What would you do?

[bigtuna]

I'll post a case from my last night on call since the forum is dead.

RN calls me at 10:00 PM to come see ICU pt for respiratory distress.
Get to the bedside 10 min later.

Morbidly obese WM (50'ish) with RR low 40's sitting upright in bed.
Pulse 115, afib
BP 80/40's by radial A -line
spO2 89% on NRB
Weight 425 lbs
massive subq air extending up to head
Head shape/size of a pumpkin
Can not open eyes due to subq air in eyelids
Awake and will follow commands but not talking
Can open his mouth about 1.5 inches


Quick update by RN:

POD #3 from CABG, EF 45 % pre-op
Extubated POD #1
Still on dobutamine for lowish CI (has triple lumen catheter, no swan)
Chest tube and mediastinal drain removed about 6 hours previously
SQ air first noted about an hour ago - has progressed rapidly

RN and RT have already gotten abg and cxr:
ABG 7.27/65/60
CXR - tons of overlying soft tissue, bilateral pneumos -> right maybe 30%, left maybe 20%

Review intubation note by anesthesia from OR:
Performed by old school anesthesiologist - has been doing cardiac cases for 20+ years
"Grade 4 view with miller 2 - 1st pass with bougie"
This guy almost never goes with a glidescope for his 1st attempt

Available to me at this time of night:
-1 anesthesiologist with 2 crna's
-probably a couple of ER and IM hospitalists in house
-CT surgeon at home kicked back with a glass of scotch

I do 90% of my own airways but I'm not afraid to ask for help when things look ugly.

Call anesthesiologist

-he's bringing back an urgent c-section with 1 crna - doesn't feel comfortable with her starting case alone. Other crna in a case. He can be there in about 30 minutes.

What to do?

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[sluggs]

1. Get some levo/neo ready
2. Get a glidescope, millers 2 and 3, bougie, and bronch/fiberoptic stuff ready, and also an LMA (I often "over-equip" for difficult airways, but better safe than sorry).
3. See what a big slug of Lasix followed by bilateral chest tubes buys you
4. With the chest tubes in, take a shot at bipap
5. If none of this helps the patient improve his sats: fentanyl, etomidate (with a paralytic at the ready in case that is the only thing standing in the way of you and a better look), try to DL with a miller or a glide (whichever you are better with-- I think I would go glide in light of the anesthes problems described above), and quickly go to your bronchoscope with a tube loaded on it.
6. When finished throw out your poop-stained undies and get a new pair out of your call=room bag.

 

[jdh71]

Hm. I don't have a ton of CVICU experience, so my reflexes could be missing something here . . . But I think I go for the bilateral chest tubes first - hope the respiratory distress settles down and patient won't need emergent (or possibly any intubation), while starting some BP support with a pressor, and having someone go get me the bronchoscope and ET tubes. Would have nursing page whoever can help with an emergency surgical airway as I've never done one in a living person. If there is time would also try and pick the brain of the CV surgeon on call.

So what happened?

 

[bigtuna]

How confident are you that you can successfully place chest tubes in a reasonable amount of time in a morbidly obese patient that can't lie flat and that realistically you can't give any sedation to?

 

[Doctor Bob]

Perhaps needling his chest bilaterally, with some of the harpoon spinal needles (the 7 inch ones) will buy you some time. If there's any improvement after that, then go the chest tube route; admittedly it won't be the easiest to do, but it can be done. If needling him doesn't help, then take the airway before his TFTB-ness overwhelms him.

 

[Hernandez]

How confident are you that you can successfully place chest tubes in a reasonable amount of time in a morbidly obese patient that can't lie flat and that realistically you can't give any sedation to?

Can't? Or won't?

More than 1 way to skin a cat. Consider staring pressors first, conscious sedation (preferably managed by second doc), surgical chest tube. and if she crumps bag the hell out of her until definitive airway established and have cric kit close. Id argue Fix the issue, don't treat the symptoms. That being said, I've seen more than a few chest tubes (seldinger or surgical) placed with local only.

If you're not comfortable, needle decompresse PRN to buy time.

 

[jdh71]

How confident are you that you can successfully place chest tubes in a reasonable amount of time in a morbidly obese patient that can't lie flat and that realistically you can't give any sedation to?

Anterior seldinger style tubes can be in pretty damn fast with local anesthetic only.

