Airway Case

[Groove]

Colleague comes and grabs me for help with this case. She says it looks like angioedema with a lot of facial swelling. Limited hx, old lady from home with hx of CAD, HTN, DLD and presumed thyroid issues? called the ambulance for difficulty breathing. Paramedics state she had sats low upper 80s on arrival and perked up to 97% on NRB. Remaining VS en route were WNL other than 115 sinus tach on the monitor. I walk in the room and see a 65kg 85 y/o white female in mild to moderate respiratory distress. She's anxious, gurgling when she takes a breath, stridorous, tachypneic. I start examining her and look inside the mouth...dentures, no tongue swelling, no palatal edema, no pharyngeal edema, mallampati 3. I glance down and then see what appears to be a gigantic goiter looking back at me. Massive, the size of a grapefruit. Completely obscures any landmarks at this location, gigantic veins overlying the goiter. I listen to her trachea adjacent to the mass and seem to localize her stridor to this location. She's leaning forward, slightly drooling and in a semi tripod position. I have no other medical history on this lady. I tell my colleague that it doesn't appear to be angio but more of an upper airway obstruction 2/2 tracheal compression from the goiter or an underlying laryngeal/endotracheal mass.

The rest of your physical exam is not pertinent to this case. She's tachycardic with no m/r/g. The remainder of her exam is essentially normal.

Current VS:

BP 170/90, HR 120, RR 32, 96% NRB, 98.8

XR: Lungs are clear, appears to have some sort of mass abutting the trachea causing mild deviation to the right.

EKG: Sinus tach, non specific ST changes, occasional PVC.

Glance back at grammy and she is still anxious, not gurgling anymore but still stridorous. She's in resp distress but isn't crashing quite yet. Of note, she has no other high risk physical features that would make intubation difficult other than the obvious already stated. Supple neck, decent anatomy (other than the mass), no small mouth, no facial dysmorphia. You cannot palpate the thyroid cartilage as it is obscured by the neck mass. I do note though that she has a short segment of distal trachea above the sternal notch that is palpable and somewhat below the mass.

Colleage asks "What do you think?" "How should we do this?"

Let's here how you guys and gals would proceed with this case. Before you say call ENT, there's no ENT at my hospital.

Let's hear it. Drugs, tools, setup, technique, etc..

I'll let you know how it turned out later.

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[Apollyon]

If she is stridulous, she is imminently crashing, like, even if you do EVERYTHING right, she's still going in the dumper.

 

[BoardingDoc]

Colleague comes and grabs me for help with this case. She says it looks like angioedema with a lot of facial swelling. Limited hx, old lady from home with hx of CAD, HTN, DLD and presumed thyroid issues? called the ambulance for difficulty breathing. Paramedics state she had sats low upper 80s on arrival and perked up to 97% on NRB. Remaining VS en route were WNL other than 115 sinus tach on the monitor. I walk in the room and see a 65kg 85 y/o white female in mild to moderate respiratory distress. She's anxious, gurgling when she takes a breath, stridorous, tachypneic. I start examining her and look inside the mouth...dentures, no tongue swelling, no palatal edema, no pharyngeal edema, mallampati 3. I glance down and then see what appears to be a gigantic goiter looking back at me. Massive, the size of a grapefruit. Completely obscures any landmarks at this location, gigantic veins overlying the goiter. I listen to her trachea adjacent to the mass and seem to localize her stridor to this location. She's leaning forward, slightly drooling and in a semi tripod position. I have no other medical history on this lady. I tell my colleague that it doesn't appear to be angio but more of an upper airway obstruction 2/2 tracheal compression from the goiter or an underlying laryngeal/endotracheal mass.

The rest of your physical exam is not pertinent to this case. She's tachycardic with no m/r/g. The remainder of her exam is essentially normal.

Current VS:

BP 170/90, HR 120, RR 32, 96% NRB, 98.8

XR: Lungs are clear, appears to have some sort of mass abutting the trachea causing mild deviation to the right.

EKG: Sinus tach, non specific ST changes, occasional PVC.

Glance back at grammy and she is still anxious, not gurgling anymore but still stridorous. She's in resp distress but isn't crashing quite yet. Of note, she has no other high risk physical features that would make intubation difficult other than the obvious already stated. Supple neck, decent anatomy (other than the mass), no small mouth, no facial dysmorphia. You cannot palpate the thyroid cartilage as it is obscured by the neck mass. I do note though that she has a short segment of distal trachea above the sternal notch that is palpable and somewhat below the mass.

Colleage asks "What do you think?" "How should we do this?"

Let's here how you guys and gals would proceed with this case. Before you say call ENT, there's no ENT at my hospital.

Let's hear it. Drugs, tools, setup, technique, etc..

I'll let you know how it turned out later.

Call surgery now to have them at bedside to assist with an emergent trach as needed.

Assuming she's cooperative, I'd just throw a fiberscope loaded with an ETT down her airway and see what it looks like. She's having trouble oxygenating it seems, so instead of hooking the suction port up to suction, I'm hooking it up to the O2 line. That way I can still blow any moisture off the end of the scope if needed and I'm keeping her sats up while I do it (unless they have a ton of secretions, this is what I always do anyway). If I can get the tube based on what I see: push meds and do it. If she's not cooperative, do the same thing but with some ketamine first.

If I look and it's super stenotic and there is no way a tube will pass, surgery is going to take a crack at that distal bit of trachea. I may try giving her a slug of ketamine first and see if I can pass the tube, but with the express understanding that if it doesn't go immediately, we go for the stabby stabby option.

