Difficult Airway - Covid, Angioedema, ETT Exchange

[inflamesdjk02]

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Thoughts on the following case:

Morbidly obese patient in ICU, thick neck+Covid, respiratory failure, high vent settings (20 PEEP, 70% FiO2). Called by ICU attending to exchange ETT because it becomes kinked when turning the patient prone, and randomly when turning the patient's head in certain directions when supine. Patient also with severe angioedema of the tongue, which is protruding several centimeters from the mouth, firm, immobile, making access to the oropharynx impossible. Patient has been in ICU for 3 weeks. Obviously, an invasive airway is indicated, but the ENT docs are not doing trachs on these patients. I recommended giving a course of steroids to see if the tongue swelling will go down, and reassess at a later date. My fear with proceeding with tube exchange, given the level of tongue swelling, is that we will have trouble advancing a new tube into the airway, given the circumstances, and with the high vent settings, there is no room for error, and no backup plan. Thoughts?

 

[nimbus]

I don’t see how exchanging the tube would solve the kinking issue. The new tube will also become soft and kink if you let it bend too much. That is no indication to change the tube. Tell them to be more careful in keeping the tube aligned. We do this all the time. A new tube will not solve this problem and you could easily kill this patient trying. As they say, don’t f*** with a perfectly good airway.

PS: I find the proneview headrest the best to prevent tube kinking in the prone position.

 

[Ezekiel2517]

Very high likelihood of death if you attempt this. Also, this patient has been intubated for 3 weeks and no one's gonna do a trach? I guess they wanna extubate lol. The only extubation in this patient's future is a terminal one.

 

[Radetzky]

I don’t see how exchanging the tube would solve the kinking issue. The new tube will also become soft and kink if you let it bend too much. That is no indication to change the tube. Tell them to be more careful in keeping the tube aligned. We do this all the time. A new tube will not solve this problem and you could easily kill this patient trying. As they say, don’t f*** with a perfectly good airway.

PS: I find the proneview headrest the best to prevent tube kinking in the prone position.

Agreed. Higher risk of death from tube exchange in this patient than keeping a tube that still sounds patent in the right position

 

[deleted59964]

foam head rest while prone.
done

 

[chocomorsel]

Just curious as to the age of patient?

 

[fittipaldi1of1]

Is the linking of tubes a common issue with all the proning? Maybe we should be putting in reinforced tubes, these patients probably aren’t getting MRIs

 

[pgg]

Seems like a terrible idea. Out of curiosity, did they just want another ordinary PVC tube, or do you have kink resistant tubes (they're not really "armored" but they have a metal coil in them so they won't kink) available?

 

[Cheddar]

I wonder if devices like springs or tube wraps can be used on an endotracheal tube to prevent kinking in this setting. I’ve used these wraps in aquarium filter tubing in the past and they’ve worked well.

The tube exchange process would likely aerosolize virus particles, adding danger to healthcare workers in addition to the patient.


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[sigrhoillusion]

Thoughts on the following case:

Morbidly obese patient in ICU, thick neck+Covid, respiratory failure, high vent settings (20 PEEP, 70% FiO2). Called by ICU attending to exchange ETT because it becomes kinked when turning the patient prone, and randomly when turning the patient's head in certain directions when supine. Patient also with severe angioedema of the tongue, which is protruding several centimeters from the mouth, firm, immobile, making access to the oropharynx impossible. Patient has been in ICU for 3 weeks. Obviously, an invasive airway is indicated, but the ENT docs are not doing trachs on these patients. I recommended giving a course of steroids to see if the tongue swelling will go down, and reassess at a later date. My fear with proceeding with tube exchange, given the level of tongue swelling, is that we will have trouble advancing a new tube into the airway, given the circumstances, and with the high vent settings, there is no room for error, and no backup plan. Thoughts?

I understand that proning is helpful for patients with COVID/ARDS, but the patient has been in the ICU for 3 weeks... how much help is it doing considering his vent settings don't seem to be improving. Risk/benefit... is going prone worth the risk of tube dislodgement. That tube comes out by accident and it's likely over. This patent either needs a trach or a talk with family for plan of care.

 

[woopedazz]

Are you sure this is a real consult and not a "we tried everything and called everyone, but it's time to withdraw care" consult?

