Difficult Airway - Covid, Angioedema, ETT Exchange

[dchz]

One could easily diagnose and treat it with a bronchoscope but I imagine that’s just not happening with COVID patients.

Too many aerosols too little PAPRs.

My pre-test probability should be higher before i decide to bronch someone.

Easy enough to switch quickly into VC, see if there’s a large difference between pip and plateau, then switch back to PC.

You can inspiration pause on PC by making the i time really long (or doing inspiration hold maneuover)- eventually your flow will become zero and then pip becomes equal to plateau. But the whole PIP/plateau concept is invalid in pressure control because of the decelerating flow.

Well not that easy, you'd have to donn and doff just to measure a plateau pressure. and you'd have to do that for every patient in the unit. with virtually no RT help.

i tried it on pressure control but it doesn't work out. conceptually, the peak pressure is the plateau pressure in pressure control in my mind, am i misunderstanding this?

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[Radetzky]

Too many aerosols too little PAPRs.

My pre-test probability should be higher before i decide to bronch someone.




Well not that easy, you'd have to donn and doff just to measure a plateau pressure. and you'd have to do that for every patient in the unit. with virtually no RT help.

i tried it on pressure control but it doesn't work out. conceptually, the peak pressure is the plateau pressure in pressure control in my mind, am i misunderstanding this?

yes peak = plateau in pressure control, as long as flow hits zero

Essentially at the start of the breath most of the pressure is due to resistance, minimal is due to alveolar distension and this inverses slowly over the course of the breath. Ie resistive pressure drops over the course of the breath to keep the pressure level constant

 

[deleted59964]

One could easily diagnose and treat it with a bronchoscope but I imagine that’s just not happening with COVID patients.

one can easily f ing diagnose it with a suction catheter -- stop over thinking stuff

 

[nimbus]

one can easily f ing diagnose it with a suction catheter -- stop over thinking stuff

Only if a big loogie comes out attached to the tip. What if it doesn’t?

 

[dchz]

one can easily f ing diagnose it with a suction catheter -- stop over thinking stuff

You can't suction it if it's dried up and clogging the tube.

 

[dhb]

You can't suction it if it's dried up and clogging the tube.

Ask @SaltyDog for advice on this one

 

[deleted162650]

Ask @SaltyDog for advice on this one

I’m a big proponent of frequent suction to prevent clogs.

 

[inflamesdjk02]

Thanks everyone for the discussion, I really appreciate it.

Update to the situation: The patient continues to be ventilated in the ICU. The vent settings have been reduced, last I checked the PEEP was 12 and the FiO2 was 50%. Apparently the patient was enrolled in the remdesivir study. The tongue swelling remains severe. The patient is in their mid-40's. Surgery has been consulted and has agreed to do a tracheostomy with "anesthesia at the bedside". I will not be involved with this, but have read that "a Cook catheter will be placed to prevent loss of airway". Procedure is scheduled for tomorrow afternoon....

 

[deleted547339]

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?

Did you suggest essential oils to go with the steroids?

 

[deleted59964]

You can't suction it if it's dried up and clogging the tube.

yep and the diagnosis is made ... can't pass the suction catheter

 

[deleted59964]

I’m a big proponent of frequent suction to prevent clogs.

me too

 

[KENY1]

As others say attempting a tube exchange would be highly dangerous. Not sure if somebody said this already but the larynx may or may not be swollen. As mentioned here the tongue swelling can be mechanical. If the ETT change would become necessary you could check and see if the larynx is actually swollen or not with a FOB or a VL. Still risk of death very high.
I have just done a tube change on a patient whose first intubation was very difficult for an apparent subglottic obstruction. An attempted tube change over a stylet failed. Further tube advances with Glidescope stylet failed until stylet pulled and a small ETT rotated in with great difficulty.

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[Arch Guillotti]

As others say attempting a tube exchange would be highly dangerous. Not sure if somebody said this already but the larynx may or may not be swollen. As mentioned here the tongue swelling can be mechanical. If the ETT change would become necessary you could check and see if the larynx is actually swollen or not with a FOB or a VL. Still risk of death very high.
I have just done a tube change on a patient whose first intubation was very difficult for an apparent subglottic obstruction. An attempted tube change over a stylet failed. Further tube advances with Glidescope stylet failed until stylet pulled and a small ETT rotated in with great difficulty.

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In the ICU or in the OR?

 

[deleted171991]

As others say attempting a tube exchange would be highly dangerous. Not sure if somebody said this already but the larynx may or may not be swollen. As mentioned here the tongue swelling can be mechanical. If the ETT change would become necessary you could check and see if the larynx is actually swollen or not with a FOB or a VL. Still risk of death very high.
I have just done a tube change on a patient whose first intubation was very difficult for an apparent subglottic obstruction. An attempted tube change over a stylet failed. Further tube advances with Glidescope stylet failed until stylet pulled and a small ETT rotated in with great difficulty.

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Over a stylet? Do you mean a regular ETT stylet?

 

[KENY1]

Sorry, tube changer stylet.

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