 

[ihearttriangles]

1. Get some levo/neo ready
2. Get a glidescope, millers 2 and 3, bougie, and bronch/fiberoptic stuff ready, and also an LMA (I often "over-equip" for difficult airways, but better safe than sorry).
3. See what a big slug of Lasix followed by bilateral chest tubes buys you
4. With the chest tubes in, take a shot at bipap
5. If none of this helps the patient improve his sats: fentanyl, etomidate (with a paralytic at the ready in case that is the only thing standing in the way of you and a better look), try to DL with a miller or a glide (whichever you are better with-- I think I would go glide in light of the anesthes problems described above), and quickly go to your bronchoscope with a tube loaded on it.
6. When finished throw out your poop-stained undies and get a new pair out of your call=room bag.

Is it OK if I ask some questions here? I'm a med student trying to slog my way through the very confusing world of critical care.
1) Isn't hypotension a contraindication for Lasix? Especially in this case cause presumably his SOB stems from the bilateral pneumos? But, what about patients that are in cardiogenic shock due to fluid overload? I would imagine these patients might get pressors and lasix?
2) Is hypotension a relative contraindication to Bipap? I heard my attending talking about how CPAP was contraindicated in hypotensive patients because theoretically it increases intrathoracic pressure and decreases preload, but I guess Bipap only does this during the inspiratory phase and does the opposite during the expiratory phase so maybe it comes out a wash.
Thanks

 

[Hernandez]

Is it OK if I ask some questions here? I'm a med student trying to slog my way through the very confusing world of critical care.
1) Isn't hypotension a contraindication for Lasix? Especially in this case cause presumably his SOB stems from the bilateral pneumos? But, what about patients that are in cardiogenic shock due to fluid overload? I would imagine these patients might get pressors and lasix?
2) Is hypotension a relative contraindication to Bipap? I heard my attending talking about how CPAP was contraindicated in hypotensive patients because theoretically it increases intrathoracic pressure and decreases preload, but I guess Bipap only does this during the inspiratory phase and does the opposite during the expiratory phase so maybe it comes out a wash.
Thanks

1) I wouldn't give Lasix here. It buys you nothing.
2) hemodynamic instability is a contraindication since you can theoretically hypoperfuse respiratory muscles and worsen your respiratory status, you don't want to intubated emergently if you don't have to.

And wrong, bipap still have PEEP on Expiratory phase which can be just as detrimental as PSV. Any positive pressure ventilation can hurt a hypovolunemic pt.

 

[bigdan]

I'd try to get the CT guy to put down his Laphroig and see if he'd meet us in the OR, if you have time. If you do (or don't have time), I'd consider awake fiberoptic, and see if I could get someone handy with a knife to make their way in.

1) Don't need to change position for AFOI; explain you're gonna place the tube with a camera
2) Would toss in some nebulized lidocaine & start dexmetetomidine gtt
3) If the mouth is a viable option, place the bite block of your choice. If not, add Neosynephrine spray to both nostrils, in case you need the nose.
3) Ketamine and glycopyrrolate in small aliquots prn
4) Spray-as-you-go with lidocaine

A valid argument could be made that this would take too long, but I think it could be done relatively quickly, and would suggest that a few extra minutes on the AOFI might be better than flailing at the neck or with an LMA.

I've seen the aftermath of subq air bad enough that we couldn't extubate, so I assume it can get bad enough that I couldn't intubate. If I can't intubate, he's still spontaneously ventilating (or at that point he might not be, but I have pharmacologically done anything to cause that).

I'm interested in what you did!

 

[idiot07]

Sub q air while unsightly, doesn't usually compromise a patients ability to maintain his airway because the pressure in the neck isn't high enough to compress the trachea as opposed to say a big neck hematoma after a central line or neck operation. Nor should it cause the patients sats to be low. He shouldnt need to be intubated purely for airway protection. His bilateral pneumothoraces however will affect his ventilation and oxygenation. Both the pneumos and the Sub q air will only get worse when you place him on positive pressure ventilation be it via an et tube or bipap. The pt needs chest tubes and then if those don't fix his respiratory issues he needs to be incubated. Any size chest tube can be placed with local only with correct techniques, the pigtails should work fine in this situation. The key for a real chest tube with the fatties is to make a bigger skin incision than usual use the scissors to sharply dissect down to chest wall rather than spread, and if needed confirm intrathoracic placement of tube with a finger in the chest. Also given that the patient has had in tubes and had chest surgery he could have some adhesions of lung to the chest was and you migh have to get creative with placement to avoid them or it may be safer to put in a real tube rather than a dart if you can't. The surgeon or his partner should really be putting them in an urgent fashion.

 

[sluggs]

1) I wouldn't give Lasix here. It buys you nothing.
2) hemodynamic instability is a contraindication since you can theoretically hypoperfuse respiratory muscles and worsen your respiratory status, you don't want to intubated emergently if you don't have to.

And wrong, bipap still have PEEP on Expiratory phase which can be just as detrimental as PSV. Any positive pressure ventilation can hurt a hypovolunemic pt.

