Weird Situation

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Carabas

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Had this thing happen to me yesterday and I'm having difficulty wrapping my head around it.

Youngish, otherwise healthy female undergoing an arm procedure. Go to intubate, Grade I view, pass the tube, no end tidal and cant see any humidity on the tube. Tube comes out, DL once again, Grade I view again, pass the tube, no end tidal and can't see any humidity anywhere.

I know my ETCO2 monitor is working, BP is not an issue. Able to bag the patient but nothing is coming out. Sats are ok (but was properly preoxygenated). At this point, attending takes a look with the tube in place. Clearly past the vocal cords, pilot is properly inflated, he advances the tube further and we end up with ETCO2. Rest of the case proceeds uneventfully.

Any ideas?
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Carabas said:
Had this thing happen to me yesterday and I'm having difficulty wrapping my head around it.

Youngish, otherwise healthy female undergoing an arm procedure. Go to intubate, Grade I view, pass the tube, no end tidal and cant see any humidity on the tube. Tube comes out, DL once again, Grade I view again, pass the tube, no end tidal and can't see any humidity anywhere.

I know my ETCO2 monitor is working, BP is not an issue. Able to bag the patient but nothing is coming out. Sats are ok (but was properly preoxygenated). At this point, attending takes a look with the tube in place. Clearly past the vocal cords, pilot is properly inflated, he advances the tube further and we end up with ETCO2. Rest of the case proceeds uneventfully.

Any ideas?
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Gas analyzer was warming up or sampling line occluded and that's why you had no CO2, Did you listen to the lungs???
 
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Nothing wrong with my gas analyzer. It was working pre-induction and wasn't resampling. Plus that wouldn't explain the absence of any humidity on the tube.

We did take a listen after we had +ve ETCO2, sounded a bit tight, but not enough to really explain what was going on. The fact we were able to bag fairly easily really put bronchospasm lower on the differential.
 
The humidity in the tube is not as reliable as you might think.
If the bag felt right, the chest was rising, auscultation was good, and your attending saw the tube in the trachea. Then this is ETCO2 monitor failure of some sort, so either the analyzer or the sampling line.
 
Bronchospasm or chest wall rigidity from opiates and paralytic not in full effect. If you saw the tube go into the right hole directly with your eyeballs, then it's in. Turn on the ventilator and increase the depth of anesthesia with propofol. Lack of humidity suggests no air movement and equipment was working appropriately. It happens occasionally.
 
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I had a similar situation on a healthy patient after tubing: low ETCO2, no mist, and slowly desaturating, despite clear and easy DL. I put a bronch through the tube and though I was at 22 at the lip the tube was in the right lower lobe wedged. Pulled back, reinflated, done. If it was the gas analyzer when you bagged her back between attempts that would have been abnormal too.
 
Had this happen to a Co resident, severe bronchospasm. But that doesnt explain your ability to bag...
 
Planktonmd said:
Gas analyzer was warming up or sampling line occluded and that's why you had no CO2, Did you listen to the lungs???
Click to expand...

This. Happens sometimes. Next time you're not sure, it takes 2 seconds to disconnect the sampling line and blow in it to see if there's any ETCO2. Just because it was sampling before doesn't mean its still sampling after you intubated. Sometimes it starts to ZERO at a bad time. Also, humidity in the tube isn't a good way to know if the tube is in. Listening to the chest and watching it rise as you bag is a better way.
 
This is not a weird situation. A weird situation is if your attending grabbed your as s while intubating.
 
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Hoya11 said:
I had a similar situation on a healthy patient after tubing: low ETCO2, no mist, and slowly desaturating, despite clear and easy DL. I put a bronch through the tube and though I was at 22 at the lip the tube was in the right lower lobe wedged. Pulled back, reinflated, done. If it was the gas analyzer when you bagged her back between attempts that would have been abnormal too.
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No offense intended - but do you put all your tubes in to 22cm and never check breath sounds?
 
Common things being common and based on the level of danger my guess would be: severe bronchospasm, esophageal intubation (remember people often swear it went through the cords but in hindsight it was in the goose), tube blockage ( can happen with sputum or if there is some soft tissue against it), sample line blockage.
 
jwk said:
No offense intended - but do you put all your tubes in to 22cm and never check breath sounds?
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arent u like a pa? dont start trouble.
 
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urge said:
Where is this residency program?
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i had an attending grab my nutsack while i was intubating and she said I like what I see.. No kidding.. Cant reveal where.. gag order
 
criticalelement said:
i had an attending grab my nutsack while i was intubating and she said I like what I see.. No kidding.. Cant reveal where.. gag order
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image.jpeg
 
criticalelement said:
i had an attending grab my nutsack while i was intubating and she said I like what I see.. No kidding.. Cant reveal where.. gag order
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What were you intubating?
 
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After that particular case with that attending i was in the introitus to be honest. I had to do it. My finishing residency depended on it
 
Really critical? Puhleez, you wanted to do her sounds like to me. You are ballsy. Had an affair with your attending in residency. That **** could have ended up really badly for you both.
 
I'm guessing something else or different to the story if it wasn't etCO2 failure.
 
Are you sure you were standing at the head of the bed? I've heard wrong-ended intubation can give some of those signs.
 
Planktonmd said:
Bronchospasm severe enough to cause complete absence of ETCO2 should be easy to detect from the way the bag feels when you try to ventialte
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Yes. I have seen it and it can confuse even seasoned vets. The bag will feel nearly normal especially to a newer anesthesiologist as this case was. You can get air into the lungs but gas exchange isn't occurring. In the case I recall, it cleared slowly as the volatile agent was cranked up.
 
