Difficult airway case

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Scotty_G

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Hey longtime lurker first time poster, CA-1 🙂

So we had a difficult airway yesterday and I want to get everyone's opinion on what they would have done differently.

So I am on MICU this month and so it begins:
We have a 34 y/o m PMHX of Duchene's Muscular Dystrophy who is wheelchair bound. He requires NIPPV and became hypercarbic the night before (probably from poor seal) His mom said he dropped his sat to the 80's prior to coming to hosp and that is why she brought him in. He sees a PMR doc at our hosp who specializes in deg muscle diseases. This doctor specializes in alternative treatments to trachs. (extubates to NIPPV) Anyway this young man is in the ICU essentially to rule out causes for his acute resp problem. Labs essentially are benign, chest x-ray shows possible LL infiltrate but looks more like small effusion to me. His vitals are okay with BP being on the lower side 90/54, Pulse of 122, R: 18, normothermic 98% Spo2 on continous NIPP mask. We ask mom about last echo but she says she does not remember. So the MICU attn decides to have him intubated even though he looks fine.

Anesthesia comes with glidescope. Pt has a long thin neck. There is limited neck extension. He cannot open his mouth as great as we would like but enough to get in blade/scope etc. He looks like MP III but it is really unclear. CRNA calls attn upstairs. Attn anesthesia would like to give Etomidate and attempt ETT w/ glidescope. So patient is put to sleep. CRNA is unsucessful on first attempt with glidescope. He tries again without any luck. Next attempt showed epiglottis only. I would say easily Grade III view. At this time 2 other attn come up. One of them tries w/ glidescope and fails. Pt appears to be very anterior and our blade is hard to keep midline. Patient has a lot of secretions(already given glyco) Next attn tries both Mac and Miller blades. Tube is passed but went in esophagus. Next intubating LMA is attempted. We cannot pass ETT through cords. We are able to ventilate patient throughout this process though (thank god!!) More etomidate is given during this process as he wakes up. Next a fast-trach LMA is tried. Unfortunately same thing happens and we cannot pass ETT. After multiple attempts patient is getting bloody and we decide to take him down to OR so we can do fiberoptic with surgical backup before it gets worse. His sat's and vitals throughout the procedure are rock-steady.

So we take him to OR w/ trauma surg there just in case. We use fiberoptic scope through the nose and attempt to find cords. We still have no luck. He still has a lot of secretions. We can easily see esophagus(plus he had feeding tube in) Image is not great and no clear picture of cords is seen. So we then try going in through the mouth with the oral mouthpiece. Essentially same thing happens and multiple attn attempt w/ fiberoptic failure 🙁 At this point a lot of time has passed. Patient still stable and satting fine. Next we try retrograde intubation. Patient has long thin neck so anatomically there are no problems. Surg threads in guidewire towards the mouth. So you think we get it?!?!?!? NO WAY! Tube cannot be placed!! I mean we glide it down and everything feels good but no luck. At this point we have no choice but to do Trach.

I felt bad for famly because I don't think he needed to be intubated in the first place. The only thing I thought I might have tried would be blind nasal early on? Or bougie? I don't know we used most of our options right. The attn didnt want to do nasal because when we were in the MICU he was starting to get bloody after many attempts and just wanted to go straight to OR. In retrospect I'm sure it would not have worked anyway. So i just thought this was a good experience to see different options to try to get ETT before surgical intervention. Thankfully he was stable the whole time and it was not during emergency. Sorry if it wasn't very detailed, I am post call... Pleas post up your ideas and thoughts thanks.
 
WTF?
I agree that a trach is the best thing for him after all of that. But wtf happened the entire time before? Was he just fighting after the etomidate since he wasn't paralyzed, therefore making it difficult to place the tube? Was he in sniffing position by any chance when all this was tried? I've had difficult intubations but this one is disturbing. There's something either left completely out /missed during this entire scenario OR maybe there is some obstruction/problem with his airway (ie: pneumo with tracheal deviation/compression) that was actually creating the "He requires NIPPV and became hypercarbic the night before (probably from poor seal)" and "this young man is in the ICU essentially to rule out causes for his acute resp problem". A CT of his chest/neck and a bronch would be nice at this point. Keep us updated on what they find and how he is doing...thanks for posting the case.
 
