Called to ED....

[seinfeld]

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When i arrive i see one of our OB's at the foot of the bed as i look to the head i see a combitube in place, Pox in the high 80's. The OB says she seized at home., She is 33 weeks, He wants to do a section, FHR 160 with no variablility. the tongue is protrduing out of the mouth. Felt like i was back in my oral boards. ED docs asking you to exchange the Airway because they are having a tough time ventilating and oxygenating.

For the residents out there how would you proceed?

 

[militarymd]

turn her on the side and put in a spinal....fht in the 160's ...you have time to do a regional and avoid the GA with the high mortality rate.

 

[Noyac]

🤣

turn her on the side and put in a spinal....fht in the 160's ...you have time to do a regional and avoid the GA with the high mortality rate.

 

[Noyac]

Is it a bad airway for some reason?

 

[seinfeld]

her tongue looks like mushroom cloud coming out her mouth, cant even see her teeth very well

 

[Ondine]

Sounds like you are lucky to have an airway. I'd confirm that you are ventilating the lungs with the combitube. Given her horribly edematous tongue/airway, I'd be concerned about losing the airway even using an airway exchange catheter. Now if you had a neck-cutter (ENT/gen surgeon) nearby and thought you needed to do this prior to section, then proceed. Otherwise I'd say she is probably hard to ventilate from pulmonary edema (possibly neurogenic) or bronchospasm. Changing the tube ain't gonna help this.
No idea about coags. Thrombocytopenia with her ecclamsia likely.
Since baby is stable:
art line in ED
to OR for section under GA - first control BP, then slow induction
ICU

 

[Noyac]

Sounds like you are lucky to have an airway. I'd confirm that you are ventilating the lungs with the combitube. Given her horribly edematous tongue/airway, I'd be concerned about losing the airway even using an airway exchange catheter. Now if you had a neck-cutter (ENT/gen surgeon) nearby and thought you needed to do this prior to section, then proceed. Otherwise I'd say she is probably hard to ventilate from pulmonary edema (possibly neurogenic) or bronchospasm. Changing the tube ain't gonna help this.
No idea about coags. Thrombocytopenia with her ecclamsia likely.
Since baby is stable:
art line in ED
to OR for section under GA - first control BP, then slow induction
ICU

Ondine, are you really going to take this pt to the OR with this airway? How long do you think this pt is going to need an airway? Will the current airway last that long? Will the edema get better or worse in the next few hours?


I believe you need to secure this airway better.

 

[powermd]

turn her on the side and put in a spinal....fht in the 160's ...you have time to do a regional and avoid the GA with the high mortality rate.

Platelet count first? Or wouldya just go for it?

If she had good air entry bilaterally I wouldn't be inclined to change the tube out. Risk/benefit probably favors a spinal (F the platelets) with a blunt 25 needle, and get the baby out. Call ENT just in case things go south and you have to get heroic with the airway.

 

[Arch Guillotti]

Platelet count first? Or wouldya just go for it?

I think he's joking...

 

[dhb]

Call ENT for trach, optimize ventilation through combitube. If sats don't improve you can try to jet through an angiocath or do a cric depending on what they have available in the ED

 

[USAnesthesiaDoc]

Had a sort of similar situation, but not an obstetric patient. Called to ED to intubate patient with combitube in. I arrived, patient was 45, had massive MI, EMT unable to intubate in field so placed combitube. Pt was morbidly obese, BMI probably around 45, apple shaped female with short neck, also large tongue protruding around the combitube. However, in this case, the patient was near coding. She was blue, and they were not ventilating her, and there was food coming out of her mouth... I grabbed a fiberoptic, intubating lma, and glidescope, and suction. Pulled the combitube out, suctioned, and was actually able to intubate easily with a miller 2. I definitely got lucky, but this patient was in more extremis. She ended up coding and dying shortly afterwards anyway.

I agree that this patient probably needs a more definitive airway before the section. Whether I would proceed with the combitube probably depends on the reason it was placed in the first place. Was she obese with a bad airway, and there was a failed intubation attempt? Versus that is what the EMT had on hand? Also, the fetal heart rate is okay for now. And moving her from the ED to a csection OR table could displace the combitube. Also, turning her on her side for a spinal could displace the combitube as well. You probably have the luxury of enough time to assemble an ENT on standby for a trach, while you have all your airway tools at the bedside to try to place an endotracheal tube.