 

[gamerEMdoc]

Personally, as I've grown wiser over the years, these are the cases I'd consider loading the boat on. If the ship is going to sink, it's going down with other people in the boat as well. Haha. If you have anesthesia or surgery available, and there is time for them to get there, they would be consulted.

Otherwise, I'd get a melker kit out to prepare for a cric. Have a small ETT. Use ketamine as an induction agent without paralytics to see if I could get a decent look without paralyzing her, if the view looked ok but you need the paralytics because lack of paralysis was making things difficult, I'd paralyze then. Use video laryngostopy with a smaller ETT available. Bougie available.

 

[WilcoWorld]

She's 85.

First thing I'm going to do is check her records for advanced directives.

After finding that there are none, then swearing a few times, I'd try to decide if she's stable enough to attempt a fiberoptic intubation - if so:

give IV glycopyrrolate as I set up & the patient preoxygenates (but really, I'm trying to de-nitrogenate the lungs)
Lido neb as the glyco sets in
get my scope set up, loaded with a small-ish tube
also set up a laryngoscope + bougie as back up
now that her oropharynx is dried up I'll hurricane spray what I can see, followed by generous
viscous lidocaine
get paralytics drawn up in case of failure, but don't push them
load the patient with ketamine 1-2 mg/kg
say a few Hail Mary's
go for the fiberoptic tube

 

[somedumbDO]

Just call anesthesia.... we do this stuff all the time

Awake fiber optic, no sedation w pharyngeal nerve blocks and trans tracheal. If air is getting out u can find a way to place a small tube. If no identifiable landmarks huff on 4% lido via neb. A couple squirts via atomizer to post pharynx, foi squirt the cords. Drive a 5.0 home. If absolutely need sedation a touch of precedex.

 

[GeneralVeers]

I don't have a fiber-optic and glidescope is unlikely to help in this case.

I had a case similar to this where an (undocumented) 40ish patient had severe stridor from a large thyroid cancer. No ENT on-call. I couldn't transfer him by ground because he would not have gotten through the border control checkpoint in San Antonio, and the CBP clearance to do this takes a few hours.

Being the only night doctor (and only physician in the hospital) I didn't consider trying to intubate him myself, as I knew a cric would be impossible if I failed.

Fortunately the general surgeon that was on call was awesome and a friend of mine. We rounded up anesthesia, general surgery, and vascular surgery. They actually put this guy on heart/lung bypass in the OR before anesthesia successfully intubated him.

 

[RoyBasch]

Similar to other posters above,

I would go for the "triple set up"

Plan A: awake fiberoptic nasotracheal intubation
Plan B: Glideoscope to assist bronchoscope into the laryngeal inlet or intubate with bougie if possible to pass to mainstem bronchus
Plan C: Neck prepped and marked with crich tray open and ready

At my hospital I would call anesthesia (in house) stat, trauma (sometimes in house) and ENT (home call) and ask all be at the bedside. Prepare patient with glycopyrolate, afrin in the nares, and topicalization with 4% lido neb, viscous 2% lido mouth swab on tongue depressor, and huricane spray the oropharynx and nares.

Probably sedate awake with ketamine 1mg/kg

have bolus of etomidate ready once tube is past cords and pt starts coughing.

fentanyl/propofol gtt after, ICU admission.

Discuss with consultants and document plan to convert in the OR over the next 12-24 hours to trach with ENT prior to extubation of translaryngeal tube.

Never seen it myself but have heard of rare situations of an "unintubatable patient" because of a advanced untreated neck tumor where patient go straight to VV ECMO in the OR and then tumor de-bulking/trach placement.

 

[Apollyon]

Just recently, our anesthesia friends had a nice thread about a similarly hairy situation that would put the fear of Jeebus into anyone.

 

[fahimaz7]

presuming you should have a view of the cords I would bury a bougie until it stops then shove a tube over the top. I'd give racemic a few times before and likely do it with ketamine and succs

 

[BoardingDoc]

Just recently, our anesthesia friends had a nice thread about a similarly hairy situation that would put the fear of Jeebus into anyone.

Link?

 

[HighPriest]

That's a tough situation. Sorry to butt in, but this is up my alley.

In a perfect world: check directives first and then call ENT. Without ENT, (and in an ideal world otherwise): I like the glycolpyrrolate. Oxygenation. If necessary heliox. Try to get her to the OR for fiberoptic intubation with a surgeon in the room who can trach. If you had to do something in the ER, I think some of these other options are reasonable, but risky. I certainly would not attempt anything in the ER if her sats came up.

The problem here is that she has a goiter. It could be simply that her cords are out from a malignancy, and so if you get a tube past her cords you're golden. But it could also be that she has tracheal compression or overt tracheal invasion - could be in the cervical or thoracic trachea. No way to determine that accurately with an NP scope. Imaging could tell you if she were stable enough to get some. Cricothyroidotomy wouldn't help, as it's too high unless this is an isolated cord issue. Tracheostomy -might- help if you can cut through all of that bleeding goiter below the actual point of stenosis, and you wouldn't know where that is without a bronch or imaging.

If she were stable enough (IF), NP scope, verify cord mobility and if the cords are normal, imaging to verify the site of her narrowed airway

I'd definitely try to manage this patient in an OR with a trach set open and a surgeon who is very upset that you called him. Let the anesthesiologist try to get a small tube in (that'd be ideal). If it's just a soft goiter with compression, you can often squeeze a tube by it. Otherwise surgical airway.

