like this. Putting a hard piece of plastic in someone's mouth for an extended period of time when they're unconscious creates a risk of pressure ischemia and sores. Nobody likes to wake up with a tongue or palate injury.

 

[BLADEMDA]

well it seems obvious to remove the gauze but clearly it was a mistake. The gauze was not in the mouth but rather in the hypo pharynx. So the gauze was never noticed on extubation .

I fully understand your post; that is where the gauze can end up all too often which is why I nag the CRNA to check the mouth to make certain the gauze is removed before arriving to PACU. More than once the PACU nurse has called to say "the CRNA left gauze in the patient's mouth" which is why I repeat this exact statement often to the same CRNAs over and over again. Even if they don't like the reminder the embarrassment of being called out for failing to follow directions despite my warnings seems to do the trick.

1. If you use gauze then a reliable CRNA or Anesthesiologist must check the mouth post extubation

2. If you are turning prone use EXTRA tape and verify the tube is secure to YOUR satisfaction (not the CRNAs).

3. If you are taping over the eyelids in an elderly patient or a person on steroids a reminder about skin tears from the tape is in order each and every time.

These are simple things but like Larry Bird used to say it's the fundamentals that matter most.

 

[Planktonmd]

There's another reason I don't like this. Putting a hard piece of plastic in someone's mouth for an extended period of time when they're unconscious creates a risk of pressure ischemia and sores. Nobody likes to wake up with a tongue or palate injury.

Do you supervise CRNAs?

 

[narcusprince]

Where I trained they used oral airways like bite blocks as they were soft and IGEL like. In the .mil they are more rigid. Do I still use them as bite blocks when the ET tube is in place and during extubation yes. Best practice for long cases greater then 2.5 hrs I place a bite block. Do you guys place bite blocks with LMA's class and or supreme?

 

[WholeLottaGame7]

http://www.ncbi.nlm.nih.gov/pubmed/10402898

Typically, a patient only partially obstructs the ETT when biting down on it. That said, case reports clearly show biting down as a cause and I have had 1-2 cases myself. The soft gauze will eliminate ETT obstruction as a cause of negative pressure pulmonary edema.

I'm totally a soft bite block person. I've almost been burned once; thankfully the tube was positioned retromolar and I was able to ventilate around the deathchomp.

 

[criticalelement]

i dont use any bite block. Patients I find dont wanna bite they wanna open their mouth (gagging). SOme DO bite in stage two, but nota a large percentage.

 

[pgg]

Do you supervise CRNAs?

Occasionally.

 

[B-Bone]

our hospital has a policy of placing long tails of tape to all soft bite blocks so they stick far out of the mouth. This makes them easier to remove and more difficult to ignore/forget about when extubating. This policy came about after a patient was sent to the ICU intubated due to "no cuff leak", and after two days of "no cuff leak", the ENT who was consulted removed the gauze bite block from the hypopharynx.

 

[Vergie]

I had an incident when I was a fresh CA1 with a young healthy male getting a gsw washout. Attending told me to leave the bite block in at the start of the case. When we were finishing I was removing the esophageal temp probe and I decided to pull the block out too not thinking much of it. Next thing I know the patient is flailing his arms around. He starts clamping his teeth down on the tube and his sats are slowly dropping and eventually start to dip into the 70s. We turned up the pressures, pushed propofol and eventually sux which finally broke it, but I remember the attending telling me he could develop negative pressure pulmonary edema. We soft suctioned the ET tube to look for fluid but it didn't get much and everything ended up ok. Really ****ing scary as a new resident. Moral of the story, every healthy young male gets some form of a bite block with intubation.

 

[GA8314]

They do it at my gig and it borderline drives me nuts. I'm working on it. I favor a soft bite block.

 

[jwk]

Rarely use an OAW - lots of expensive dental work in many of my patients. Soft bite block works fine - don't stick it in so far you can't see it - duh - then it's not a problem "forgetting" that it's there.

Extubate deep - or extubate awake. In between is what gets you in trouble.

 

[caligas]

I have also seen negative pressure Edema from a football player type biting down on the tube at the end of the case. I was a med student observing but I will never forget it.

 

[BuzzPhreed]

Using one of these as a bite block...

... is a move I've only seen done by hack anesthesiologists and CRNAs. It stimulates the retropharynx, increases oral secretions, and they wind up with a gagging sensation and having a more agitated emergence.

Don't believe me? Take your finger -- right now -- and jam it into the back of your throat. Why people use this thing as a bite block is baffling to me.

Gauze. Rolled up. On the molars. Already covered here. That's the correct method. Nothing bumping against the uvula.

If you see this practice, please actively try to stop it and educate the ***** doing it to also stop it.

 

[OB1🤙]

Agree with the common sentiment here. Soft bite block on the molars. Oral airway as a bite block is asking for a dental bill.