Hypotension does not always equal hypovolemia, especially in cardiogenic shock/cardiorenal syndrome. Facct trial = a dry lung is a happy lung. Primary problem here is resp failure... support the hemodynamics with pressors to avoid intubation. Bipap could help forestall or avoid intubation here.

 

[jdh71]

Hypotension does not always equal hypovolemia, especially in cardiogenic shock/cardiorenal syndrome. Facct trial = a dry lung is a happy lung. Primary problem here is resp failure... support the hemodynamics with pressors to avoid intubation. Bipap could help forestall or avoid intubation here.

Agreed and we've all used nipride in bad heart failures too. Though, I think the OP mentioned a decent EF on echo. Perhaps now would be a good time to bedside as well, just to see what is going on, but I think we all agree this patient's problem probably isn't bad heart failure though, it's bilateral pneumo's with subsequent acute hypercarbic and hypoxic respiratory failure, and possible tamponading physiology(??).

I'm interested to see how the case played out. I know I am, like everyone else, nervous about that airway and the ability to get in there if need be, but I really wonder if the chest tubes will cure all that ails us here.

 

[bigtuna]

1. As others have said, trying to take this airway up front without backup is a big mistake. The subq air was actually bad enough to limit his mouth opening a bit. That's a big red flag - can make the glidescope difficult. If coding - sure give something a shot but you've got some time here.

2. I wouldn't worry about the effect of bipap on his bp too much but i would worry that the positive pressure might make the pneumo's get bigger fast

3. He needed urgent decompression of the pneumo's. I'm very confident in my ability to place a surgical chest tube and didn't think that was a good option up front. Trying to make a big skin incision and then dig deep on a morbidly obese dude in respiratory distress that you can't adequately position is not going to be easy.

4. Lasix not going to help you here


I placed bilateral anterior pneumocaths. We have the Arrow kits. They are very small bore and flimsy. They are notorious for kinking off in obese patients but i knew they would work initially.

Took less than five minutes to place two. SBP back up above 100, RR down to 20's, O2 down to ventimask. Good air leak on both sides.

Guy went on to develop the worst subq air i've ever seen (and that's saying something). Ended up going back to the OR the next am where he was an awake FOI, had surgical chest tubes placed, and actually got decompressive skin incisions. Still on the vent as of this AM but likely to be extubated in the next few days.

 

[Hernandez]

Hypotension does not always equal hypovolemia, especially in cardiogenic shock/cardiorenal syndrome. Facct trial = a dry lung is a happy lung. Primary problem here is resp failure... support the hemodynamics with pressors to avoid intubation. Bipap could help forestall or avoid intubation here.

I'm aware, but the issue here is PTX. The Lasix might help dry it out the lung and improve sats a little, but it's not going to help by the time one should be getting chest tubes in.

By the time bipap is hooked up you could already have a CT in. And if you're wanting that to be a time buying device, I've seen bipap exacerbate pneumos from interns who droppe slings and then threw on bipap without asking why someone admitted without lung issues is now hypoxemic.

In this case, I agin think Lasix buys you nothing within the critical window before decompensation.

FACCT Trial = an hour of grown men arguing whether a CVP tracing was 11 or 12. But not really applicable here as he doesn't give us info that argues this is ARDS but does tell us "CXR - tons of overlying soft tissue, bilateral pneumos -> right maybe 30%, left maybe 20%"

I also mentioned hypovolunemia for the med student talking about bipap causing hypotension, it does but almost exclusively in hypovolunemic pts,

 

[sluggs]

Hence my plan: "with Chest tubes in, go to bipap"

 

[gro2001]

1. As others have said, trying to take this airway up front without backup is a big mistake. The subq air was actually bad enough to limit his mouth opening a bit. That's a big red flag - can make the glidescope difficult. If coding - sure give something a shot but you've got some time here.

2. I wouldn't worry about the effect of bipap on his bp too much but i would worry that the positive pressure might make the pneumo's get bigger fast

3. He needed urgent decompression of the pneumo's. I'm very confident in my ability to place a surgical chest tube and didn't think that was a good option up front. Trying to make a big skin incision and then dig deep on a morbidly obese dude in respiratory distress that you can't adequately position is not going to be easy.

4. Lasix not going to help you here


I placed bilateral anterior pneumocaths. We have the Arrow kits. They are very small bore and flimsy. They are notorious for kinking off in obese patients but i knew they would work initially.

Took less than five minutes to place two. SBP back up above 100, RR down to 20's, O2 down to ventimask. Good air leak on both sides.