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Did the retrograde wire come out of the mouth or nose? if so did you try a 6.0 over the wire? can use blade/FO/glide and watch to see if tube is gettin hung up on arytenoids or if the problem is actually subglottic. Strange.

He was given a paralytic right
 
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If I had a view at all, I'd break out the bougie for the win. If that wasn't happening, LMA and regroup. If you could vent through the LMA, I probably would have paralyzed him to make everything easier at some point as well. I would have tried the fiber through the LMA, did they try that? If that fails, retrograde wire. If a 6 Parker flex tip tube can't be passed, I'd try the tube from the fastrack lma. These tubes have different tips which make it much easier to pass over a wire, fiber, etc. At the same time I'd fiber down and see where the tube was getting hung up. If it's subglottic, I'd try a smaller tube. Please tell us that your attendings tried a 5 or even 4 ETT before going ahead with the trach of unclear necessity. He might just have some stenosis, etc. What size and type of ETT did they fail to place with the retrograde wire?
This description of events made me uncomfortable.
 
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Another trick is the Glidescope + FO combo. Stick the Glidescope in the mouth and get your Grade III view. Do a nasal fiber optic (or maybe even oral FO). Use the view on the Glidescope screen to help you guide the tip of the FO scope to the glottis. Once near the glottis, then take a look at the FO view or the FO screen to see what the problem is. This technique is useful when you are having problems initally visualizing anatomy with the FO scope as you said you were. With this technique the Glidescope view can make it very easy for you to get the FO scope right next to the glottis
 
somedumbDO said:
Retrograde, if u do > 10 easy to do... Something is off he has a trachea and was breathing
Click to expand...

I have not done any. But going thru it in my head, when the tube hits the wire insertion in the trachea, how do you know you are in and can actually remove the wire or are actually banging outside the cords and if you remove the wire have to start all over again?
 
IlDestriero said:
When you're in the airway and at the insertion point, you'll get resistance as you continue to advance and the wire will flex up. Then you know.
Click to expand...

I can picture that.

Thanks
 
Idiopathic said:
doesnt sound like it. sometimes situations get massaged (i.e. no trach, no paralytics) and that compounds the difficulty, turning a marginal airway into an impossible one.
Click to expand...


I have found that etomidate alone without paralytics provides awful intubating conditions unless the patient is obtunded, which he did not appear to be. As was mentioned previously, if you could ventilate via the lma and there was not any obvious airway obstruction via physical exam or imaging I would just push the paralytic (NOT sux in this DMD patient) and save yourself the excessive airway trauma. Based on what I have read about the scenario I wouldn't be surprised if the patient was fight you.
 
Any thoughts of a light wand after all of the multiple failed attempts? Seems like you had a pretty tough time visualizing anything even with the scope.

And why not push paralytic (non-sux obviously) given that you were able to ventilate him? Could have made things easier on you.
 
HalO'Thane said:
I have found that etomidate alone without paralytics provides awful intubating conditions unless the patient is obtunded, which he did not appear to be. As was mentioned previously, if you could ventilate via the lma and there was not any obvious airway obstruction via physical exam or imaging I would just push the paralytic (NOT sux in this DMD patient) and save yourself the excessive airway trauma. Based on what I have read about the scenario I wouldn't be surprised if the patient was fight you.
Click to expand...

my mantra for ICU airways is first shot, best shot and this almost uniformly mandates paralytic. there is almost no reason not to give it, but everybody needs to be aware that this patient is not a candidate for sux. that does not mean he shouldnt get roc, in fact you would need to give it early, so there wouldnt be a "wait and see what kind of glidescope view i get and then push the roc" yada yada.

i get the fear, everyone thinks they can back out of an ICU airway if things go south, but I have yet to see someone get "woken up" so you can start over with an awake procedure (ive only seen it twice in the OR, and those were both cannot intubate, CAN mask scenarios.) theres just no room for it. you go down the airway algorithm pretty quick or you are doing chest compressions, and nobody got time for that.

unfortunately, it always seem like the least experienced intubators (or at least among the urgent intubators) are the ones who dont want to give themselves optimal intubating conditions. you will have no doubt with a fully relaxed patient what the best view you can get is, they cant fight you and then you will know whether or not you have a chance at intubating.