 

[LivetoTell]

I also dislike the practice of automatically putting oral airways in at the start of the case. A hard piece of plastic that may or may not fit well in the hypopharnynx, for hours, seems like bad practice. I don't care for wads of gauze in my airway either. If I have someone bite down on my tube which is rare since I extubate deep most of the time, I let down the cuff, and that allows them to breathe around the tube. Luckily, I don't have many big football types, and would try to extubate deep if possible.

 

[dhb]

I'd rather give 20mg of sux once in a lifetime than a bite block on every patient

 

[dA pilot]

i dont use any bite block. Patients I find dont wanna bite they wanna open their mouth (gagging). SOme DO bite in stage two, but nota a large percentage.

Either you haven't done enough cases or you have a different patient population, but it doesn't take a large percentage to have one case of a patient biting down and resulting in NPPE. An ounce of prevention, with a simple soft bite block may have prevented the young healthy patient from a complication.

I typically use a soft bite block, but if I anticipate the need to assist in ventilation upon extubation, I will use an OPA. I wouldn't leave the hard airway in place during the case but place it when I am ready to emerge the patient.

 

[criticalelement]

Either you haven't done enough cases or you have a different patient population, but it doesn't take a large percentage to have one case of a patient biting down and resulting in NPPE. An ounce of prevention, with a simple soft bite block may have prevented the young healthy patient from a complication.

I typically use a soft bite block, but if I anticipate the need to assist in ventilation upon extubation, I will use an OPA. I wouldn't leave the hard airway in place during the case but place it when I am ready to emerge the patient.

i do plenty of cases. I dont see too much of biting down on the tube. Especially to the point of giving sux. Occasionally but not that often. The rule is that of gagging on wake up. Not biting down.. BUt its not bad practice to place a soft bite block. Provided it doesnt drop into the airway.

 

[Twiggidy]

Do you guys/gals routinely place oral airways as bite blocks on all your tubed GA patients? They do where I'm at and I find it odd. Story goes someone bit down on tube and got negative pressure Pulm edema years ago so that's how the thing got started. Problem is they come to the ICU like that and no one removes them until I come in the next day yelling!(obviously a systems problem - but that's not the point of this post).

Thanks!

I do. Also my ICU/PACU knows when to take them out.

Sure I've heard stories of erroded tongues and I think a patient even bit so hard he may have broke his cap, but I still do it anyway. That's just me.

 

[Depakote]

There's another reason I don't like this. Putting a hard piece of plastic in someone's mouth for an extended period of time when they're unconscious creates a risk of pressure ischemia and sores. Nobody likes to wake up with a tongue or palate injury.

This is my logic. I really don't want a bite block in place for the entire case.

I'd rather use a soft bite block between the molars (as pictured in previous posts) than something that could cause pressure or dislodge teeth if the patient bites down too hard.

I really only use hard oral airways to improve air exchange during mask ventilation.

 

[pgg]

I really only use hard oral airways to improve air exchange during mask ventilation.

I agree with this.

I don't think there's much of a place for oral airways around extubation. I'd even go so far as to say that if you think you routinely need oral airways peri-extubation, maybe you should reconsider how you're waking up patients in the first place, maybe step back and think about some of your other life choices too. Most of the patients I see who roll into PACU with an oral airway in place belong to our nursely colleagues, make of that what you will.

I use oral airways occasionally after induction, prior to intubation. Mostly in chubby kids who obstruct during inhalational inductions.

I truly cannot even remember the last time I put an oral airway into a patient on the emerging side of anesthesia. If I think someone will obstruct after extubation, they get nasal airways.

I'll stop short of calling routine oral airway use around extubation wrong, but I don't think it's right.

 

[Twiggidy]

Be careful of bloody noses with those nasals. I'm not saying "you're crazy" which seems to have turned into the overall theme of this thread, but just lube the crap out of that thing. I hate bloody noses so I use this as a very last resort in an obstructing patient.

I'd like to add, in my limited experience versus the old guys on here, that I'd also argue if you're waking someone up and they're biting hard, then you're not waking them up comfortable. People are acting like emergence with an oral airway is borderline malpractice, which is ridiculous. There's nothing wrong and no one is "a *****" or "need to evaluate career choices" for emerging a patient with an oral airway to help with airway patency, especially if you're waking people up deep.

 

[Planktonmd]

I agree with this.

I don't think there's much of a place for oral airways around extubation. I'd even go so far as to say that if you think you routinely need oral airways peri-extubation, maybe you should reconsider how you're waking up patients in the first place, maybe step back and think about some of your other life choices too. Most of the patients I see who roll into PACU with an oral airway in place belong to our nursely colleagues, make of that what you will.

I use oral airways occasionally after induction, prior to intubation. Mostly in chubby kids who obstruct during inhalational inductions.

I truly cannot even remember the last time I put an oral airway into a patient on the emerging side of anesthesia. If I think someone will obstruct after extubation, they get nasal airways.