 

[Monty Python]

Thoughts on the following case:

Morbidly obese patient in ICU, thick neck+Covid, respiratory failure, high vent settings (20 PEEP, 70% FiO2). Called by ICU attending to exchange ETT because it becomes kinked when turning the patient prone, and randomly when turning the patient's head in certain directions when supine. Patient also with severe angioedema of the tongue, which is protruding several centimeters from the mouth, firm, immobile, making access to the oropharynx impossible. Patient has been in ICU for 3 weeks. Obviously, an invasive airway is indicated, but the ENT docs are not doing trachs on these patients. I recommended giving a course of steroids to see if the tongue swelling will go down, and reassess at a later date. My fear with proceeding with tube exchange, given the level of tongue swelling, is that we will have trouble advancing a new tube into the airway, given the circumstances, and with the high vent settings, there is no room for error, and no backup plan. Thoughts?

Looking at all those variables, this is classic "the enemy of good is better."

 

[deleted697535]

Tube exchange to a face mask using 10mg morphine, glyco midaz

 

[Ronin786]

Seems like a terrible idea. Out of curiosity, did they just want another ordinary PVC tube, or do you have kink resistant tubes (they're not really "armored" but they have a metal coil in them so they won't kink) available?

Those tubes might not kink as easily, but once they do, there's no unkinking them. If somebody bites into them, that's a death sentence.

 

[chocomorsel]

Those tubes might not kink as easily, but once they do, there's no unkinking them. If somebody bites into them, that's a death sentence.

Seems like this patient already has a death sentence.
Where is palliative care? They may be overwhelmed.

 

[jthedestroyr]

Tube exchange to a face mask using 10mg morphine, glyco midaz

Those vent settings are insane, nobody would even attempt that trach. I have a GS that is probably the fastest person I've ever seen put in a trach and we would have to be at peep of 12 before considering.

This seems like goals of care discussion and no to the airway unless you're using the above cocktail when the tube comes out

 

[MoMoGesiologist]

Are you sure this is a real consult and not a "we tried everything and called everyone, but it's time to withdraw care" consult?

Lmao, they are tryna get anesthesia to withdraw care on the patient

 

[vector2]

Thoughts on the following case:

Morbidly obese patient in ICU, thick neck+Covid, respiratory failure, high vent settings (20 PEEP, 70% FiO2). Called by ICU attending to exchange ETT because it becomes kinked when turning the patient prone, and randomly when turning the patient's head in certain directions when supine. Patient also with severe angioedema of the tongue, which is protruding several centimeters from the mouth, firm, immobile, making access to theT oropharynx impossible. Patient has been in ICU for 3 weeks. Obviously, an invasive airway is indicated, but the ENT docs are not doing trachs on these patients. I recommended giving a course of steroids to see if the tongue swelling will go down, and reassess at a later date. My fear with proceeding with tube exchange, given the level of tongue swelling, is that we will have trouble advancing a new tube into the airway, given the circumstances, and with the high vent settings, there is no room for error, and no backup plan. Thoughts?

I wouldn't be changing this guys ETT in this circumstance anyway, but even if there was an indication I would very much be reconsidering if I couldn't get a low-profile videolaryngoscope like a mcgrath X blade into the mouth. ICU tube changes are best done under video or direct visualization with a blade, and if you can't get a blade into the mouth cause the swelling is so bad then almost certainly you are going to catch something with the bevel of the ETT if you try to do it blind over a cook catheter.

 

[drmwvr]

Even with VL, you'd really need something very stiff, along the lines of an eschmann. An aintree catheter can be way too flexible especially when anatomy is forcing the catheter and tube to bow posteriorly and hang up on the cuniform and corniculate cartilages. No amount of twist and turn will release it if the catheter is too flexible.

 

[Ezekiel2517]

If the tongue is that edematous, that means the airway is edematous. There’s a good chance the cords won’t be visible the second you remove that tube. And if you got an eschmann or some other kind of catheter in there, it’ll be engulfed by tissue. A patient like this has literally 0 reserve.

 

[buccsmf1]

patient has been in the ICU for 3 weeks so I assume theyve been intubated for the majority of that. doubt steroids are going to help. ive seen these patients get macroglossia from impaired venous drainage of the tounge, possibly due to the ETT. agree with others, no way id exchange tube, extremely high chance of death. have a real goc discussion with the family.

 

[IlDestriero]

Trach or leave it. When the tube comes out, it’s not going to go back.