 

[proman]

I've used Combitubes as a rescue device when I was a paramedic. What you do matters on what lumen you're ventilating. Lumen 1 is when the tip is esophageal and it acts like a supraglottic airway (but does seal off the esophagus). You're only hope is to do what DreamMachine said and attempt to intubate around the tube. Lumen 2 is used when the tip of the tube is in the trachea (happens ~25% of the time). In that case, it's just like an ET tube. The airway is secure but it will have to be non-emergently changed out. The proximal cuff holds 85-100cc and can cause necrosis if left in too long. I don't think a bougie is long enough to work through Lumen 2.

Assuming adequate oxygenation of the mother, I'd leave the Combitube in (especially with the description of the tongue) until after the baby is out and I can have adequate backup equipment and help.

Lumen 1:

Lumen 2:

 

[Fastrach]

My suggestion: Take every remaining Combitube in existence and throw them all in the garbage where they belong. Then, teach EMT's how to put in an intubating LMA.

 

[Bertelman]

Sounds like you are lucky to have an airway. I'd confirm that you are ventilating the lungs with the combitube. Given her horribly edematous tongue/airway, I'd be concerned about losing the airway even using an airway exchange catheter. Now if you had a neck-cutter (ENT/gen surgeon) nearby and thought you needed to do this prior to section, then proceed. Otherwise I'd say she is probably hard to ventilate from pulmonary edema (possibly neurogenic) or bronchospasm. Changing the tube ain't gonna help this.
No idea about coags. Thrombocytopenia with her ecclamsia likely.
Since baby is stable:
art line in ED
to OR for section under GA - first control BP, then slow induction
ICU

I'm not so sure how long baby will be "stable". He said no variability. And why do you need an a-line? You don't even know what her pressure is.

 

[Jeff05]

When i arrive i see one of our OB's at the foot of the bed as i look to the head i see a combitube in place, Pox in the high 80's. The OB says she seized at home., She is 33 weeks, He wants to do a section, FHR 160 with no variablility. the tongue is protrduing out of the mouth. Felt like i was back in my oral boards. ED docs asking you to exchange the Airway because they are having a tough time ventilating and oxygenating.

For the residents out there how would you proceed?

use fiberoptic or glidescope to appropriately position combitube. do not remove.

also, patient may be hypoxic and have an increase in Ds due to aspiration during seizure (not necessarily devise malposition).

 

[Noyac]

use fiberoptic or glidescope to appropriately position combitube. do not remove.

also, patient may be hypoxic and have an increase in Ds due to aspiration during seizure (not necessarily devise malposition).

If she is hypoxic from aspiration then she is going to need a ETT for respiratory support post-op. I don't know about your ICU but if I brought a pt to my ICU with a combitube I don't think things would go very well.

Your best chance at exchange is early b/4 fluid resuscitation and the accompanied third spacing.

 

[Surfer]

Etomidate or Ketamine. Then I'd take the combi-tube out, DLx1, if bad view straight to the LMA with a bronchoscope.

GA with STAT c-section. She has already seized, time to get the baby out. She is already having respiratory issues, time to secure the airway. It is possible the decreased sat is due to the seizure and hypoventilation, but regardless, with the baby there its time to secure the airway with an ETT.

If she wasn't prego i'd be ok with the sats in the 80's if she was actively seizing. I'd control the seizure first, and then if necessary control the airway. In this case (prego), she needs the baby out. The only safe way to do this (for baby and mother) is STAT c-section under GA.

 

[countingdays]

I've used Combitubes as a rescue device when I was a paramedic. What you do matters on what lumen you're ventilating. Lumen 1 is when the tip is esophageal and it acts like a supraglottic airway (but does seal off the esophagus). You're only hope is to do what DreamMachine said and attempt to intubate around the tube. Lumen 2 is used when the tip of the tube is in the trachea (happens ~25% of the time). In that case, it's just like an ET tube. The airway is secure but it will have to be non-emergently changed out. The proximal cuff holds 85-100cc and can cause necrosis if left in too long. I don't think a bougie is long enough to work through Lumen 2.