I'll stop short of calling routine oral airway use around extubation wrong, but I don't think it's right.

Actually these strong statements are pretty irritating to say the least!
People obstruct after extubation all the time when the extubation is done by someone who doesn't know what the F they are doing and if you are supervising such individual you need something that will prevent that disaster.
Your nasal airway will not splint the soft tissue in the oro-pharynx open in a patient who was extubated at the wrong time.

 

[Planktonmd]

Be careful of bloody noses with those nasals. I'm not saying "you're crazy" which seems to have turned into the overall theme of this thread, but just lube the crap out of that thing. I hate bloody noses so I use this as a very last resort in an obstructing patient.

I'd like to add, in my limited experience versus the old guys on here, that I'd also argue if you're waking someone up and they're biting hard, then you're not waking them up comfortable. People are acting like emergence with an oral airway is borderline malpractice, which is ridiculous. There's nothing wrong and no one is "a *****" or "need to evaluate career choices" for emerging a patient with an oral airway to help with airway patency, especially if you're waking people up deep.

I have been using oral airways almost on every case for many many years and I never had one complication attributed the use of the airway!
There are people here who are still green and already think their way is the only way... very amusing actually!

 

[BLADEMDA]

i do plenty of cases. I dont see too much of biting down on the tube. Especially to the point of giving sux. Occasionally but not that often. The rule is that of gagging on wake up. Not biting down.. BUt its not bad practice to place a soft bite block. Provided it doesnt drop into the airway.

It depends of how you do the anesthetic. If you titrate in the narcotic at the end (spont. Breathing) the chance of biting down is far less; also, these days our fast inhalational agents makes biting down less likely than in the past. Finally, if the patient does bite down a little propofol (0.5 mg/kg) goes a long way in smoothing the transition through stage 2. (Precedex works nicely as well- low dose).

 

[BLADEMDA]

Be careful of bloody noses with those nasals. I'm not saying "you're crazy" which seems to have turned into the overall theme of this thread, but just lube the crap out of that thing. I hate bloody noses so I use this as a very last resort in an obstructing patient.

I'd like to add, in my limited experience versus the old guys on here, that I'd also argue if you're waking someone up and they're biting hard, then you're not waking them up comfortable. People are acting like emergence with an oral airway is borderline malpractice, which is ridiculous. There's nothing wrong and no one is "a *****" or "need to evaluate career choices" for emerging a patient with an oral airway to help with airway patency, especially if you're waking people up deep.

Nice post. And nothing is stopping from you from doing both for a patient to avoid dental damage (gauze) while providing airway patency with the OPA. These days I rarely use either the gauze or the OPA but I prefer the CRNAs do so for younger patients (late teens to mid 20s).

 

[BLADEMDA]

I agree with this.

I don't think there's much of a place for oral airways around extubation. I'd even go so far as to say that if you think you routinely need oral airways peri-extubation, maybe you should reconsider how you're waking up patients in the first place, maybe step back and think about some of your other life choices too. Most of the patients I see who roll into PACU with an oral airway in place belong to our nursely colleagues, make of that what you will.

I use oral airways occasionally after induction, prior to intubation. Mostly in chubby kids who obstruct during inhalational inductions.

I truly cannot even remember the last time I put an oral airway into a patient on the emerging side of anesthesia. If I think someone will obstruct after extubation, they get nasal airways.

I'll stop short of calling routine oral airway use around extubation wrong, but I don't think it's right.

PGG, I've got to disagree with you about the nasal airway. More than a few times I've seen some pretty bloody noses/airways as a result of a crna trying to insert a nasal airway at the end of the case. If I had to choose between an OPA and a nasal airway I'd go with the latter most of the time. Fortunately, most patients don't need either of those devices. I'm sure in your hands the nasal airway is the go to device but not so much in my practice.

 

[pgg]

Actually these strong statements are pretty irritating to say the least!

You mean like

The oral airway is necessary on emergence

People obstruct after extubation all the time when the extubation is done by someone who doesn't know what the F they are doing and if you are supervising such individual you need something that will prevent that disaster.

Sure, can't argue with that. You have to work with the limitations of the people around you.

Your nasal airway will not splint the soft tissue in the oro-pharynx open in a patient who was extubated at the wrong time.

All the tools in the world can't turn a sloppy anesthetic into something elegant.

In my experience the great majority of patients - even the obese OSA'ers - don't need an airway device at all if they're extubated at the right time after a well-designed anesthetic.

For that subset of patients who I think will need an airway adjunct after extubation, ie when they're awake, I prefer nasal trumpets. A little Afrin, some lube +/- phenylephrine, an appropriate size, the discretion to not keep jamming away causing trauma if it doesn't go in easy ... I just don't have problems with bloody noses. So much nicer and better tolerated than an oral airway.

When I see patients arrive in PACU with oral airways, they're obtunded enough to tolerate them, and it always strikes me as, well, sub-optimal.