For what it's worth, I've seen a few cases like this, a few more with laryngeal cancer, a couple with tracheal compression from sclerotic tracheal stenosis...

You can do ECMO, but obviously you'd have to have that available. It'd be weird to me if you were at a facility with no ENT but you did have ECMO.

 

[Apollyon]

Link?

Happy Holidays - my gift from ENT

 

[HighPriest]

I had a case while moonlighting. 40-something lady with some unusual type of achondroplasia, can't remember which, but the associated physical findings included tracheal stenosis, short stature, short neck, scoliosis (couldn't lay flat at all, neck was at about 45 degrees from her shoulderblades), and absence of the IVC. It's like a disease dedicated to airway problems. She had had a previous tracheostomy and had classic infracture of her tracheal rings with additional narrowing of the airway from that. The stenotic area in her trachea was about 2.5cm, plus the surgerized area. She had been in an MVA and came in with a flail segment of chest wall. Desatting (80s and dropping), also anemic from bleeding. Can't place ECMO without an IVC, I'm told.

That was a fun day.

 

[gamerEMdoc]

Had a case where a 95 yo DNR/DNI (only if pulseless) on an ACE inhibitor brushed her teeth with capsacin cream. Tough swelled up to fill her mouth. It was legit impressive. Her and her family was ok with intubation since they viewed it as short term. I was pretty much like, "this is not going to go well". I prepped her neck, and had anesthesia come down. Anesthesia stood by while we gave her etomidate only, passed a bougie, then tubed her. She got extubated two days later without issues. Sometimes calling down the Anesthesia folks just wards off the evil spirits.

 

[BoardingDoc]

Happy Holidays - my gift from ENT

Crap that was a stressful read. Having the CT imaging at the beginning was extremely helpful for painting the picture. Nicely done @Noyac.

 

[RustedFox]

That's a tough situation. Sorry to butt in, but this is up my alley.

In a perfect world: check directives first and then call ENT. Without ENT, (and in an ideal world otherwise): I like the glycolpyrrolate. Oxygenation. If necessary heliox. Try to get her to the OR for fiberoptic intubation with a surgeon in the room who can trach. If you had to do something in the ER, I think some of these other options are reasonable, but risky. I certainly would not attempt anything in the ER if her sats came up.

The problem here is that she has a goiter. It could be simply that her cords are out from a malignancy, and so if you get a tube past her cords you're golden. But it could also be that she has tracheal compression or overt tracheal invasion - could be in the cervical or thoracic trachea. No way to determine that accurately with an NP scope. Imaging could tell you if she were stable enough to get some. Cricothyroidotomy wouldn't help, as it's too high unless this is an isolated cord issue. Tracheostomy -might- help if you can cut through all of that bleeding goiter below the actual point of stenosis, and you wouldn't know where that is without a bronch or imaging.

If she were stable enough (IF), NP scope, verify cord mobility and if the cords are normal, imaging to verify the site of her narrowed airway

I'd definitely try to manage this patient in an OR with a trach set open and a surgeon who is very upset that you called him. Let the anesthesiologist try to get a small tube in (that'd be ideal). Otherwise surgical airway.

For what it's worth, I've seen a few cases like this, a few more with laryngeal cancer, a couple with tracheal compression from sclerotic tracheal stenosis...

You can do ECMO, but obviously you'd have to have that available. It'd be weird to me if you were at a facility with no ENT but you did have ECMO.

Are you ENT or Anesthesia, or ... something else?

 

[HighPriest]

Are you ENT or Anesthesia, or ... something else?

ENT. Although my Momma told me I'm something else.

 

[RustedFox]

ENT. Although my Momma told me I'm something else.

Lol.

Thanks for the input. I hope you stick around here, amigo.

 

[Tenk]

Probably at least attempt bipap while awake but with low pressures at first. Might help, might not. I have set up numerous respiratory distress patients with bipap prior to intubation and I feel like it usually works.

If that helps, great! Buys more time. If it does not, oh well, high flow oxygen. I don’t think my shop has heliox.

Next I would get all the airway equipment I can and if I have absolutely no surgical backup I’d probably ketamine alone first (may actually help with breathing who knows), no paralytic yet and have just a look at the cords with either fiber optics or glide. If the cords look fantastic, I’d prolly try to pass a smaller tube like a 6.0 with multiple smaller tubes ready and see if that goes, paralytic if needed, probably sux for this one although I usually use roc. Obviously if I had surgical backup I’d try all this with as much help as possible but like op said, sometimes that isn’t available.

Remember, this probably didn’t happen overnight with that growth, so if you can just slightly improve a patient like this, you can probably buy a lot of time. Sometimes it won’t though and you just have to go for it.

 

[deleted547339]

25 mcg fent, lido neb, awake FOI.

Chances are the issue is subglottic, so you could actually presumably RSI the patient. The issue is that you may not be able to pass the tube. Agree with above that I’d primarily use a bougie if using DL/VL and try to pass a 5.0 or something thereabouts.

 

[scummie]

I already get nervous before night shifts because we go down to single coverage. Why did I read this thread??

 

[VisionaryTics]

ENT. Although my Momma told me I'm something else.

Another ENT. I love reading these threads. Really enjoy seeing the perspective from anesthesia/EM on these patients.

My thought is to never do anything that changes the situation from urgent to emergent. Keep the patient awake and breathing and supporting their airway until the tube is in.