 

[deleted171991]

Covid-19 patient is still alive after 3 weeks in the ICU, on just 70% O2 (especially while supine)? And you want to have a goals of care discussion?

He's probably edematous (and possibly high FiO2) from all the fluids he got during the 3 weeks. I doubt it's just airway edema, and just from Covid-19. It's probably anasarca. Half of that PEEP could be from poor positioning (e.g. not reverse Trendelenburg) in a morbidly obese (proned) guy. In a regular ICU bed, that abdominal fat will push on the diaphragm like crazy, even supine (why do they have small lung capacities?).

That patient needs a good intensivist first. Then, when everything possible has been optimized, then you can talk about "goals of care".

And if the tube kinks when the patient is prone, even in the right bed/frame/pillow etc., make him semiprone. It may help with that belly, too.

Btw, he cannot be trached. If the fresh trach gets dislodged, he's dead. And the first differential for "morbidly obese" in the ICU should be anasarca from 3 weeks worth of fluid overload, until proven otherwise.

 

[MoMoGesiologist]

Covid-19 patient is still alive after 3 weeks in the ICU, on just 70% O2 (especially while supine)? And you want to do goals of care discussion? WTH is wrong with you, wannabe intensivists?

He's probably edematous (and possibly high FiO2) from all the fluids he got during the 3 weeks. I doubt it's just airway edema, and just from Covid-19. It's probably anasarca. Half of that PEEP could be from poor positioning (e.g. not reverse Trendelenburg) in a morbidly obese (proned) guy. In a regular ICU bed, that abdominal fat will push on the diaphragm like crazy, even supine (why do they have small lungs?).

That patient needs a good intensivist first. Then, when everything possible has been optimized, you can talk about "goals of care".

And if the tube kinks when the patient is prone, even in the right bed/frame/pillow etc., make him semiprone. It may help with that belly, too.

Btw, he cannot be trached. If the fresh trach gets dislodged, he's dead. And the first differential for "morbidly obese" in the ICU should be anasarca from 3 weeks worth of fluid overload, until proven otherwise.

Don’t worry. At least we are giving the 30ml/kg, probably once down in the ED and probably once or twice in the ICU

 

[deleted171991]

Don’t worry. At least we are giving the 30ml/kg, probably once down in the ED and probably once or twice in the ICU

Let's not mention the continuous infusions of maintenance *****ic IV fluids.

 

[vector2]

Don’t worry. At least we are giving the 30ml/kg, probably once down in the ED and probably once or twice in the ICU

Honestly I think “run them dry” is one of the few things that’s actually permeated into the general medical consciousness about COVID

 

[46Long]

I don’t see how exchanging the tube would solve the kinking issue. The new tube will also become soft and kink if you let it bend too much. That is no indication to change the tube. Tell them to be more careful in keeping the tube aligned. We do this all the time. A new tube will not solve this problem and you could easily kill this patient trying. As they say, don’t f*** with a perfectly good airway.

PS: I find the proneview headrest the best to prevent tube kinking in the prone position.

I agree. exchanging that tube under those circumstances can lead to badness quickly.
The other thing when intubating these folks initially put a re inforced tube in.

 

[chocomorsel]

Covid-19 patient is still alive after 3 weeks in the ICU, on just 70% O2 (especially while supine)? And you want to do goals of care discussion?

He's probably edematous (and possibly high FiO2) from all the fluids he got during the 3 weeks. I doubt it's just airway edema, and just from Covid-19. It's probably anasarca. Half of that PEEP could be from poor positioning (e.g. not reverse Trendelenburg) in a morbidly obese (proned) guy. In a regular ICU bed, that abdominal fat will push on the diaphragm like crazy, even supine (why do they have small lung capacities?).

That patient needs a good intensivist first. Then, when everything possible has been optimized, then you can talk about "goals of care".

And if the tube kinks when the patient is prone, even in the right bed/frame/pillow etc., make him semiprone. It may help with that belly, too.

Btw, he cannot be trached. If the fresh trach gets dislodged, he's dead. And the first differential for "morbidly obese" in the ICU should be anasarca from 3 weeks worth of fluid overload, until proven otherwise.

Is no one doing Is and Os or something?

This is America. Morbid obesity is about 40% of the population. Not exactly unusual.

Could he be edematous? Sure. Could he be just fat? Absolutely.

 

[MirrorTodd]

Is no one doing Is and Os or something?

