Another Airway case

[Laurel123]

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Not my case, but I helped out.

50 year old brought in by paramedics after collapsing at a bar. 350 + pounds, 5'9", huge round head, full mountain man beard. Out of it, moving a little bit but he is obstructed and not moving any air. I wasn't there initially so I didn't know if he was making respiratory effort - but either way, he wasn't ventilating. Paramedics try to intubate, can't, and put in a combitube and bring his to ER.

When I do see him, he is on the vent with combitube, moving some air, sat's 88% - not good but not going down. No neck, giant belly, giant head and a huge, fat, swollen tongue that is protruding out about an inch and fills up the entire mouth opening except for the combitube. The anesthesiologist tries to DL with tube in - nothing but tongue and tissue. Tries Glidescope - nothing. Fiberoptic through mouth and nose - nothing. So how to secure the airway? Anyone have any other tricks? Will update later on what was done.

 

[Monty Python]

Not my case, but I helped out.

50 year old brought in by paramedics after collapsing at a bar. 350 + pounds, 5'9", huge round head, full mountain man beard. Out of it, moving a little bit but he is obstructed and not moving any air. I wasn't there initially so I didn't know if he was making respiratory effort - but either way, he wasn't ventilating. Paramedics try to intubate, can't, and put in a combitube and bring his to ER.

When I do see him, he is on the vent with combitube, moving some air, sat's 88% - not good but not going down. No neck, giant belly, giant head and a huge, fat, swollen tongue that is protruding out about an inch and fills up the entire mouth opening except for the combitube. The anesthesiologist tries to DL with tube in - nothing but tongue and tissue. Tries Glidescope - nothing. Fiberoptic through mouth and nose - nothing. So how to secure the airway? Anyone have any other tricks? Will update later on what was done.

Did anyone try the intubating Fastrack LMA?

 

[pd4emergence]

Take him to the OR and have somebody ready to do a trach. I haven't dealt much with the combitube but the next question to answer is where is it. In my experience they have always been in the esophagus but you can always hope. Assuming that is where it is (in the esophagus), I would be pretty leary about pulling it since the guy seems so tenuous. I probably would try to DL, try for a bougie, if that doesn't work, have someone else puts a scope in. Sometimes getting that tissue out of the way makes a big difference. If these maneuvers don't work, say uncle, get your friendly ent who should already be in the room to trach him.

 

[Laurel123]

Did anyone try the intubating Fastrack LMA?

Well, my partner was very nervous about removing the combitube. Even though it is at best a tenuous airway, at least it is an airway and some air movement was happening. Would you guys totally avoid pulling out the combitube?

 

[Planktonmd]

Well, my partner was very nervous about removing the combitube. Even though it is at best a tenuous airway, at least it is an airway and some air movement was happening. Would you guys totally avoid pulling out the combitube?

It really depends on how confident you are in your ability to reestablish the airway if you take the combitube out, it appears from your description that this patient was pretty scary.
I would do a nasal fiberoptic look with the combitube in place and if I can't identify the anatomy then surgical airway it is.

 

[Planktonmd]

By the way, combitubes always make the tongue protrude and make the airway look more horrible than it really is.

 

[gasnewby]

Take him to the OR and have somebody ready to do a trach. I haven't dealt much with the combitube but the next question to answer is where is it. In my experience they have always been in the esophagus but you can always hope.

i thought the combitube was kind of designed to be in the esophagus?

 

[VentdependenT]

Not my case, but I helped out.

50 year old brought in by paramedics after collapsing at a bar. 350 + pounds, 5'9", huge round head, full mountain man beard. Out of it, moving a little bit but he is obstructed and not moving any air. I wasn't there initially so I didn't know if he was making respiratory effort - but either way, he wasn't ventilating. Paramedics try to intubate, can't, and put in a combitube and bring his to ER.

When I do see him, he is on the vent with combitube, moving some air, sat's 88% - not good but not going down. No neck, giant belly, giant head and a huge, fat, swollen tongue that is protruding out about an inch and fills up the entire mouth opening except for the combitube. The anesthesiologist tries to DL with tube in - nothing but tongue and tissue. Tries Glidescope - nothing. Fiberoptic through mouth and nose - nothing. So how to secure the airway? Anyone have any other tricks? Will update later on what was done.

Yeah, an LMA and get a surgeon to come down. Have the ER physician come over and get ready to help you do a cricothyrotomy if you can't ventilate with the LMA.

That combitube has gotta go. Its not gonna cut it for much longer. Yank it. Pop in an LMA 5. Get a arndt bronchial blocker, attach it to the FO scope and snake it through the LMA. If you get it through cords just slip a tube over the blocker (you'll obviously have to cut the end of it off to get the tube on it)

You can try LMA fastrach too. In my limited experience with em, they are fastidious to say the least.

Another thing you can try is have someone do a DL with a MAC 4 and then try the FO scope. Getting all that crap outta the way may seriously help you with your view.

Other stuff you can try, which I have no experience with, is retrograde intubation. YOu can try and fish some sort of guide wire up through an 18 in his trachea and pray it comes into view in the oropharynx. If I have to do this, and I have no view in the first place, then I screwed up somewhere....in otherwords I should be thinking cricothyrotomy.

As long as you can ventilate this dude you have time...at least some time.