Had a case last week shortly after reading that anesthesia forum post:

Young woman with anaplastic thyroid cancer, s/p previous total thyroid about 4 months ago, received radiotherapy, tumor immediately recurred and persisted through first round of chemo. Presents with biphasic stridor to university ER where she is planning to go on a clinical trial.

She is stridulous but comfortable on 4 L NC. Scope exam shows her right cord is out, but upper airway otherwise patent. CT scan shows thyroid mass invading strap muscles, SCM, bilateral carotids, esophagus, and mass effect on trachea with shifted narrowed tracheal airway (like 5mm on scan). On exam her neck feels like a rock from radiation and recurrent tumor, can't feel any landmarks below chin or above sternum. She's thin, mallampati 1, and aside from this, otherwise healthy.

Discussion between ER and medical oncology first asking whether chemo will shrink the tumor so wouldn't need any intervention. Med onc asks for ENT input.


Plan: Awake trach under local anesthesia realistically out of the question. Controlled trachs after transoral intubation through anaplastic thyroid cancer can routinely have blood loss >2L. We can't feel anything, can't numb anything, and trach may take an hour.

Decide for awake fiberoptic intubation with small tube (6.0) on Precedex, no other sedation. She is counseled about the realistic chance she doesn't survive procedure. Trach set is available in the OR, but wishful thinking if anything goes wrong. Lidocaine nebulizer on the way to OR per anesthesia (I think it's useless compared to directed topical lidocaine).

In the OR, Ovassapian airway is placed after spraying 4% in oropharynx. Scope introduced transorally. I ask for a good quality video bronchoscope, so multiple people can see what's going on and help. She's on high flow nasal cannula, sitting straight up on the OR table, with me standing in front of her. This allows the tongue to fall out of the airway and get the best view. I spray down tongue base, epiglottis, bilateral aryepiglottic folds and false cords, true cords, and subglottis, sequentially. I take my time, let the lidocaine work. No rush, no emergency yet.

During actual intubation, I make sure she's strapped down tight in case she tries to pull the tube after it goes in. Scope goes smoothly past the cords, smoothly past the tracheal stenosis. At this point she starts coughing and bucking and the tight straps are helpful. A Parker Flextip Tube is spiralled over the scope, past the cords, and pushed HARD past the obstruction. It takes muscle, but slips through. Scope confirms position in the trachea. Scope removed, cuff inflated, end-tidal confirmed, propofol goes in.


During subsequent tracheostomy, it takes 50 minutes to find the airway through tumor. Shiley distal XLT 6.0 trach tube is placed to get the tube past the obstruction.

This is a different problem than exophytic tumor within the tracheal lumen with acute airway obstruction. Hermes Grillo has a great chapter on management of these patients in his textbook; essentially he recommends driving a rigid ventilating bronch through the tumor to clear airway, coring it out, removing the cored tumor, and then replacing bronch and hooking up circuit on the bronch. I've never had to do this (thankfully), but something to think about.

 

[Groove]

Great responses. Bunch of pros in here.

Here's how it went down. Planned for AFOI+VL

Lido and Racemic epi nebs, didn't have time to get any hurricaine or topicalize further. Ketamine for sedation. Double operator setup. Glide and bronch. 7.0ETT on the rigid stylet for glide. I had a 6.5ETT loaded on the bronch. We both stood at the head of the bed. Spent some time optimizing her positioning. The plan was to take a look with the glide first and if there were no fungating masses, blood or severely dysmorphic anatomy, then to just go for it with the 7.0. If things looked hairy, then I planned to FOI with the bronch. Operator one in this case holds the view with the glide and takes the bronch with their free hand and passes the tip close to the epiglottis for first landmark and then lets operator two drive through the cords.

Back ups within reach: loaded fiberoptic intubating stylet (Levitan), mcgrath, gum elastic bougie, LMA 4, melker cric kit, perc trach kit. Paralytics on stand by.

Exit strategy:

1) LMA if we can't pass any of the tubes. She is at the very least passing air through her trachea and glottis and I feel fairly confident I could at the very least ventilate her through a well seated LMA. That would also save me some time to set up for #2.
2) Cric or perc trach through the lower tracheal segment above the sternal notch. I should be able to put the melker through that, preferably while ventilating her through the LMA.

What happened:

Colleague took a look with glide and we didn't see any abnormal anatomy though the laryngeal inlet seemed constricted to me. Grade 2 view. I said go for it. She couldn't pass the 7.0ETT. Struggling, possibly a subglottic stricture or mass. It just wouldn't go. While she has the tip of ETT pressed against the cords, we slam down a bougie through the ETT which slides through the cords just fine. Take off 7.0 and I take the 6.5 off the bronch and feed it over. It also won't pass though this time it seems to be hung up on the arytenoids. I rotate it counter clockwise and doesn't seem to free and I'm not positive it's the arytenoids and not a subglottic lesion. With some muscle and further rotations I finally push it through.

That's it folks. We paralyzed her, sedated her and colleague transferred her to a hospital where ENT was available.

Thanks for the great replies.

 

[HighPriest]

My thought is to never do anything that changes the situation from urgent to emergent. Keep the patient awake and breathing and supporting their airway until the tube is in.

This was my thought as well. If you’re in a bind, and you have to intubate or the patient dies, you do what you have to do. But if not, just supportive measures until the patient is in the most amenable position to intervene.