Assuming adequate oxygenation of the mother, I'd leave the Combitube in (especially with the description of the tongue) until after the baby is out and I can have adequate backup equipment and help.

Lumen 1:

Lumen 2:

Intubate around the tube? Even though you may be much better with airways than the ER guys, it seems like if they had a hard enough time that they needed a combitube, you are likely to have an even harder time with both a difficult airway and a combitube in the way. It's an interesting idea, but I don't know what you're odds of success would be. I would think they'd be pretty low with a difficult airway, huge tongue, a tube in the way proximally, and the distal cuff distorting the already swollen anatomy distally.

 

[Arch Guillotti]

slow induction

A slow induction? In a pt. with crappy sats with a bad baby?

 

[Noyac]

I think some of you are getting pretty accustomed to your big university settings. If this pt came to my hospital it would be at 2am. Once I walked in the door the airway is my issue and the baby is relying on to get mom ready for delivery. Then I gotta deal with where mom goes post-op and how stable she is including her airway. I'm not f*cking around here with this case. I'm changing out that combitube with an ETT and we are getting that baby out STAT. I will more than likely be successful with the ETT either with DL or Glidescope based on past experience but if not I go to jet vent and a trach kit if necessary. If we wait for me to call in surgical airway backup this baby does very poorly and possibly mom does just as bad. Plus, how fast are the guys that get surgical airways in your area. They are not fast enough for this situation unless they slash and put a tube in which I can do just as well.

This pt gets induction with whatever necessary (usually propofol in my hands) and full paralysis.

 

[pgg]

When i arrive i see one of our OB's at the foot of the bed as i look to the head i see a combitube in place, Pox in the high 80's.

The proximal cuff holds 85-100cc and can cause necrosis if left in too long.

When I teach airway classes (either standalone or part of ACLS) I always ask the students how much air to put in the proximal cuff. It's unusual for someone to know it takes up to 100 cc.

Before I gave up on the Combitube I'd make sure the hypoxia and ventilation difficulties weren't due to something so simple as an improperly inflated proximal cuff.

 

[Pilot Doc]

I think some of you are getting pretty accustomed to your big university settings.

What ... you mean your hospital doesn't have an anesthesiologist in house 24-7 solely devoted to intubation and and ENT in house 24-7 with an emergency surgical airway beeper? 🙂

 

[Noyac]

What ... you mean your hospital doesn't have an anesthesiologist in house 24-7 solely devoted to intubation and and ENT in house 24-7 with an emergency surgical airway beeper? 🙂

 

[proman]

When I teach airway classes (either standalone or part of ACLS) I always ask the students how much air to put in the proximal cuff. It's unusual for someone to know it takes up to 100 cc.

Before I gave up on the Combitube I'd make sure the hypoxia and ventilation difficulties weren't due to something so simple as an improperly inflated proximal cuff.

I've actually used the Combitube as my backup in the field. For those who haven't had to intubate outside a hospital, it's miserable. The Combitube is, in my opinion, superior to an LMA because it seals off the esophagus. Trust me, everyone pukes in the field. Combitube is easier to place consistently well. Don't trash it until you've used it. The cuffs are labeled with how much air to put in. The lumens are labeled so you know which to use in what order.. It is a completely acceptable supraglottic (and sometimes endotracheal) airway that seals the esophagus.

But, this patient may not be a difficult airway. Failure to intubate in the field does not mean difficult airway. Most prehospital intubations are attempted without paralysis or induction agents. We know how successful those go.

As for bringing a Combitube to the ICU, I've seen it. Massive facial trauma from car wreck. RSI by the helicopter service, failed, Combitube placed, we kept it in until plastics did a trach on day 2 as part of the repair. You take what you can get.

I stick by that the baby needs to come out before the Combitube.

 

[seinfeld]

My first thought on seeing the patient was surgical airway. The combitube was working somewhat, so i sedated and paralyzed her thinking it would be easier if she were not to resist our attempts at ventilation and i did not want her to remove the only airway she had. I called for a trach kit and a general surgeon stat. I felt her neck and a trach would not be difficult (I have experience in the ICU setting with doing perc trachs and am comfortable using the Blue Rhino kit, having said that i always like surgical backup). With the sedation and paralysis she became easier to ventilate and her SaO2 went up to 99. Had the boys up stairs open up a room for the trach and c-section. When they were done she went to the ICU.