This is America. Morbid obesity is about 40% of the population. Not exactly unusual.

Could he be edematous? Sure. Could he be just fat? Absolutely.

Lol we're lucky if we even get an admission weight.

 

[GravelRider]

I’m a big “goals of care” person, but it’s a waste of time here. Even if this patient did warrant it, we are finding out is that these discussions are even more difficult than ever. Often family is unable to see their loved one or be at their bedside as they pass away. They are getting brief updates over the phone from a nurse or doctor whom they’ve never met. There is no chance to earn trust. The whole situation is terrible and many deaths will be prolonged because of it.

In terms of the tube, if you can ventilate, don’t touch it.

 

[Aether2000]

Nearly 100% chance of death no matter what course is chosen.

 

[jthedestroyr]

I’m a big “goals of care” person, but it’s a waste of time here. Even if this patient did warrant it, we are finding out is that these discussions are even more difficult than ever. Often family is unable to see their loved one or be at their bedside as they pass away. They are getting brief updates over the phone from a nurse or doctor whom they’ve never met. There is no chance to earn trust. The whole situation is terrible and many deaths will be prolonged because of it.

In terms of the tube, if you can ventilate, don’t touch it

Hospital where I am has an exemption for compassionate care for family to come see them for gravely sick, none covid which has helped greatly at times.

I honestly love this now visitor policy. Yes. Its harder to build rapport, but often the people that aren't going to budge, weren't going to anyways regardless of rapport.

 

[deleted171991]

Honestly I think “run them dry” is one of the few things that’s actually permeated into the general medical consciousness about COVID

I'm not so sure.

On one of the evening news, just last night, I saw a poor doc who's parents were both admitted with Covid. They showed a picture of the father; he clearly had the swollen hands of somebody with 10+ liters of extra fluid on board.

I have seen non-Covid patients who got fluid overloaded in SICU with 30-40 pounds, after 2-3 weeks. It's very easy, even with the best of intentions, if people don't pay attention on a daily basis, especially in intubated patients. Beyond the famous Michelin man (below), it also makes the patient look worse (more obese and sicker), which induces a complacency and rationalization in the team (e.g. "goals of care"). It drives me nuts.

I keep seeing it again and again, and from intensivists, not amateurs. It's one of the reasons I don't let anybody manage my patients' fluids beyond the first day or so.

 

[Hoya11]

Thoughts on the following case:

Morbidly obese patient in ICU, thick neck+Covid, respiratory failure, high vent settings (20 PEEP, 70% FiO2). Called by ICU attending to exchange ETT because it becomes kinked when turning the patient prone, and randomly when turning the patient's head in certain directions when supine. Patient also with severe angioedema of the tongue, which is protruding several centimeters from the mouth, firm, immobile, making access to the oropharynx impossible. Patient has been in ICU for 3 weeks. Obviously, an invasive airway is indicated, but the ENT docs are not doing trachs on these patients. I recommended giving a course of steroids to see if the tongue swelling will go down, and reassess at a later date. My fear with proceeding with tube exchange, given the level of tongue swelling, is that we will have trouble advancing a new tube into the airway, given the circumstances, and with the high vent settings, there is no room for error, and no backup plan. Thoughts?

Why are they prone with only 70% fio2? Maybe try coming down on that PEEP if your PAo2 is high enough, and turning this high risk prone patient supine, reverse T in case of an airway emergency. Prone position with an intubated patient is somethine the ICUs are struggling with IMO. I mean how much is the prone position helping oxygenation vs leading to these airway emergencies with tubes kinking and becoming dislodged? Its probably the first time having a prone patient for many docs and RTs and they dont really know what they are doing..

If I am trying to oxygenate this patient in the OR, they are supine, in reverese tberg, 100% o2, variable PEEP until I find optimal peep, albuterol puffs down the tube, recruitment maneuvers, etc... Leaving behind the principles that we know to be effective, for techniques that "may" or "the book or an article 10 years ago" said may be marginally better, is frustrating..

 

[dmk5n]

Obviously, an invasive airway is indicated, but the ENT docs are not doing trachs on these patients.

How are ENT able to say that? We don't have that Luxury.

 

[Arch Guillotti]

How are ENT able to say that? We don't have that Luxury.

Because they can. And I also believe their professional society has released guidelines. Tube exchanges are "elective" procedures when you want them to be. This one could be done successfully, but it is a suicide mission.