Guy went on to develop the worst subq air i've ever seen (and that's saying something). Ended up going back to the OR the next am where he was an awake FOI, had surgical chest tubes placed, and actually got decompressive skin incisions. Still on the vent as of this AM but likely to be extubated in the next few days.

Sounds like you did a fantastic job. For the sake of discussion, if you did't have the percutaneous kits available to you, would you have gone for the bilateral surgical chest tubes, called the CT surgeon in, needle decompressed (possibly repeatedly) or done something else entirely?

 

[bigtuna]

Sounds like you did a fantastic job. For the sake of discussion, if you did't have the percutaneous kits available to you, would you have gone for the bilateral surgical chest tubes, called the CT surgeon in, needle decompressed (possibly repeatedly) or done something else entirely?

I would have called CT surgeon in and gone for the surgical tubes simultaneously.

I don't think the needle decompression would be that helpful. I'm not exactly sure what the mechanism is for the post cabg pneumo's that occasionally happen but they tend to produce air leaks for a few days at least. The fact that the pneumo's were bilateral probably means that there is some connection between the hemithoraces - the pneumo's would probably just keep coming back. It's also hard to find an appropriate needle to decompress with. I was 6 or 7 inches in before I got air back with the pneumocath. Needle decompression generally for coding unilateral tension ptx. only

 

[TallScrubs]

Hm. I don't have a ton of CVICU experience, so my reflexes could be missing something here . . . But I think I go for the bilateral chest tubes first - hope the respiratory distress settles down and patient won't need emergent (or possibly any intubation), while starting some BP support with a pressor, and having someone go get me the bronchoscope and ET tubes. Would have nursing page whoever can help with an emergency surgical airway as I've never done one in a living person. If there is time would also try and pick the brain of the CV surgeon on call.

So what happened?

Curious: how would you feel if the pt's BP was 90/40? Still warrant pressors? What MAP are you routinely happy with on a patient like this?

Thanks

 

[deuist]

Lots of good discussion here. The chest tubes would be the first thing---preferably pig tails due to time. Avoid the lasix. I may even try a liter bolus to increase venous return. I would also draw up a syringe of phenylephrine for push-dose pressors. Once you put the patient on positive pressure---whether from intubation or BiPAP---the BP will drop.

 

[Bostonredsox]

What boston would do.

1. Place him on NIPPV.
2. Start Levo/dobutamine or epi. IM assuming post bypass EF of 45 part of that hypotension is poor CO and forward flow from impaired squeeze. Ionotrope would help a bit.
3. Have all my difficult airway stuff at bedside. McGrath/glide. Bougie. Cric/trach kit. LMA.
4. B/l chest tubes. I would go percutaneous if possible, might need an extra long needle. I would go high. Assuming he's sitting nearly straight up as you described the air should be mostly apical. Awake the perc will hurt less than the open technique. I would be ok giving him fentanyl or morphine too. Would help his resp distress a bit and pain. S*** ton of local. Put in both tubes. If a secondary provider, ed, hospitalist, skilled resident can help so you place the chest tubes simultaneously and have atleast some backup in case he crashes that would be ideal. Have anesthesia on their way in case things get ugly while your putting in chest tubes.
5. Agree with hern, Lasix unlikely to help much, I wouldn't give any. I would actually give a bolus assuming the hypotension may be cardiogenic shock and impaired venous return.
6. Once tubes are in, reassess. If his resp effort isnt s great and it still looks like he's going to fail, and anesthesia is now available, have them try an awake FOI. If they are not, assess ventilation. Easy to ventilate? Etom/sux tube. If you can't get in, bag till the sux wears off and proceed to perc trach. If he can't be ventilated well, move right to cric/trach.

Reading the whole case to me I think poor underlying cardiopulmonary reserve with b/l PTX is the source of the resp failure. I agree with JDH and hern, would go for the chest tubes first. Putting them in fast with bipap might save him from needing an ETT and the ensuing trauma if its a bad airway.

In terms of surgical airway, I had a case a few days ago who had self extubated the day before but done ok on bipap. Suddenly went into failure and I couldn't reintubate him. ( I intubated him first time rather easily actually) difficult view, but i can see cords. bougie won't pass, obstructed by aspiration ball. Sats low 80s. I called gen surg to back me up. Had CRNA, who also couldn't pass bougie after I failed, stick in LMA and bag. We did the perc trach in about 4 minutes. I know cric is the "emergent surgical airway" but in my LIMITED experience, in slick hands these perc trachs can be done very fast with just local and are far less messy then the cric and don't require a formal revision. The more and more of them I do I'm learning they can be an emergent surgical airway, especially of your pt can atleast be somewhat bagged effectively for a few minutes.