Off the vent onto trach mask on POD #1 and seeing her baby. On POD #5 she still could not breath with plugging of her trach.

I have tried different maneuvers with exchanging like described above never been that thrilled with how precarious it always felt. combitubes

 

[proman]

Why have they gotten rid of it in most places? It hasn't been available at most places I've worked. What are the down sides?

I don't think it's been taught to most practicing anesthesiologists. The LMA wins in the hospital because 1) we use it everyday 2) we can intubate through it with a FOB.

I personally would redesign the Combitube with an wide opening instead of the small holes in Lumen 1 (so you could do a FOB through it like an LMA).

The Combitube (full name is Esophageal Tracheal Combitube) was developed after problems with the EOA (Esophageal Obturator Airway). The EOA can be misplaced in the trachea, and kill the patient. If you put the Combitube in the trachea, you ventilate through Lumen 2 and it's like a single lumen ETT.

Downsides: what the scenario presents. It's not perfect. 75% of the time it'll be supraglottic not endotracheal. You have to change it out eventually (though if it's functional, there's no hurry). Contraindications: intact gag, esophageal pathology like varices, less than 5 foot tall (there's a short version).

Maybe PGG can put more detail.

 

[Surfer]

My first thought on seeing the patient was surgical airway. The combitube was working somewhat, so i sedated and paralyzed her thinking it would be easier if she were not to resist our attempts at ventilation and i did not want her to remove the only airway she had. I called for a trach kit and a general surgeon stat. I felt her neck and a trach would not be difficult (I have experience in the ICU setting with doing perc trachs and am comfortable using the Blue Rhino kit, having said that i always like surgical backup). With the sedation and paralysis she became easier to ventilate and her SaO2 went up to 99. Had the boys up stairs open up a room for the trach and c-section. When they were done she went to the ICU.

Off the vent onto trach mask on POD #1 and seeing her baby. On POD #5 she still could not breath with plugging of her trach.

I have tried different maneuvers with exchanging like described above never been that thrilled with how precarious it always felt. combitubes

wow you trached her right there? without even trying to get a controlled airway first? Why not take a look with the DL?? Why not try a bronchoscope through the LMA? It just seems a little harsh to go straight to the last option and give a young girl a nice scar in the middle of her neck. I'd have tried to get a tube in first.

 

[Apollyon]

Are any of you gas guys familiar yet with the King airway device?

A friend of mine does EMS at a casino, and she said that that is all they have now, and it's almost idiot-proof (although we've all been amazed by the ingenuity of idiots).

 

[Bertelman]

wow you trached her right there? without even trying to get a controlled airway first? Why not take a look with the DL?? Why not try a bronchoscope through the LMA? It just seems a little harsh to go straight to the last option and give a young girl a nice scar in the middle of her neck. I'd have tried to get a tube in first.

Word.

 

[militarymd]

Are any of you gas guys familiar yet with the King airway device?

A friend of mine does EMS at a casino, and she said that that is all they have now, and it's almost idiot-proof (although we've all been amazed by the ingenuity of idiots).

Our hospital tried to switch to it altogether...to replace the lma....so we gave it a good try...it's ok...not as good as a lma

 

[thegasman]

I think some of you are getting pretty accustomed to your big university settings. If this pt came to my hospital it would be at 2am. Once I walked in the door the airway is my issue and the baby is relying on to get mom ready for delivery. Then I gotta deal with where mom goes post-op and how stable she is including her airway. I'm not f*cking around here with this case. I'm changing out that combitube with an ETT and we are getting that baby out STAT. I will more than likely be successful with the ETT either with DL or Glidescope based on past experience but if not I go to jet vent and a trach kit if necessary. If we wait for me to call in surgical airway backup this baby does very poorly and possibly mom does just as bad. Plus, how fast are the guys that get surgical airways in your area. They are not fast enough for this situation unless they slash and put a tube in which I can do just as well.

This pt gets induction with whatever necessary (usually propofol in my hands) and full paralysis.

as usual here is the voice of reality.