 

[Ezekiel2517]

It’s easy to be critical of the management by other physicians and make assumptions. Here we can only go by what the OP is telling us. And the fact remains that the mortality rate of vented COVID+ patients is around 80%. Likely much higher for morbidly obese patients.

 

[WheezyBaby]

Those vent settings are insane, nobody would even attempt that trach. I have a GS that is probably the fastest person I've ever seen put in a trach and we would have to be at peep of 12 before considering.

This seems like goals of care discussion and no to the airway unless you're using the above cocktail when the tube comes out

Depending on the degree of obesity, not necessarily an outrageous PEEP. I agree the idea of tube exchange is illogical though

Honestly I think “run them dry” is one of the few things that’s actually permeated into the general medical consciousness about COVID

I do wonder if some of the early "shock" might be underresuscitation related to their home insensible losses / poor po / diarrhea combined with the change in intrathoracic dynamics following tubing. Surely still better to lean on the dry side though

I'm not so sure.

On one of the evening news, just last night, I saw a poor doc who's parents were both admitted with Covid. They showed a picture of the father; he clearly had the swollen hands of somebody with 10+ liters of extra fluid on board.

I have seen non-Covid patients who got fluid overloaded in SICU with 30-40 pounds, after 2-3 weeks. It's very easy, even with the best of intentions, if people don't pay attention on a daily basis, especially in intubated patients. Beyond the famous Michelin man (below), it also makes the patient look worse (more obese and sicker), which induces a complacency and rationalization in the team (e.g. "goals of care"). It drives me nuts.

I keep seeing it again and again, and from intensivists, not amateurs. It's one of the reasons I don't let anybody manage my patients' fluids beyond the first day or so.

Did you create that diagram? Going to have to steal it, it's great

 

[deleted171991]

It’s easy to be critical of the management by other physicians and make assumptions. Here we can only go by what the OP is telling us. And the fact remains that the mortality rate of vented COVID+ patients is around 80%. Likely much higher for morbidly obese patients.

I am sorry, I didn't want to sound dismissive of the hard work people are doing in NYC, and other overwhelmed places. It's not their fault that they are put in situations well-above their pay grade or normal human workload. They are cannon fodder, and they are doing their best.

That doesn't change the fact that most physicians don't have the proper respect for the malignant effects of IV fluids, which may have had an effect in this patient. I also get pissed when people talk about "goals of care" in patients they don't know much about, especially when they could be seriously wrong, and especially when the patient is suffering iatrogenic effects. Every human life is worth fighting for, it ain't over till it's over (e.g. can't oxygenate even with everything at max). All these people are somebody's dear ones, even in a pandemic.

 

[deleted171991]

Did you create that diagram? Going to have to steal it, it's great

No, I didn't. I don't know who did. I think it came from a paper. Just Google "Michelin man fluid overload" for images.

 

[deleted171991]

I do wonder if some of the early "shock" might be underresuscitation related to their home insensible losses / poor po / diarrhea combined with the change in intrathoracic dynamics following tubing. Surely still better to lean on the dry side though

Very possible. It's been reported to happen, in the quest for keeping patients dry. Another reason why intensivists are needed.

 

[Mman]

How are ENT able to say that? We don't have that Luxury.

Because a trach is a much higher risk procedure than an intubation and the benefits of a trach are in people that are going to survive to discharge. With these patients, leaving an ETT in longer could result in some morbidity down the road if they survive but that is about it. And since the mortality is so sky high once they get intubated, how about you let them make sure they are going to live first before worrying about the post discharge morbidity.

 

[Hamhock]

Those vent settings are insane, nobody would even attempt that trach.

There's a few surgical intensivists I work with who would perc trach this lady...or even open trach in the ICU...or "open cric" in the ICU.

That said, I think more conservative measures should be maximized first.

I also wonder if this tube is actually intermittently kinking or is caked with secretions. We had to exchange four tubes my first COVID week due to nearly occluded ETTs in patients with minimal in-line suctioning return. Somehow (small changes in position, I suspect) these patients only had intermittent evidence of high resistance or decreasing tidal volumes. It was very strange.

HH

 

[10KHertz]

Assume you attempted this ETT exchange in the OR with fiber optics and ENT on call, you would still likely have to reduce your tube lumen/size during the swap(angioedema), and cause more resistance and ventilation problems down the road. So scrap it , working on alternative vent setting , suction, mucus clearance, saline washes, etc.