just one mans opinion
 
excalibur said:
Another trick is the Glidescope + FO combo. Stick the Glidescope in the mouth and get your Grade III view. Do a nasal fiber optic (or maybe even oral FO). Use the view on the Glidescope screen to help you guide the tip of the FO scope to the glottis. Once near the glottis, then take a look at the FO view or the FO screen to see what the problem is. This technique is useful when you are having problems initally visualizing anatomy with the FO scope as you said you were. With this technique the Glidescope view can make it very easy for you to get the FO scope right next to the glottis
Click to expand...

half the time you actually don't even have to look through the FO scope. Just utilize it like a flexible bougie that you can steer by looking at the glidescope screen.
 
Assuming you only pushed etomidate to start (and not also roc)

Wake him up, topicalize him, awake GS vs FOB. Glyco, glyco, glyco. Take your time. Do ti right. Yes, it takes an anesthesiologist to do this.
 
Some wise words I was taught:

Patients don't die because you can't intubate

They might die if you don't know when to stop trying
 
Mman said:
half the time you actually don't even have to look through the FO scope. Just utilize it like a flexible bougie that you can steer by looking at the glidescope screen.
Click to expand...

Right.

I just learned about a new tool. The flexible Bougie. Huh. Never heard of that before, but it looks cool. Don't have those in our small county hospital.

ATTENTION TO RESIDENTS:

Look at all the different interventions mentioned in this thread like:
FO scope
Glidescope
Intubating LMA
Retrograde wire
Lightwand

If you haven't practiced some of these in residency, you should make an effort to attempt these. I say this because residency is the best time to try and learn these methods. You have skilled attendings in these aspects and the tools.

When you get in private practice, you will probably become complacent, and the desire to learn new tricks may start to diminish
 
Patient was not paralyzed. I agree the conditions were not optimal. I agree maybe etomidate on the first time. But later on I would have switched agents as his BP was higher (from us obviously) and paralyze the dude. As a first year I do not always paralyze for a floor/icu intubation. I think I am going to do it every time unless there is a specific reason not to after this. Anyway it was hard to know if he was fighting because he cannot communicate well. He can speak a little before loosing his strength. He did not have any pneumo I can assure you of that. Chest x-ray was okay. Like i said small little effusion/atelectasis on the Lt base. The fact that he requires NIPPV is a side note. We already know his muscles are weak and has low Vital capacity. We have many muscular deg diseases that come to see this doc at our hospital and they all use some form NIPPV instead of getting trached. Okay so we did use small tubes but we did not use a 4 or 5 ETT. The smallest tube we used was a 6.0. When we went to OR they tried 6.5 and 7.0 ETT w/ the fiberoptic and retrograde wire. I am not sure the size of the retrograde. It was the kit from our difficult airway cart. They tried a 6.5 ETT over that. We did try glidescope + fiberoptic. I believe we did fiber through LMA as well. We had one descent view with glidescope in the micu. This was only after a few attempts. I think that was our time to get it done. I mentioned bougie but no one really uses that in my institution. I haven't tried it myself but i def would. One attn wanted to paralyze, but the one running the show did not. The pt must have had some subglottic stenosis right?
 
Scotty_G said:
Patient was not paralyzed. I agree the conditions were not optimal. I agree maybe etomidate on the first time. But later on I would have switched agents as his BP was higher (from us obviously) and paralyze the dude. As a first year I do not always paralyze for a floor/icu intubation. I think I am going to do it every time unless there is a specific reason not to after this. Anyway it was hard to know if he was fighting because he cannot communicate well. He can speak a little before loosing his strength. He did not have any pneumo I can assure you of that. Chest x-ray was okay. Like i said small little effusion/atelectasis on the Lt base. The fact that he requires NIPPV is a side note. We already know his muscles are weak and has low Vital capacity. We have many muscular deg diseases that come to see this doc at our hospital and they all use some form NIPPV instead of getting trached. Okay so we did use small tubes but we did not use a 4 or 5 ETT. The smallest tube we used was a 6.0. When we went to OR they tried 6.5 and 7.0 ETT w/ the fiberoptic and retrograde wire. I am not sure the size of the retrograde. It was the kit from our difficult airway cart. They tried a 6.5 ETT over that. We did try glidescope + fiberoptic. I believe we did fiber through LMA as well. We had one descent view with glidescope in the micu. This was only after a few attempts. I think that was our time to get it done. I mentioned bougie but no one really uses that in my institution. I haven't tried it myself but i def would. One attn wanted to paralyze, but the one running the show did not. The pt must have had some subglottic stenosis right?
Click to expand...