 

[seinfeld]

wow you trached her right there? without even trying to get a controlled airway first? Why not take a look with the DL?? Why not try a bronchoscope through the LMA? It just seems a little harsh to go straight to the last option and give a young girl a nice scar in the middle of her neck. I'd have tried to get a tube in first.

In person i dont think you would have had the same conclusion, there wanst one anesthesiologist who thought differently after seeing her.

I brought this case to discussion because i often felt i went to the trach option too late in my alogirthym during codes with difficult airways. Also i feel that sometimes all our gadgets make us feel invincivble with getting an ETT in place. I did think about using all the toys to put in an ETT but she was pregnant with non stable airway requiring emergernt C-Section, it did not look as it i could get my pinky finger in her mouth even paralyized none the less a scope, the Safest thing for her and the baby was trach. BTW by the time she made it to the OR the baby started to decel, Imagine having that happen while you were messing with the airway.

I have learned to always put pt saftey above pt comfort. PT has known Grade 4 DL, AFOI regardless of how the patient feels about the process. A 50 male doesnt want a colonoscopy but has hx of colon ca in family, you are going to push to have the pt get one.

Considering she was off the vent on pod1 and unable to breath with a capped trach for another 4 + days tells me it was an appropriate decision. Had she had a ETT she would have been on the vent sedated waiting for swelling to go down meanwhile increasing her risk of VAP, DVT, etc. As a additional benefit (was not part of my thought process in the ED) she was able to see her baby, her husband happy to know both were alive and well etc.

Just to clarify the csection and the trach occured basically simultaneously in the OR. The OBs started cutting once the knew she was anethetized just in case something did happen to her airway. this all happened in the late morning , youre right noyac things would have been different if it were 2am.

 

[Noyac]

I wasn't there Sienfeld so of course I'd have to defer to you on this case. Well done, nice save. I didn't get the impression from the original post that the airway was as bad as you have now described. I may have had to adjust my approach had I seen her.

 

[Idiopathic]

combitube is an awful thing

have seen something like this: px from outside, failed intubation multiple times, combitube in place but crummy sats needs definitive airway, report was that several practitioners tried intubation at osh and in the field for several hours (yes thats right) fro suspected overdose, so we are obviously concerned. also subq air clearly evident. looked in the mouth with the fo scope and dropped the cuffs down but soft tissue simply took up that space so we elected to have gs do a trach, which they could almost not do, given the subq air

afterwards, removed the combitube, put in a mac 4 and had grade 1 view. turned out that the osh tried a miller 3 and traumatized the oropharynx creating a false passage, everyfuture attempt when into that soft tissue, got obscured, bleeding etc, and thats where the air came from and whatnot.

i guess my take home point is that when a combitube is in place you really have no idea whats going on and you cant do anything with that in place. i think its fine to pull it as long as your backup plans are in place, but you cant really proceed with it as your definitive airway either IMHO

 

[MTGas2B]

Nice work. Great plan. I would have to agree with your course of action. Ultimately she'll need a surgical airway, especially with pending OB badness, there's just not time or wiggle room do dink around with this one.

 

[USAnesthesiaDoc]

I agree with Noyac, Seinfeld, that you made a good call and it worked out. Just wondering though if you were at a smaller, community hospital, and ENT or general surgery were not in house and would have to come from home (and perhaps take 30 minutes or more to get to the hospital), would that have changed things for you? Fortunately, you have some skills with trach, so maybe you would have done it yourself anyway. I think the paralysis and sedation were excellent ideas, and clearly that improved the situation, at least for the mother. I know the baby started to decel by the time you got to the OR, but for those of us who don't have much experience with trach, do you think you could have left the combitube in until the baby was out since your ventilation and oxygenation were so much better? Clearly, you needed a definitive airway at some point (sooner than later), and it sounds like airway edema in her would have been a major issue if you had removed the combitube and tried something else. Maybe you would have lost the airway. Do you think you could have put in an intubating LMA and regained the airway? A really great case and management.

 

[Licoricestick]

The fact that this thread started with "Called to ED..." just proved that lots of badness was coming.

 

[jwk]

I don't think it's been taught to most practicing anesthesiologists. The LMA wins in the hospital because 1) we use it everyday 2) we can intubate through it with a FOB.