Noyac said:
Yes. I have seen it and it can confuse even seasoned vets. The bag will feel nearly normal especially to a newer anesthesiologist as this case was. You can get air into the lungs but gas exchange isn't occurring. In the case I recall, it cleared slowly as the volatile agent was cranked up.
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I don't understand. There was no gas exchange but it fixed after delivering more inhalational anesthetic without gas exchange?
 
chocomorsel said:
Really critical? Puhleez, you wanted to do her sounds like to me. You are ballsy. Had an affair with your attending in residency. That **** could have ended up really badly for you both.
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It's really only bad for the attending! And it's not uncommon to hook up with the hospital hot ones.... That's a great call night!
 
Noyac said:
Try reading Barash.
How does volatile agents improve status asthmaticus?
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The bronchioles are not totally constricted to where no etCO2 would be seen in status asthmaticus. So there is some small degree of gas exchange, just not a lot. That allows the gas to get to it's end point for bronchodilation. Not showing any etco2 suggests completely occluded bronchioles, in which gas the gas would not get to its endpoint for bronchodilation.
 
The gas probably relaxes progressively distal bronchiolar segmentst through smooth muscle relaxation. It doesn't necessarily have to dilate the most distal bronchioles immediately to ultimately be effective.
 
^^as I'm sure in this case there was a small amount of CO2 exchange but not much picked up as ETCO2 because the flows were high in effect diluting out what little CO2 was present. Like I said, I've seen it before. It may not be what happened here but it would get my vote.

Maybe the OP will weigh in on what happened?
 
Planktonmd said:
The humidity in the tube is not as reliable as you might think.
If the bag felt right, the chest was rising, auscultation was good, and your attending saw the tube in the trachea. Then this is ETCO2 monitor failure of some sort, so either the analyzer or the sampling line.
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This. No way in this is bronchospasm.
 
weird situation i was in.. This relationship went on for 18 months until she moved with her husband and kids.
 
Noyac said:
^^as I'm sure in this case there was a small amount of CO2 exchange but not much picked up as ETCO2 because the flows were high in effect diluting out what little CO2 was present. Like I said, I've seen it before. It may not be what happened here but it would get my vote.

Maybe the OP will weigh in on what happened?
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My guess is that it was one of those "all bleeding eventually stops" scenarios. All bronchospasms eventually stop. Hypoxia is really good at breaking a bronchospasm. I'm not too sure about this CO2/02 not exchanging but somehow volatile agent gets in and bronchodilates. That's a hard sell and doesn't make sense. But whatevs. No point in me harping on it further.

Regarding the OP, I would say the majority of the time, especially as beginners, that something seems weird, it's usually something simple. My guess is etco2 failure or unrecognized esophageal or non-intubation. Sometimes when you are new, and I did this a lot, you get jacked up when you put the tube in on adrenaline and Mountain Dew and you have some degree of confirmation bias.
 
Noyac said:
Yes. I have seen it and it can confuse even seasoned vets. The bag will feel nearly normal especially to a newer anesthesiologist as this case was. You can get air into the lungs but gas exchange isn't occurring. In the case I recall, it cleared slowly as the volatile agent was cranked up.
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I guess this makes the most sense to me. I'm 100% sure it wasn't the ETCo2 monitor and that I was in the trachea both times. She did have significant bronchospasm once we took a listen and had ET on our monitor. I can't recall if we had any gas running after we intubated the first time around and that might have helped break the spasm.

Going by your thoughts, I guess pushing the tube in further could have gotten it deep enough to better detect whatever little gas was being exchanged?
 
chocomorsel said:
Wow critical, do you have a conscience? She was married w kids and you were screwing her? Wow. Just wow. Karma.
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Well, that's on her. For all we know her husband was a wife-beater and the kids were teenagers who wanted to run off and join ISIS.

Besides, criticalelement is an online persona, he says he does stuff like this, and he says he crank calls groups advertising in gaswork, and he says [...] and he says [...] but you've just got to figure 90% of it is hyperbole or outright BS posted for entertainment value.

The alternative, that it's all true, would detract from any comic relief his posts would otherwise provide, so I choose to believe he's just a joker.
 
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pgg said:
Well, that's on her. For all we know her husband was a wife-beater and the kids were teenagers who wanted to run off and join ISIS.

Besides, criticalelement is an online persona, he says he does stuff like this, and he says he crank calls groups advertising in gaswork, and he says [...] and he says [...] but you've just got to figure 90% of it is hyperbole or outright BS posted for entertainment value.

The alternative, that it's all true, would detract from any comic relief his posts would otherwise provide, so I choose to believe he's just a joker.
Click to expand...

Are you kidding me? All my posts are accurate. I do and did call groups to call them out on their bull****, and I 100 percent was involved with that woman. She is divorced now. Not on account of my relationship with her but because her husband is a pansy yes man. No woman respects that. I digress.
 
Carabas said:
I guess this makes the most sense to me. I'm 100% sure it wasn't the ETCo2 monitor and that I was in the trachea both times. She did have significant bronchospasm once we took a listen and had ET on our monitor. I can't recall if we had any gas running after we intubated the first time around and that might have helped break the spasm.

Going by your thoughts, I guess pushing the tube in further could have gotten it deep enough to better detect whatever little gas was being exchanged?
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I rest my case.

Btw, pushing the tube in deeper would not have changed anything except possibly worsen the spasm.

In my experience, the bronchospasm starts to relax before the volatile really starts to rise. I don't know if it is the lack of exchange or decreased perfusion along with the decreased ventilation that causes it to relax. The times that I have seen this, it was only a couple minutes at worse of zero ETCO2. Then you start to get some CO2 detection and you are driving in the volatile. Everything begins to improve.

But you guys can continue to doubt me if you like.
 
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