 

[pseudoknot]

We did the perc trach in about 4 minutes. I know cric is the "emergent surgical airway" but in my LIMITED experience, in slick hands these perc trachs can be done very fast with just local and are far less messy then the cric and don't require a formal revision.

An experienced operator can do a perc trach pretty quickly, yes. However, a cric can be done in less than thirty seconds. Four minutes is a long time in a hypoxic crashing patient. And Seldinger methods did have a much higher failure rate in the NAP4 audit than open.

Also, if you look at the literature there's really not good evidence that a cric needs to be revised, although I know people like to do it anyway.

 

[Bostonredsox]

An experienced operator can do a perc trach pretty quickly, yes. However, a cric can be done in less than thirty seconds. Four minutes is a long time in a hypoxic crashing patient. And Seldinger methods did have a much higher failure rate in the NAP4 audit than open.

Also, if you look at the literature there's really not good evidence that a cric needs to be revised, although I know people like to do it anyway.

thanks for the info man.

and yeah in a crashing hypoxic pt no question, cric all the way. but I have found many surgical airways along the way that have been, "cant intubate, can sort of ventilate ok, not great but ok". surg preferred the perc trach bedside in them.

 

[dotcb]

1. As others have said, trying to take this airway up front without backup is a big mistake. The subq air was actually bad enough to limit his mouth opening a bit. That's a big red flag - can make the glidescope difficult. If coding - sure give something a shot but you've got some time here.

2. I wouldn't worry about the effect of bipap on his bp too much but i would worry that the positive pressure might make the pneumo's get bigger fast

3. He needed urgent decompression of the pneumo's. I'm very confident in my ability to place a surgical chest tube and didn't think that was a good option up front. Trying to make a big skin incision and then dig deep on a morbidly obese dude in respiratory distress that you can't adequately position is not going to be easy.

4. Lasix not going to help you here


I placed bilateral anterior pneumocaths. We have the Arrow kits. They are very small bore and flimsy. They are notorious for kinking off in obese patients but i knew they would work initially.

Took less than five minutes to place two. SBP back up above 100, RR down to 20's, O2 down to ventimask. Good air leak on both sides.

Guy went on to develop the worst subq air i've ever seen (and that's saying something). Ended up going back to the OR the next am where he was an awake FOI, had surgical chest tubes placed, and actually got decompressive skin incisions. Still on the vent as of this AM but likely to be extubated in the next few days.

I'm a little surprised you waited til the next AM to do AFOI. I think I would've mobilized to take that airway prophylactically as soon as he'd stabilized, AFOI with anesthesia and all difficult airway equipment at the bedside. If either or both of those tubes malfunction, big trouble.

 

[Bostonredsox]

I'm a little surprised you waited til the next AM to do AFOI. I think I would've mobilized to take that airway prophylactically as soon as he'd stabilized, AFOI with anesthesia and all difficult airway equipment at the bedside. If either or both of those tubes malfunction, big trouble.

agreed. even with stabilization after the chest tubes, I wouldn't have been able to sleep that night knowing that airway was unprotected.

 

[jdh71]

I don't know. Fix the acute respiratory failure with the chest tubes. If the guy is protecting his own airway, why poke that skunk when you don't necessarily need to?

 

[bigtuna]

What boston would do.

In terms of surgical airway, I had a case a few days ago who had self extubated the day before but done ok on bipap. Suddenly went into failure and I couldn't reintubate him. ( I intubated him first time rather easily actually) difficult view, but i can see cords. bougie won't pass, obstructed by aspiration ball. Sats low 80s. I called gen surg to back me up. Had CRNA, who also couldn't pass bougie after I failed, stick in LMA and bag. We did the perc trach in about 4 minutes. I know cric is the "emergent surgical airway" but in my LIMITED experience, in slick hands these perc trachs can be done very fast with just local and are far less messy then the cric and don't require a formal revision. The more and more of them I do I'm learning they can be an emergent surgical airway, especially of your pt can atleast be somewhat bagged effectively for a few minutes.

The majority of these I've seen attempted have not turned out well. That technique is pretty difficult with someone coughing and moving around and no bronchoscopic visualization. I've done some "semi-urgent" ones but only in people that we were ventilating well enough with an LMA to paralyze.

 

[Bostonredsox]

I don't know. Fix the acute respiratory failure with the chest tubes. If the guy is protecting his own airway, why poke that skunk when you don't necessarily need to?