I personally would redesign the Combitube with an wide opening instead of the small holes in Lumen 1 (so you could do a FOB through it like an LMA).

The Combitube (full name is Esophageal Tracheal Combitube) was developed after problems with the EOA (Esophageal Obturator Airway). The EOA can be misplaced in the trachea, and kill the patient. If you put the Combitube in the trachea, you ventilate through Lumen 2 and it's like a single lumen ETT.

Downsides: what the scenario presents. It's not perfect. 75% of the time it'll be supraglottic not endotracheal. You have to change it out eventually (though if it's functional, there's no hurry). Contraindications: intact gag, esophageal pathology like varices, less than 5 foot tall (there's a short version).

Maybe PGG can put more detail.

We don't use Combitubes because they're primarily a rescue device for EMT's/paramedics who generally don't have great advanced airway skills because they can't do it every day to stay in practice. (that's also why more emergency crics are done in the field than anywhere else - they don't have the skills) We have them in our airway carts, and they're about #8 on the go-to list of devices - consequently, we've NEVER used one.

 

[jd1572]

wow you trached her right there? without even trying to get a controlled airway first? Why not take a look with the DL?? Why not try a bronchoscope through the LMA? It just seems a little harsh to go straight to the last option and give a young girl a nice scar in the middle of her neck. I'd have tried to get a tube in first.

I disagree with Surfer, and I completely agree with the management of the original poster. My reasoning is that whoever put the combitube in probably did a bunch of DL attempts before resorting to the combitube. So the airway is probably full of blood, secretions, and even worse edema. Blood and secretions will make visualization with a fiberoptic bronchoscope difficult. If the combitube is working, at least you have an airway. If you take it out to try another intubation technique, you may end up with a can't ventilate/can't intubate scenario. Better to leave the combitube in and get a definitive surgical airway. Scar on neck is not as bad as dead mom/baby.

 

[Surfer]

I disagree with Surfer, and I completely agree with the management of the original poster. My reasoning is that whoever put the combitube in probably did a bunch of DL attempts before resorting to the combitube. So the airway is probably full of blood, secretions, and even worse edema. Blood and secretions will make visualization with a fiberoptic bronchoscope difficult. If the combitube is working, at least you have an airway. If you take it out to try another intubation technique, you may end up with a can't ventilate/can't intubate scenario. Better to leave the combitube in and get a definitive surgical airway. Scar on neck is not as bad as dead mom/baby.

How long does it take to put a knife in the neck and establish a surgical airway? Not long. And most combitubes are put in by people who don't know what they're doing (EMT's, etc). Did she ever need the combitube? maybe the combitube is actually making it worse?! Some people think every seizure needs a tube down the throat. I disagree. If they're seizing let stop the seizure first, then control the airway if necessary. Most of the time they don't need to be intubated if you can stop the seizure.

 

[Licoricestick]

How long does it take to put a knife in the neck and establish a surgical airway? Not long.

Only if you do it yourself and you do it well. Many people seem to want to wait for ENT/Surg to come to do it for them and how many emergency crics have most people out there actually done?

Pretty sure I wouldn't be as fast as I would think. That said, one of the guys where I work who has a serious airway interest has timed anaesthetists on dummies and the fastest way he found to an emergency surgical airway was scapel to cricothyroid membrane, artery forceps into the hole, remove scalpel, open forceps, place size 5 tube.

I can only hope that I never need to do it, but that if I do I don't wait too long.

 

[Planktonmd]

I haven't checked this forum for a while but today I did and I saw this thread and It made me think that there is hope for this forum after all!
My only rule in anesthesia is "keep it simple and do what you do best every time".
So, as a private practice anesthesiologist who is used to not having much of a backup and operating solo here is how I see it:
I am good at intubating people and I am good at placing LMA's, so in a situation like this this is exactly what I am going to do (intubate or place LMA):
1- Put her to sleep (Propofol + Sux), take the crappy combitube out and try to intubate with DL then Glidescope, most likely this will succeeed but if it doesn't (very unlikely) I am going to plan # 2
2- Place an LMA in then do a Fiberoptic intubation through it while they are doing the C section in the OR.
This might not be what you want to say on your oral boards but this is what makes sense in my hands.
Keep in mind that I can intubate a gravid ant with clift palate anytime of the day so if you are not that good then do what others have said.