 

[deleted171991]

The whole thread is worth reading:

Thread by @msiuba: Interesting issue in mechanical ventilation of #COVID19 patients, each one here after >10 days of mechanical ventilation. How might we mo…

Thread by @msiuba: Interesting issue in mechanical ventilation of #COVID19 patients, each one here after >10 days of mechanical ventilatiow might we monitor for development of this? Time to pay attention to resistance, oft neglected in the age of COVI…

threadreaderapp.com

 

[Radetzky]

Why are they prone with only 70% fio2? Maybe try coming down on that PEEP if your PAo2 is high enough, and turning this high risk prone patient supine, reverse T in case of an airway emergency. Prone position with an intubated patient is somethine the ICUs are struggling with IMO. I mean how much is the prone position helping oxygenation vs leading to these airway emergencies with tubes kinking and becoming dislodged? Its probably the first time having a prone patient for many docs and RTs and they dont really know what they are doing..

If I am trying to oxygenate this patient in the OR, they are supine, in reverese tberg, 100% o2, variable PEEP until I find optimal peep, albuterol puffs down the tube, recruitment maneuvers, etc... Leaving behind the principles that we know to be effective, for techniques that "may" or "the book or an article 10 years ago" said may be marginally better, is frustrating..

Only 70%??

Prone positioning is an established treatment with good evidence behind it, much more than recruitment manoeuvres and bronchodilators for someone who doesn’t have bronchospasm.

 

[Radetzky]

I also get pissed when people talk about "goals of care" in patients they don't know much about, especially when they could be seriously wrong, and especially when the patient is suffering iatrogenic effects. Every human life is worth fighting for, it ain't over till it's over (e.g. can't oxygenate even with everything at max). All these people are somebody's dear ones, even in a pandemic.

While I agree in the case presented, is “it ain’t over till it’s over” a good principle in all cases? I would be pissed if a physician flogged my loved one to the point of a survival that could only exist in a rest home or care facility- that’s not what they want for themselves. As dumbledore said “there are sometimes fates that are worse than death”.

 

[deleted171991]

While I agree in the case presented, is “it ain’t over till it’s over” a good principle in all cases? I would be pissed if a physician flogged my loved one to the point of a survival that could only exist in a rest home or care facility- that’s not what they want for themselves. As dumbledore said “there are sometimes fates that are worse than death”.

Absolutely. I try not to go further than I'd like people to go for me (and I hate even the idea of being inpatient, not to mention the ICU). To me, every day a patient spends in most ICUs is torture (just the noise the nurses and their lazy alarms make should be unacceptable).

But I've seen enough turnarounds to be less pessimistic than people who underestimate the power of iatrogenic ****-ups in their differential diagnoses. As long as one is not too late. Unfortunately, there is badness caused by disease, and badness caused by bad treatments.

 

[dhb]

@FFP : Re the Michelin man

Patients in the ICU pretty much all get extra cellular edema, i often saw patients with maybe moderate extra total body volume but also generally depleted intra-vascular volume (hypotensive, high urinary osmolarity) how do you get these patients volume to balance?

 

[Hoya11]

Only 70%??

Prone positioning is an established treatment with good evidence behind it, much more than recruitment manoeuvres and bronchodilators for someone who doesn’t have bronchospasm.

Right, as in, if the paO2 doesnt require 100% fi02 , why are they prone at all? I would think that I would reserve turning prone (and all the complications that go with it) for those who have no other option, they are already maxed out on other oxygenation efforts..

can you provide evidence that it reduces mortality?

From what I have seen the evidence of reduced mortality is marginal even in a study with questionable methods

Here is an interesting one: Prone position for acute respiratory failure in adults. - PubMed - NCBI

And also, Im pretty sure that If i tried as hard as the guys who do most ICU studies, I could eek out a study that showed marginal benefit to recruitment manuevers and bronchodilators... or almost any intervention that i chose to study

I cant tell you how many times I have a patient with respiratory distress, no asthma history (but just had an LMA or a ETT in place) low sats, someone says "they are not wheezing" you give albuterol and they feel better and sats improve..

I think beta agonists are being underused from what Im seeing for that exact reasoning. You don't have to necessarily have a history of asthma or acute bronchospasm to get some oxygenation benefit from albuterol, especially when you have a viral infection of your airway causing some degree of reactivity.