Had a guy once who was an Ironman participant. Was training on his bike, riding with his head down. Looked up at the last minute to see a truck with the bed down, which he promptly ran in to. Sheered all the teeth off his bottom jaw. Bled like a stuck pig. He happened to be an OB/GYN and realized he was choking on blood. So he rolled on his stomach and found that he could breath just fine so long as the blood was running away from his airway. EMTs came and tried to roll him on to his back, and he asked them not to. Surprisingly they did not. He then presented to the ER, where the residents rolled him over. He started to choke again, so they pushed sux and etomidate and then realized they couldn’t see his airway, and the trauma surgeon ended up doing a slash trach. By the time we got there it was all said and done, and we took him to the OR and ran a single 4-O chromic stitch over his gum line and asked him to follow up with his dentist. After he got out of the hospital with his trach wound.
Now, that could have gone a lot of ways for a lot of reasons. No criticism. But the point is: stable patient, made unstable, then made an emergency by sedating and paralyzing.

Sometimes that’s the right call. Sometimes it isn’t.

 

[WilcoWorld]

This was my thought as well. If you’re in a bind, and you have to intubate or the patient dies, you do what you have to do. But if not, just supportive measures until the patient is in the most amenable position to intervene.

Had a guy once who was an Ironman participant. Was training on his bike, riding with his head down. Looked up at the last minute to see a truck with the bed down, which he promptly ran in to. Sheered all the teeth off his bottom jaw. Bled like a stuck pig. He happened to be an OB/GYN and realized he was choking on blood. So he rolled on his stomach and found that he could breath just fine so long as the blood was running away from his airway. EMTs came and tried to roll him on to his back, and he asked them not to. Surprisingly they did not. He then presented to the ER, where the residents rolled him over. He started to choke again, so they pushed sux and etomidate and then realized they couldn’t see his airway, and the trauma surgeon ended up doing a slash trach. By the time we got there it was all said and done, and we took him to the OR and ran a single 4-O chromic stitch over his gum line and asked him to follow up with his dentist. After he got out of the hospital with his trach wound.
Now, that could have gone a lot of ways for a lot of reasons. No criticism. But the point is: stable patient, made unstable, then made an emergency by sedating and paralyzing.

Sometimes that’s the right call. Sometimes it isn’t.

The other point is that we probably cause more harm than good by insisting on spinal immobilization for alert patients.

Nature is smarter than you are - if a sick patient is refusing to lay supine, there may be a good reason for it!

 

[RoyBasch]

25 mcg fent, lido neb, awake FOI.

Chances are the issue is subglottic, so you could actually presumably RSI the patient. The issue is that you may not be able to pass the tube. Agree with above that I’d primarily use a bougie if using DL/VL and try to pass a 5.0 or something thereabouts.

Agree, the issue is not going to be vocal cord visualization, the problem is going to be actually advancing the tube because the obstruction is subglottic. I think any non-surgical airway here needs some kind of device bridging the stenotic point to help seldinger the relatively soft tube such as either a bougie or a bronchoscope.

 

[RoyBasch]

While she has the tip of ETT pressed against the cords, we slam down a bougie through the ETT which slides through the cords just fine. Take off 7.0 and I take the 6.5 off the bronch and feed it over. It also won't pass though this time it seems to be hung up on the arytenoids. I rotate it counter clockwise and doesn't seem to free and I'm not positive it's the arytenoids and not a subglottic lesion. With some muscle and further rotations I finally push it through.

I've done this move twice before with good success in the same situation with good laryngeal view but cannot advance tube because of a subglottic stenosis.

 

[RustedFox]

 

[WilcoWorld]

Lemmy!

 

[deleted859535]

Great responses. Bunch of pros in here.

Here's how it went down. Planned for AFOI+VL

Lido and Racemic epi nebs, didn't have time to get any hurricaine or topicalize further. Ketamine for sedation. Double operator setup. Glide and bronch. 7.0ETT on the rigid stylet for glide. I had a 6.5ETT loaded on the bronch. We both stood at the head of the bed. Spent some time optimizing her positioning. The plan was to take a look with the glide first and if there were no fungating masses, blood or severely dysmorphic anatomy, then to just go for it with the 7.0. If things looked hairy, then I planned to FOI with the bronch. Operator one in this case holds the view with the glide and takes the bronch with their free hand and passes the tip close to the epiglottis for first landmark and then lets operator two drive through the cords.

Back ups within reach: loaded fiberoptic intubating stylet (Levitan), mcgrath, gum elastic bougie, LMA 4, melker cric kit, perc trach kit. Paralytics on stand by.

Exit strategy:

1) LMA if we can't pass any of the tubes. She is at the very least passing air through her trachea and glottis and I feel fairly confident I could at the very least ventilate her through a well seated LMA. That would also save me some time to set up for #2.
2) Cric or perc trach through the lower tracheal segment above the sternal notch. I should be able to put the melker through that, preferably while ventilating her through the LMA.

What happened:

Colleague took a look with glide and we didn't see any abnormal anatomy though the laryngeal inlet seemed constricted to me. Grade 2 view. I said go for it. She couldn't pass the 7.0ETT. Struggling, possibly a subglottic stricture or mass. It just wouldn't go. While she has the tip of ETT pressed against the cords, we slam down a bougie through the ETT which slides through the cords just fine. Take off 7.0 and I take the 6.5 off the bronch and feed it over. It also won't pass though this time it seems to be hung up on the arytenoids. I rotate it counter clockwise and doesn't seem to free and I'm not positive it's the arytenoids and not a subglottic lesion. With some muscle and further rotations I finally push it through.

That's it folks. We paralyzed her, sedated her and colleague transferred her to a hospital where ENT was available.