 

[DrN2O]

Are any of you gas guys familiar yet with the King airway device?

A friend of mine does EMS at a casino, and she said that that is all they have now, and it's almost idiot-proof (although we've all been amazed by the ingenuity of idiots).

I was told the King has only one balloon for two cuffs, so unlike the combitube, you can't selectively deflate the proximal supraglottic cuff to take a look without losing protection from gastric regurg.

 

[Monty Python]

Keep in mind that I can intubate a gravid ant with clift palate anytime of the day.

For the benefit of those still in training, how about experienced folks sharing their particular intubation pearls (those learned from experience, and not found in Miller or Barash.) The ones which have proven to be particularly helpful in the middle of the night, when all alone, and you have that sudden need to stain your Fruit of the Looms.

 

[Monty Python]

Place an LMA.

.


Currently overseas, and we have I-Gels. To me they are the next century's improvement over the LMA. I've heard I-Gels are still not available in the USA. I really encourage everyone to try to get their hands on one if at all possible.

 

[Coastie]

Intubate around the tube? Even though you may be much better with airways than the ER guys, it seems like if they had a hard enough time that they needed a combitube, you are likely to have an even harder time with both a difficult airway and a combitube in the way. It's an interesting idea, but I don't know what you're odds of success would be. I would think they'd be pretty low with a difficult airway, huge tongue, a tube in the way proximally, and the distal cuff distorting the already swollen anatomy distally.

I don't have much faith in ED guys ability to out-intubate me, so I think a DL to check things out is warranted.

If I can ventilate with combitube, do so. Step 1: DL. Step 2: Glide/FOB, depending on how she looks. Surgical airway backup needed if that goes.

 

[Coastie]

how much jet vent/trachs did you do in residency?

I think some of you are getting pretty accustomed to your big university settings. If this pt came to my hospital it would be at 2am. Once I walked in the door the airway is my issue and the baby is relying on to get mom ready for delivery. Then I gotta deal with where mom goes post-op and how stable she is including her airway. I'm not f*cking around here with this case. I'm changing out that combitube with an ETT and we are getting that baby out STAT. I will more than likely be successful with the ETT either with DL or Glidescope based on past experience but if not I go to jet vent and a trach kit if necessary. If we wait for me to call in surgical airway backup this baby does very poorly and possibly mom does just as bad. Plus, how fast are the guys that get surgical airways in your area. They are not fast enough for this situation unless they slash and put a tube in which I can do just as well.

This pt gets induction with whatever necessary (usually propofol in my hands) and full paralysis.

 

[Coastie]

I've used I-gels at the VA, they're great, but not the end all, IMHO.

We had a grand rounds last year on the extreme danger of exchanging tubes of any kind over exchangers, esp in this kind of situation. What are the experiences of the board?

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Currently overseas, and we have I-Gels. To me they are the next century's improvement over the LMA. I've heard I-Gels are still not available in the USA. I really encourage everyone to try to get their hands on one if at all possible.

 

[Planktonmd]

We had a grand rounds last year on the extreme danger of exchanging tubes of any kind over exchangers, esp in this kind of situation. What are the experiences of the board?

You can't exchange a combitube using a tube exchanger, you simply don't know where your exchanger is going to end.
On the danger of exchangers I have seen a guy perforate a distal bronchus causing a fatal pnuomothorax while trying to exchange the tube in a burn patient who was on a jet ventilator to start with.
But exchangers are still a good tool to have around, I use them to place double lumen tubes in patients who are difficult to intubate.
You just have to always remember that these things are very stiff and can cause real damage if you push them too far.

 

[Noyac]

how much jet vent/trachs did you do in residency?

In residency, not many. We would jet ventilate for ENT procedures and on occasion when the airway looked awful we would put an angiocath through the cricothyroid membrane for a trans tracheal injection of lidocaine and leave it in place in case we couldn't intubate we could jet ventilate. It isn't very difficult. I scrubbed in on some trach's as an intern on the trauma service and again on my ICU rotations (we did some at bedside).

In PP I have jet ventilated a couple times.