Are you confident with all that described subq emphysema tracking up the neck, the worst he's ever seen, that he can truly protect is own airway? Im sure with two chest tubes in hes getting a good dose of opiods for pain. little bit of respiratory depression whilst sleeping, expanding subq air, poor effort at baseline probably from obesity hypoventilation, limited insp volumes due to pleuritic pain....suddenly not looking so good and its 3am. Might just be because I'm still a newbie to CCM but unless the person I'm signing out to has equivalent or superior airway skills than me, I get really bothered signing out a difficult airway that could collapse. Have that feeling, if only I had tubed him before he crashed and situation was a bit more under control....

 

[jdh71]

Are you confident with all that described subq emphysema tracking up the neck, the worst he's ever seen, that he can truly protect is own airway? Im sure with two chest tubes in hes getting a good dose of opiods for pain. little bit of respiratory depression whilst sleeping, expanding subq air, poor effort at baseline probably from obesity hypoventilation, limited insp volumes due to pleuritic pain....suddenly not looking so good and its 3am. Might just be because I'm still a newbie to CCM but unless the person I'm signing out to has equivalent or superior airway skills than me, I get really bothered signing out a difficult airway that could collapse. Have that feeling, if only I had tubed him before he crashed and situation was a bit more under control....

Hey, man that's why they pay you the big bucks to make the hard decisions. I'm not saying tubing the guy immediately is wrong necessarily. I'm saying that its not right necessarily. It's nuanced but I think you can handle it. We can create all kinds if then zomg WTF scenarios with any patient. What you had here was a patient who's airway was fine enough and an explanable fixable reason for his respiratory failure. Why go out of your way to create a potential problem if you don't have a problem. I don't tend to fix things that are not broken. And I don't tube patients because the next guy coming on might not be better than me at airways. I put tubes in patients I think need them. And you can make arguments that I'd buy that this guy should get a tube. I wouldn't call you a "bad doctor" if you decided to put one in. I'm not convinced I would "just because".

 

[Hernandez]

Are you confident with all that described subq emphysema tracking up the neck, the

Sub-q emphysema is pretty damn rare in laryngeal areas. I'd bet if you pub-med it, you'd only find a hand full of case reports of it causing respiratory issues.

If he improved with chest tubes, I'd have very easily gone back to bed and not worried about it.

 

[Bostonredsox]

Hey, man that's why they pay you the big bucks to make the hard decisions. I'm not saying tubing the guy immediately is wrong necessarily. I'm saying that its not right necessarily. It's nuanced but I think you can handle it. We can create all kinds if then zomg WTF scenarios with any patient. What you had here was a patient who's airway was fine enough and an explanable fixable reason for his respiratory failure. Why go out of your way to create a potential problem if you don't have a problem. I don't tend to fix things that are not broken. And I don't tube patients because the next guy coming on might not be better than me at airways. I put tubes in patients I think need them. And you can make arguments that I'd buy that this guy should get a tube. I wouldn't call you a "bad doctor" if you decided to put one in. I'm not convinced I would "just because".

Fair enough

 

[ORL10]

I've seen a lot of trauma especially GSWs to the neck working on the south side of chicago and subQ air that tracks underneath the tongue is never good. It's almost always a recipe for airway disaster and a f*** S*** moment. I think I probably would have tried to place chest tubes with ketamine sedation as needed and have been topicalizing his airway at the same time the chest tubes were going in.

This way when my chest tubes are in (5-10 minutes?) he's gotten topicalized and had some glyco with ketamine ready to go and I would have attempted intubation if he still looked like a** only because I would have assumed his airway was going to get worse, unless of course he markedly improved with CT's which it sounded like he did. I also am impressed at identifying the size of a pneumo on CXR in a morbidly obese guys with fatty folds, tons of subQ emphysema post-CABG?

I probably would not be ballsy enough to put chest tubes in and go back to bed, although Ill be honest I wish was.

 

[ketap]

hi..i am not the airway specialist, but i usually give hypnotic and narctoics drugs to shock patient by titration..they usually need only very little (i have seen my patient given only 20 mg propofol and half dose of fentanyl and he immediately fall asleep) ...i'll wait for the drug's time to peak effect and add another mg if i need to..because in my country, we only have propofol and midz, i would rather use propofol by titration..works fine until today, i haven't seen my patient blood pressure drops to much with this approach.....

 

[ThoracicGuy]

Are you confident with all that described subq emphysema tracking up the neck, the worst he's ever seen, that he can truly protect is own airway? Im sure with two chest tubes in hes getting a good dose of opiods for pain. little bit of respiratory depression whilst sleeping, expanding subq air, poor effort at baseline probably from obesity hypoventilation, limited insp volumes due to pleuritic pain....suddenly not looking so good and its 3am. Might just be because I'm still a newbie to CCM but unless the person I'm signing out to has equivalent or superior airway skills than me, I get really bothered signing out a difficult airway that could collapse. Have that feeling, if only I had tubed him before he crashed and situation was a bit more under control....