Thanks for the great replies.

Strong work!

Had an angioedema case once that makes me wonder about others' thoughts (I ultimately got her intubated, she did fine) -- in an upright, sedated FOI, has anyone had to go with good sedation only but without topicalization for whatever reason, allergies or availability or what have you?

 

[RoyBasch]

Of course the text book answer to a lot of these cases is FOI; however, how many of you feel comfortable doing this yourself? When I plan for a FOI, I call anesthesia and they are the actual operator. My experience when I was a resident with bronchoscopy was very limited (did some in sim, did 2 in the ICU and 1 in the ER under heavy supervision). I am several years post residency, is there a good way to learn these skills post residency?

 

[BoardingDoc]

Of course the text book answer to a lot of these cases is FOI; however, how many of you feel comfortable doing this yourself? When I plan for a FOI, I call anesthesia and they are the actual operator. My experience when I was a resident with bronchoscopy was very limited (did some in sim, did 2 in the ICU and 1 in the ER under heavy supervision). I am several years post residency, is there a good way to learn these skills post residency?

If you have a case that needs an FOI in the future, go ahead and call anesthesia but tell them that you would like to do the first pass. They can take over if you feel uncomfortable.
You can also practice with an intubating mannequin independently. Those things are obviously flawed, but it's not a bad way to practice actually playing with the scope and learning how to manipulate your view.

To answer your original question: I have had anesthesia on hand for maybe half of the FOIs I've done, but I've been the operator each time. Both in and out of residency. I did several as a resident and a bunch of bronchs as a resident as well. Obviously different case with the latter but the device control is essentially the same.

 

[B-Bone]

If you have a case that needs an FOI in the future, go ahead and call anesthesia but tell them that you would like to do the first pass. They can take over if you feel uncomfortable.
You can also practice with an intubating mannequin independently. Those things are obviously flawed, but it's not a bad way to practice actually playing with the scope and learning how to manipulate your view.

To answer your original question: I have had anesthesia on hand for maybe half of the FOIs I've done, but I've been the operator each time. Both in and out of residency. I did several as a resident and a bunch of bronchs as a resident as well. Obviously different case with the latter but the device control is essentially the same.

Wrong answer. If I get a call from anyone to "help" or "observe" a procedure, I am doing that procedure. Especially in a known or anticipated difficult airway, you always want to have the most skilled, most experienced person take the first (i.e. best chance for success) attempt. Difficult airways are one of the procedures that previous attempts can really mess up. Blood, secretions, and swelling show up surprisingly quickly and can make things exponentially more difficult (or impossible). Outside of an academic center, there shouldn't be any "doc supervising doc".

 

[BoardingDoc]

Wrong answer. If I get a call from anyone to "help" or "observe" a procedure, I am doing that procedure. Especially in a known or anticipated difficult airway, you always want to have the most skilled, most experienced person take the first (i.e. best chance for success) attempt. Difficult airways are one of the procedures that previous attempts can really mess up. Blood, secretions, and swelling show up surprisingly quickly and can make things exponentially more difficult (or impossible). Outside of an academic center, there shouldn't be any "doc supervising doc".

I hear where you're coming from, and I'd respect that as your personal policy if I consulted you. That said, it's your policy, not everyone's policy. You state that "doc supervising doc" shouldn't happen outside of an academic center. Why? Your implication is that you better have learned everything you need to know during residency and if you didn't then I guess you're SOL? Again, I'm not saying that you personally need to be the one on hand to help people learn these skills, and I'm not saying that the less experienced operator should always be given a crack at it, but to imply that my suggestion is universally the "wrong answer" is an opinion that neither I nor many of your colleagues share.

 

[B-Bone]

Agreed. To each his own. I did generalize a bit. I am happy to help a colleague learn a new skill, just not when it's emergent, time-sensitive with potential for dire consequences if they are unsuccessful. There's also an element for respect for other people's time. I'm not generally at work, sitting around doing nothing. Being called away from the OR to the ED for an airway is fine; that's part of my job. The OR (or OB or ICU or whatever) can wait if I'm attending to an emergency elsewhere. But if I put the OR on hold (stop seeing patients, stop taking patients back, stop doing labor epidurals, make surgeons wait, etc) it's generally not going to be for a teaching session. In residency, I learned to do fiberoptic bronchoscopy either bronching in the ICU or doing elective asleep fiberoptic intubations in the OR. I had many elective, easy, fiberoptic intubations under my belt before I ever tried an awake, emergent or difficult one. Personally, I'd recommend asking anesthesia about doing elective asleep fiberoptics in the OR. I'd be happy to accommodate that. Also, it makes the time commitment yours rather than some random person you may or may not know who has a bunch of other stuff to do.

 

[Beeftenderloin]

Another ENT. I love reading these threads. Really enjoy seeing the perspective from anesthesia/EM on these patients.

My thought is to never do anything that changes the situation from urgent to emergent. Keep the patient awake and breathing and supporting their airway until the tube is in.

Had a case last week shortly after reading that anesthesia forum post:

Young woman with anaplastic thyroid cancer, s/p previous total thyroid about 4 months ago, received radiotherapy, tumor immediately recurred and persisted through first round of chemo. Presents with biphasic stridor to university ER where she is planning to go on a clinical trial.