I dunno but I would consult pulm or ent to do fiberoptic exam of larynx and trachea. next time paralyse. Where did the guide wire from the retrograde come out?

I would have called ENT to the OR to check it out and do the trach.
 
This sounds like a self-made fiasco from start to finish. First, there was probably no need to intubate him with RR 18 and sat 98% on NIPPV. Second, the patient likely still had all the airway reflexes since only etomidate was given and he was stable. It is very diffcult to pass ETT through close vocal cords. If you were so afraid of NDMB/propofol even in the setting of easy ventilation, why not wake him up and do a fiberoptic exam/intubation.
 
Mac4 said:
This sounds like a self-made fiasco from start to finish. First, there was probably no need to intubate him with RR 18 and sat 98% on NIPPV. Second, the patient likely still had all the airway reflexes since only etomidate was given and he was stable. It is very diffcult to pass ETT through close vocal cords. If you were so afraid of NDMB/propofol even in the setting of easy ventilation, why not wake him up and do a fiberoptic exam/intubation.
Click to expand...

embarrassing story time. so I am in the or, 24 yo kid. thin. easy lookin airway. induce, easy mask. dl, gIII view. no problem, grab the bougie, can't get it to go. so I call for the glidescope, get a good view of cords that are still moving, partially closed. So this kid has a big time tolerance to narcs, so I thought I just under dosed it. So I push a little more propofol, grab the syringe of roc, thinking I'll give a little more. This is the embarrassing part. The syringe is still full. I forgot to push it. So after actually paralyzing him, easy airway. moral of the story? it's easier to intubate a paralyzed patient. once you prove it's easy to ventilate, I give it, assuming no other big contraindications
 
IlDestriero said:
The Bullard is great but it's a dying art.
Click to expand...

There is a reason for the Glidescope being 100 times more popular than the Bullard. I tried it during residency a few times but never worked for me. When I saw that it didn't work for the attending who was always peddling it, I moved on to better things.
 
You said you tried an intubating LMA but were unable to pass the tube through the cords.
Were you able to ventilate with the LMA?
Have you tried putting the fiberoptic scope through the intubating LMA?

I have done the scope through the fastrach when I couldn't get the tube through and had good results.

I graduated from residency about 2 years ago and I have never once done a retrograde intubation. None of my recent grad colleagues have done one either.

I agree with the post that stresses the importance of using all of the airway toys as much as you can before you leave residency. That being said, when you get to private practice smaller places won't have all of them. Many of the surgicenters I work at have bougies, fastrachs, and a glidescope. No fiberoptic scope, lightwand, or retrograde wires.
 
inmyslumber said:
Another vote for Glidescope with Fiberoptic. Takes practice.
Click to expand...

Yes, and three sets of hands. One to hold the glidescope, another to guide the fiberoptic and another to manipulate the tube. I've done it with two but it can end up being a bit of a flail.

Others have already hinted at the paradox of the difficult airway here--you don't want to give paralytic for fear of not being able to secure the airway...however, it is often exactly what is needed in order to be able to do so.
 
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RocurWorld said:
embarrassing story time. so I am in the or, 24 yo kid. thin. easy lookin airway. induce, easy mask. dl, gIII view. no problem, grab the bougie, can't get it to go. so I call for the glidescope, get a good view of cords that are still moving, partially closed. So this kid has a big time tolerance to narcs, so I thought I just under dosed it. So I push a little more propofol, grab the syringe of roc, thinking I'll give a little more. This is the embarrassing part. The syringe is still full. I forgot to push it. So after actually paralyzing him, easy airway. moral of the story? it's easier to intubate a paralyzed patient. once you prove it's easy to ventilate, I give it, assuming no other big contraindications
Click to expand...