 

[Planktonmd]

As long as you can ventilate this dude you have time...at least some time.

Yes, but if you take the combitube out you might not be able to ventilate anymore.

 

[pd4emergence]

i thought the combitube was kind of designed to be in the esophagus?

In my limited experience they alway have been. Take a look at this website.
http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijrdm/vol3n1/combi.xml

They have a distal ballon and are doulble lumen so that if by some grace of god they actually go in the trachea you can ventilate.

 

[VentdependenT]

Yes, but if you take the combitube out you might not be able to ventilate anymore.

Very true, so I would have the cric stuff ready to go and in-house surgeon down in the ER with trach crap ready to go. If no surgeon available too bad, cric time. Waiting much longer and I'll have to cric the guy as were doing chest compressions on him for global hypoxia. His CO2 is probably a million by now with a sweet Ph to boot.

 

[proman]

What tube were they ventilating through? If it's tube 1 then the Combitube is in the esophagus. Tube 2 means it's in the trachea and you can use a tube exchanger to switch. Was the proximal ballon deflated before the FOB attempts? It's a 100 cc, and occludes the hypopharyx.

http://vam.anest.ufl.edu/airwaydevice/combitube/index.html

Shows how to use it and change to a regular ET tube.

 

[gasnewby]

might be a dumb question. if the combitube is in the trachea, why do you need to change it? is that generally done or just b/c this pt's sats aren't great. thanks for the links.

 

[militarymd]

I know this may seem stupid but


SHAVE HIS ASS CLEAN like a baby's bottom

before you do anything else.....wait..I meant his beard in case you guys didn't know what I meant....

After you do that....you can do whatever you want...because the chances are good that you will be able to mask ventilate him with help.

 

[DrDre']

Vent, I love u man, and we all can tell u r rock star solid but the combitube IS cutting it still. I would leave that thing in until u were positive it was not working and the neck was prepped...

Yes, but if you take the combitube out you might not be able to ventilate anymore.

 

[VentdependenT]

Vent, I love u man, and we all can tell u r rock star solid but the combitube IS cutting it still. I would leave that thing in until u were positive it was not working and the neck was prepped...

I am not familiar with the combitube. If it was my airway I wouldn't trust it if the dude is sating at 88% on 100%. However I dig these discussions and I'd much rather this crap happen on this website FIRST before in real life. 🙂

At least now I'll be motivated to read up on em. Gotta get my skills on.

MMD, thanks for the suggestion. Didn't even think of that. If nothing else, that dry cheap ass hospital razor scraping across his face just might provide some stimulation to get him to ventilate.

 

[DrDre']

Combitubes are a great rescue. IF you are lucky enough to have the combitube in the trachea, you can switch it out with an exchanger or over a FOB and save your butt that way. It is of course rare that the combitube ends up in the trachea but it can happen.

I am not familiar with the combitube. If it was my airway I wouldn't trust it if the dude is sating at 88% on 100%. However I dig these discussions and I'd much rather this crap happen on this website FIRST before in real life. 🙂

At least now I'll be motivated to read up on em. Gotta get my skills on.

MMD, thanks for the suggestion. Didn't even think of that. If nothing else, that dry cheap ass hospital razor scraping across his face just might provide some stimulation to get him to ventilate.

 

[Carm]

Someone mentioned this earlier, but any attempt to take DL or even FO with combitube in place has to be done with proximal cuff down. The proximal cuff sits in hypopharynx and would occlude any attempt at a view.

This is true whether you attempt FO, DL or even retrograde (difficult to get wire past cuff even when deflated.

Been in very similar situation except patient was neuro trauma with combitube functioning with 100% sats and absolutely terrible looking airway. Pt's tongue and face were so swollen by the time I saw her in ER I could not even get a blade in her both around the tube. Mucked around way too long with these adjunct airways (wasting precious time with pt with probably increased ICP) and ended up traching in ER.

I don't know much about the condition of your patient, but in hindsight I would have went immediately to OR with combitube😱 or immediately trached patient.

 

[Laurel123]

Well, of course the combitube was in the esophagus, so oh well. We definately considered removing the combitube after the ENT arrived, but we were afraid that this was the one thing stenting his terrible airway open, so disaster was possible. We took him up to the OR and got him in the room with all the difficult airway stuff ready to go. The ENT got there, we all looked at the patient again, turned on the gas and trached him. Then took out the combitube.

But I think had the patient started being difficult to ventilate with the combitube, we would have tried LMA with fast track.

Shaving the face is also a great call.

 

[UTSouthwestern]

Take the combitube out, try any variation of the above you want with surgeon on standby, if it doesn't work, PUT THE COMBITUBE BACK IN. Just try to hyperventilate the patient person before removing it to maximize the ventilation as much as possible before removing the tube.

 

[numbmd]

Good case, the issue at hand is how well do you trust a questionable airway? Using an airway that is only giving you an 88% sats for a case with limited access to the head takes balls of the brass kind. What if it was 85%, 80% ?And what is your plan B thru F going to be if A fails? Because it sounds like you might get BFed if A fails. Actually, you won't get BFed, Mr 400 pounder will.

I'm certainly not second guessing the management of the case. It worked. One less call to the Medical Examiner is always a good thing. Just wondering what the thinking of the anesthesiologist was.