She is stridulous but comfortable on 4 L NC. Scope exam shows her right cord is out, but upper airway otherwise patent. CT scan shows thyroid mass invading strap muscles, SCM, bilateral carotids, esophagus, and mass effect on trachea with shifted narrowed tracheal airway (like 5mm on scan). On exam her neck feels like a rock from radiation and recurrent tumor, can't feel any landmarks below chin or above sternum. She's thin, mallampati 1, and aside from this, otherwise healthy.

Discussion between ER and medical oncology first asking whether chemo will shrink the tumor so wouldn't need any intervention. Med onc asks for ENT input.


Plan: Awake trach under local anesthesia realistically out of the question. Controlled trachs after transoral intubation through anaplastic thyroid cancer can routinely have blood loss >2L. We can't feel anything, can't numb anything, and trach may take an hour.

Decide for awake fiberoptic intubation with small tube (6.0) on Precedex, no other sedation. She is counseled about the realistic chance she doesn't survive procedure. Trach set is available in the OR, but wishful thinking if anything goes wrong. Lidocaine nebulizer on the way to OR per anesthesia (I think it's useless compared to directed topical lidocaine).

In the OR, Ovassapian airway is placed after spraying 4% in oropharynx. Scope introduced transorally. I ask for a good quality video bronchoscope, so multiple people can see what's going on and help. She's on high flow nasal cannula, sitting straight up on the OR table, with me standing in front of her. This allows the tongue to fall out of the airway and get the best view. I spray down tongue base, epiglottis, bilateral aryepiglottic folds and false cords, true cords, and subglottis, sequentially. I take my time, let the lidocaine work. No rush, no emergency yet.

During actual intubation, I make sure she's strapped down tight in case she tries to pull the tube after it goes in. Scope goes smoothly past the cords, smoothly past the tracheal stenosis. At this point she starts coughing and bucking and the tight straps are helpful. A Parker Flextip Tube is spiralled over the scope, past the cords, and pushed HARD past the obstruction. It takes muscle, but slips through. Scope confirms position in the trachea. Scope removed, cuff inflated, end-tidal confirmed, propofol goes in.


During subsequent tracheostomy, it takes 50 minutes to find the airway through tumor. Shiley distal XLT 6.0 trach tube is placed to get the tube past the obstruction.

This is a different problem than exophytic tumor within the tracheal lumen with acute airway obstruction. Hermes Grillo has a great chapter on management of these patients in his textbook; essentially he recommends driving a rigid ventilating bronch through the tumor to clear airway, coring it out, removing the cored tumor, and then replacing bronch and hooking up circuit on the bronch. I've never had to do this (thankfully), but something to think about.

There’s a cases similar to this described on the anesthesia forum. End of the algorithm type situation. Thoracic surgeon put the rigid bronch down attempting to “core out” the tumor. Ended up tearing away from the trachea entirely. Moved to a crash sternotomy, cut down on the right main stem and intubated that. Supposedly the patient did okay.

 

[RoyBasch]

There’s a cases similar to this described on the anesthesia forum. End of the algorithm type situation. Thoracic surgeon put the rigid bronch down attempting to “core out” the tumor. Ended up tearing away from the trachea entirely.

I'm way out of my depth on this one, (no experience with rigid bronchs) but that would be my concern that if you have distorted anatomy with stiff non compliant tissue from an invasive malignancy it would be very easy to false passage and just shred the airway.

 

[B-Bone]

Anterior mediastinal masses are bad news as they can compress the trachea or even more distal airways in the chest, completely blocking any air exchange at a level way beyond where any tube or surgical airway would be of utility. Concern is that negative pressure ventilation is the only thing stenting open the extremely tenuous airway and any decreased respiratory drive or attempt at PPV could lead to complete airway collapse. I suspect that's what happened in the case mentioned above. Appropriate "airway" equipment to have in the OR includes rigid bronch plus/minus peripheral cardiopulmonary bypass cannulas and a surgeon who knows how to use them. I've only done a few really bad ones of these, but I did do one where we put the patient on fem-fem CPB completely awake with no sedation and intubated the patient after sternotomy and tumor mobilization. Serious business.

 

[Groove]

Strong work!

Had an angioedema case once that makes me wonder about others' thoughts (I ultimately got her intubated, she did fine) -- in an upright, sedated FOI, has anyone had to go with good sedation only but without topicalization for whatever reason, allergies or availability or what have you?

Thanks man. Yes, I've had other AFOI where I didn't have time to topicalize. Specifically remember an angio where I used ketofol and it worked great. Failed nasotracheal FOI and converted to cric but everything went as smoothly as to be expected from that scenario (minus the pucker coefficient) with only the above sedation. I think I used 1:1 on the ketamine: propofol and slammed paralytics right as the melker went in. The pt was spontaneously breathing but totally out for the procedure.

 

[Groove]

I don't really have the luxury of reliable anesthesia as my shop. Honestly, it's the pulm/cc docs that are more readily available to come down and help out if we need a second operator or any assistance. One of them is very skilled at perc trachs and can sometimes be standby to just do a trach instead of the cric if AFOI fails. It's pretty rare for me to call someone though. One of my colleagues called anesthesia one time and only a CRNA was available who reportedly took one look at the airway, started shaking his head, cursing under his breath and walk/ran out of the room dialing someone on the cell phone (attending?). We seem to only have CRNAs available and haven't had great experiences with them in the past on the rare occasions anyone called them. I would consider myself skilled with AFOI (for EM) but I'm not an egomaniac and if I need someone on stand by or even am required to hand over the procedure, I would do it in the heart beat if I thought it was in the pt's best interest. In my case, the times I've gained the most experience, I really didn't have anybody available which in hindsight was a good thing I guess depending on how you look at it. Sometimes though you just don't have time...