Wait, so your handle is "RocurWorld" and you didn't give the roc? So disappointing...
 
Here is what you guys should have done:
Wake him up, put him back on his NIPPV, take a few hours break to allow for the secretions to dry and the bleeding to stop, then come back and do good airway anesthesia followed by an elective smooth fiberoptic intubation.
 
dhb said:
MICU att should get his head checked why the F*** does he want to tube this dude?
Click to expand...

Without knowing the whole story, my first thought it NIPPV is a bridge, not a destination. I don't let people linger on bipap for days on end.
 
slavin said:
if he wasn't paralyzed why did they trach him instead of waking him up?
Click to expand...

Because prolonged amateur hour airway mishandling probably made waking up and regrouping questionable. Though they could have left the LMA in and let things settle down for a while before going back in with the fiber or waking him up to try an awake fiber on Dex, etc.
 
So I asked the original attn the other day about paralyzing the patient. He said that the patient was weak and wasn't fighting at all that he didn't think muscle relaxant would add much. And he did wake up guys.... They kept pushing etomidate early on. Again I pushed to not intubate in the first place. On a side note his EF was 25% although we didn't know it at the time.
 
Scotty_G said:
So I asked the original attn the other day about paralyzing the patient. He said that the patient was weak and wasn't fighting at all that he didn't think muscle relaxant would add much. And he did wake up guys.... They kept pushing etomidate early on. Again I pushed to not intubate in the first place. On a side note his EF was 25% although we didn't know it at the time.
Click to expand...

Who cares about the EF.

Weak doesnt mean the cords are open. Weak what? proximal muscles, diaphragm, oropharyngeal muscles? Who cares. Paralyse.
 
Sounds like the cords were never seen with a lot of blind tube advancements. I wonder if the guy needed the longer Glidescope blade. You said he had a long neck. Was a different Glidescope blade ever attempted?
 
Like Hern I am on the MICU side of this not the gas side but a few things I have noticed. I agree with Idiopathc....if he was easy to ventilate with LMA and there were no issues with hypoxia the entire time....why not paralyze him? I as an intern had the same thought as you...I dont want to paralyze till I am sure I can see the cords, have a decent view etc. But as can be seen in my earlier thread discussions, I have learned the mantra...pts dont die because they couldnt be intubated, they die because they couldnt be ventilated. If bag mask/LMA was 100% sats, paralyze him. It can only help. I agree obv no sux...but double dose roc?? Any reason not too? gas guys chirp in if im wrong on that but if this were my MICU pt and I could ventilate fine just couldnt intubate, Id have prop/DD roc or etom/DD roc then tried with Mac/miller/glide etc. If I am still ventilating fine and I just cant see cords but I can see the esophagus as you have mentioned, then I know where the cords should be. Id try a bougie and see if I can get it to pass through the open cords, as I have paralyzed, that are just not in my view. If with that I stil got nothing, I keep ventilating as the roc wears off and give a call to Anesthesia/ENT come and take a look with your cool FO stuff. Maybe its stenosis. Maybe its something crazy I dont even know about, (the likely truth). He is ventilating fine so no reason for me to messily cric him, can wait for the retrograde attempt or formal non-messy ENT bedside trach.

And as with Hern, Bipap is a bridge. Sats may be fine. Vitals fine. But if he looks like he is tiring, dont know info was not provided, or his numbers when I take the bipap off after a few hours still suck/not improving, he goes on the vent.

Also agree with Barker....30 y.o with severe duchennes and ischemic CM should not be a full code. aggresive family talk may have avoided the need for the vent altogether,

Just my 2cents from 'the other side"
 
VentdependenT said:
I never got an answer as to where or IF the retrograde guidewire came out
Click to expand...

sounded like it came out appropriately and they couldnt pass the tube through the cords, although one possibility is their wire insertion was too high and they were getting the tube past the cords but it was meeting the skin entry point and getting hung up, especially if they were keeping a taut wire
 
Arch Guillotti said:
I think you are going to be waiting a while for the roc to wear off.
Click to expand...

thats ok as I am having not trouble ventilating. RT can stand there giving a breath every 5-6 seconds until more help arrives. The situation would be different if we couldnt ventilate from the start as I mentioned, in that situation I wouldnt paralyze.
 
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