SQ air is unseemly and can get to the point where the patient's eyes can't open. It can track to the vocal cords and change their voice. SQ air will not compromise their airway. Chest tubes can be placed with the patient in an upright, sitting position if needed. As for why there can be leaks, the pleural spaces are usually entered during a CABG, particularly the left side during takedown of the IMA for bypass. The lung can sometimes be injured during this process, particularly if there are adhesions making the dissection of the IMA difficult. Another point where airleaks can occur is with injury to the lungs during placement of the sternal wires.

 

[jdh71]

SQ air is unseemly and can get to the point where the patient's eyes can't open. It can track to the vocal cords and change their voice. SQ air will not compromise their airway. Chest tubes can be placed with the patient in an upright, sitting position if needed. As for why there can be leaks, the pleural spaces are usually entered during a CABG, particularly the left side during takedown of the IMA for bypass. The lung can sometimes be injured during this process, particularly if there are adhesions making the dissection of the IMA difficult. Another point where airleaks can occur is with injury to the lungs during placement of the sternal wires.

great info

this is the kind of stuff that always kind of bugs me a bit about helping out with post-op patients, not doing the procedures to understand the ins and outs of what happened in the OR and not spending years following these type of patients out of the OR, I don't have certain reflexes. I suppose if a guy co-managed long enough he'd pick it up reasonably enough. I mean I can run the vent, pressors, fluids, nutrition, etc. but there are just some things that are rather specialty specific, and this is a good little nugget to put away to be referenced at a later time if necessary

thanks

 

[bigtuna]

Thanks for the post thoracic guy. Useful info.

To clarify - I didn't think the Subq air was causing laryngeal obstruction but did seem to be limiting mouth opening to some extent and also distorted his facial anatomy enough to make an already difficult mask look more difficult.

 

[ThoracicGuy]

Thanks for the post thoracic guy. Useful info.

To clarify - I didn't think the Subq air was causing laryngeal obstruction but did seem to be limiting mouth opening to some extent and also distorted his facial anatomy enough to make an already difficult mask look more difficult.

Sometimes if you have alot of SQ air and the patient (or nurse) is really concerned about it you can place an 18g angiocath to the anterior chest into the SQ tissue and have the nurses milk the air out occasionally. That will help it go down quicker.

If the SQ air is onto the chest, it can sometimes make placing a chest tube (not one of those needle guided tubes, but a real chest tube) easier since the air has dissected alot of the planes already. In elective patients, I tend to make the incision for the tube just barely larger than the tube itself (24 Fr for air, 28 Fr for fluid usually). In a larger person, often this method isn't possible. I also tend to do it with the patient in a lateral position as this allows alot of the fat to fall away by gravity. This also helps in women with large, pendulous breasts to have them out of the way. This does have to be adapted to each individual patient/situation, of course.

 

[Buzz Me]

We did the perc trach in about 4 minutes. I know cric is the "emergent surgical airway" but in my LIMITED experience, in slick hands these perc trachs can be done very fast with just local and are far less messy then the cric and don't require a formal revision.

I wouldn't do a perc trach in an emergent situation. This is without bronchoscopic guidance?

Remember one of the reasons to revise an emergent crich is also to washout the neck since it's less than sterile conditions during the code. So a semi-clean perc trach in an emergent situation still isn't ideal in trying to avoid a takeback to the OR.

 

[Hernandez]

I wouldn't do a perc trach in an emergent situation. This is without bronchoscopic guidance?.

Blind perc trachs are the norm at many institutions and they're safety is on par with bronch visualized perc trachs & surgical trachs.

 

[ORL10]

The SubQ airway problems I have had are related to limited oral view due to elevation of the tongue from the subglossal air. It makes visualizing the cords with DL extremely difficult.

 

[Bostonredsox]

The SubQ airway problems I have had are related to limited oral view due to elevation of the tongue from the subglossal air. It makes visualizing the cords with DL extremely difficult.

So essentially bad subq air can alter an airway in a similar fashion to angioedema. Make the view impossible and the ability to pass the tube far more difficult. To me that's still an unstable airway.

We had a guy who had a thyroid mass that was so large it nearly completely obstructed his mid trachea. It was 2.4mm wife on CT. Anesthesia wouldn't even attempt to intubate. They attempted the trach, open, under local. After 2 hours the two ents couldn't even find the trachea. He was shipped to tertiary care, put on ecmo, then put to sleep and then had a sternotomoy to access the lower trachea to get a trach in.