 

[Groove]

Of course the text book answer to a lot of these cases is FOI; however, how many of you feel comfortable doing this yourself? When I plan for a FOI, I call anesthesia and they are the actual operator. My experience when I was a resident with bronchoscopy was very limited (did some in sim, did 2 in the ICU and 1 in the ER under heavy supervision). I am several years post residency, is there a good way to learn these skills post residency?

Agree with BoardingDoc. I've gone to a respiratory conferences in the past (ok, there was a hot RT involved) and they always seem to have labs with vendors showing off their equipment. I'll drive the scope for awhile during those. The Difficult Airway Course is good. I did that last year, maybe year before?...and it was solid. Spent a lot of time in the labs and even picked up a few things from the fellow ER docs. I think ACEP also has an airway lab.

We had a nasopharyngoscope in the ED during residency and I tried to use it as often as I could and luckily had attendings that let me. I'm sure that helped. If you have the ambuascope they have a slim bronch that you can use for nasopharyngoscopy and could practice that way. Use it on the pt's that have mild angioedema that you are thinking of sending home after obs and take a quick peek at their cords.

 

[RoyBasch]

The Difficult Airway Course is good. I did that last year, maybe year before?...and it was solid.

Is this the Rich Levitan course?

 

[Groove]

Is this the Rich Levitan course?

No, though I want to do that one.

It's this one. Welcome to The Definitive Site for Airway Management Education - The Difficult Airway Course - TheAirwaySite

 

[Hamhock]

Lido and Racemic epi nebs, .

Does anyone know if these two are compatible?

That is, can they just be placed in the same neb?

HH

 

[Groove]

Does anyone know if these two are compatible?

That is, can they just be placed in the same neb?

HH

I don't see why not? I'll double check with pharmacy or respiratory today at work. In this case, she was on lido neb and I swapped it over to racemic as we prepped for procedure. She wasn't on either very long so I'm doubtful there was any true benefit. I've never combined them.

 

[TheComebacKid]

This patient is getting a fiberoptic intubation, or the neck is getting cut. There is no way in hell I would attempt to RSI this lady.

I don't know who taught me this, but I found it to be useful for the few that I've done in residency.

1. Ketamine
2. A little more ketamine.
3. Nebulized/atomized lidocaine
4. Nasal trumpet. Cut the nasal trumpet longitudinally. and insert it.
5. Fiberoptic scope with ETT tube loaded on
6. Pass the scope through the nasal trumpet
7. Once you are passed the cords, remove the nasal trumpet
8. Pass the tube (can paralyze at this point)
9. Find a new pair of boxers
10. Find a new pair of scrub pants

I find the nasal trumpet technique to be money since I waste about 99% of my time trying to get past the damn turbinates, the patient is freaking out and if they start bleeding it's game over.

 

[deleted109597]

Does anyone know if these two are compatible?

That is, can they just be placed in the same neb?

HH

Yes. It's topical, so there's not going to be any harms with precipitation.

 

[FirstNobleTruth]

This patient is getting a fiberoptic intubation, or the neck is getting cut. There is no way in hell I would attempt to RSI this lady.

I don't know who taught me this, but I found it to be useful for the few that I've done in residency.

1. Ketamine
2. A little more ketamine.
3. Nebulized/atomized lidocaine
4. Nasal trumpet. Cut the nasal trumpet longitudinally. and insert it.
5. Fiberoptic scope with ETT tube loaded on
6. Pass the scope through the nasal trumpet
7. Once you are passed the cords, remove the nasal trumpet
8. Pass the tube (can paralyze at this point)
9. Find a new pair of boxers
10. Find a new pair of scrub pants

I find the nasal trumpet technique to be money since I waste about 99% of my time trying to get past the damn turbinates, the patient is freaking out and if they start bleeding it's game over.

Solid strategy.

I was always a big proponent of the nasal trumpet as well, but one thing that we've been playing with and found effective (I'm in academics) is actually pre-placing the endotracheal tube.

So instead of placing the nasal trumpet in the nare, you actually just gently place the 6-0 endotracheal tube blindly until you are passed the turbinates. The tip of the balloon will then be in the nasopharynx but still well above the cords - where the end of your nasal trumpet would usually be. You then use this as the conduit to pass your fiberoptic without picking up mucus on the turbinates, and when the fiberoptic is through the cords you can then just advance the ETT the rest of the way. This eliminates the step of removing the nasal trumpet (easy enough with the pre-cutting, but still), as well as that unfortunate situation where your fiberoptic is through the cords but the ETT won't get through the turbinates

Food for thought my friends.

 

[WilcoWorld]

Solid strategy.

I was always a big proponent of the nasal trumpet as well, but one thing that we've been playing with and found effective (I'm in academics) is actually pre-placing the endotracheal tube.

So instead of placing the nasal trumpet in the nare, you actually just gently place the 6-0 endotracheal tube blindly until you are passed the turbinates. The tip of the balloon will then be in the nasopharynx but still well above the cords - where the end of your nasal trumpet would usually be. You then use this as the conduit to pass your fiberoptic without picking up mucus on the turbinates, and when the fiberoptic is through the cords you can then just advance the ETT the rest of the way. This eliminates the step of removing the nasal trumpet (easy enough with the pre-cutting, but still), as well as that unfortunate situation where your fiberoptic is through the cords but the ETT won't get through the turbinates

Food for thought my friends.

I love this idea!

May I never to have occasion to use it.