The guy was never in respiratory failure. Mildly short of breath with some chest pain, so got a ct chest in Ed for pe and they saw the mass. But ent conveyed to me if he swallows his spit it could be enough to occlude that mid trachea segment and it will be over. He's not cricable. He'd die in the code. Obviously the guy in the OPs case doesn't have this crazy scenario, but I was thinking along the lines of ORL10. He is on resp failure, albeit from the pneumos which I hope will improve with the chest tubes rapidly, and he has subq air which Can make my view so bad it will be very hard to get a tube in if he crashes. Would really make me want to prophylacticly intubate him. But I am a 'rook in this field. Actually I'm technically not even a rook I'm still in the minors so I see all of your points. I just wouldn't have had the balls to go to bed without the tube in.

 

[ThoracicGuy]

So essentially bad subq air can alter an airway in a similar fashion to angioedema. Make the view impossible and the ability to pass the tube far more difficult. To me that's still an unstable airway.

A difficult airway and an unstable airway are two different things, though. SQ air just won't kill you. Make an intubation tough? Sure, but it's presence even a severe case is not an indication for intubation.

 

[Arch Guillotti]

In terms of surgical airway, I had a case a few days ago who had self extubated the day before but done ok on bipap. Suddenly went into failure and I couldn't reintubate him. ( I intubated him first time rather easily actually) difficult view, but i can see cords. bougie won't pass, obstructed by aspiration ball. Sats low 80s. I called gen surg to back me up. Had CRNA, who also couldn't pass bougie after I failed, stick in LMA and bag. We did the perc trach in about 4 minutes. I know cric is the "emergent surgical airway" but in my LIMITED experience, in slick hands these perc trachs can be done very fast with just local and are far less messy then the cric and don't require a formal revision. The more and more of them I do I'm learning they can be an emergent surgical airway, especially of your pt can atleast be somewhat bagged effectively for a few minutes.

So you could ventilate but the patient got a trach?

 

[Bostonredsox]

So you could ventilate but the patient got a trach?

We could ventilate sats up to 88-91ish. With bagging. Couldn't intubate despite using all modalities and three different providers with increasing skill level. Plus this was his third intubation this admission. He has slowly dwindled down to needing the tube again each time. Should I have just left the LMA in and hooked him to the vent and hoped his sats stayed up? And then stuck the bronchoscope in through LMA? I'm not sure what your getting at arch

 

[ThoracicGuy]

An ET tube through an LMA is certainly a viable method as long as the patient is stable. I can't fault you for the trach based on the info given, certainly.

 

[Bostonredsox]

I wouldn't call him stable. We got sats to 91 bagging through an LMA. If you stopped bagging he dropped rather quickly. We don't have intubating LMAs. I've never attempted to put an ETT through a standard LMA, if that's even possible. Anesthesia wasn't keen to try any other modality after I let them have a go after me and we all failed. To me the only answer was a surgical airway. I felt, and surgery agreed, conditions were stable enough to do a perc at bedside and a cric was not needed.

 

[ThoracicGuy]

I wouldn't call him stable. We got sats to 91 bagging through an LMA. If you stopped bagging he dropped rather quickly. We don't have intubating LMAs. I've never attempted to put an ETT through a standard LMA, if that's even possible. Anesthesia wasn't keen to try any other modality after I let them have a go after me and we all failed. To me the only answer was a surgical airway. I felt, and surgery agreed, conditions were stable enough to do a perc at bedside and a cric was not needed.

The Anesthesia team where I did my CT training used the Mercury AirQ as their LMA device. It has a cap at the top that can pop off and allow a lubricated ET tube to be passed through the LMA with bronch guidance and into the trachea. The LMA is then removed with the ET tube remaining in place. It's a pretty slick way to do it. If you can ventilate your patient through the LMA and have the equipment ready, it might be worth a shot. The link to a photo of these LMAs is here:

http://www.ddmed.com/products/supraglottic_airway_masks.html

 

[jdh71]

The Anesthesia team where I did my CT training used the Mercury AirQ as their LMA device. It has a cap at the top that can pop off and allow a lubricated ET tube to be passed through the LMA with bronch guidance and into the trachea. The LMA is then removed with the ET tube remaining in place. It's a pretty slick way to do it. If you can ventilate your patient through the LMA and have the equipment ready, it might be worth a shot. The link to a photo of these LMAs is here:

http://www.ddmed.com/products/supraglottic_airway_masks.html

That's pretty slick. Do you know what size ET tube they were able to get through there??

 

[ThoracicGuy]

That's pretty slick. Do you know what size ET tube they were able to get through there??

I'm pretty sure it was between a 6 and 7. It's been a while since I saw them do it, so I'm a bit fuzzy on the details.

 

[CDI]

This thread is awesome. (Don't have much to contribute, but learned a lot reading through it.)