Difficult Airway

[zippa]

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http://emphysician.blogspot.com/2008/06/difficult-airway.html

I was reading this blog and was curious if there was anything you would have done differently. Any other techniques you would have tried before calling ENT?

 

[huktonfonix]

If you have an idea where you are anatomically then a light wand is always and option. However, given the circumstances, a call to ENT or doing a crich yourself seems to have been the right call.

 

[NaeBlis]

http://emphysician.blogspot.com/2008/06/difficult-airway.html

I was reading this blog and was curious if there was anything you would have done differently. Any other techniques you would have tried before calling ENT?

IMHO, the approach was wrong from the start. They never should have knocked the patient out in the first place, you never stop spontaneous ventilation when you have the possibility of a swollen/obstructed airway.

The patient should have been given mild sedation and local for an awake fiberoptic intubation, or an awake look with a blade.

If for any reason the awake approaches were not possible and the pt continues to decline (pt combative, not successful ect.) it is reasonable to induce general anesthesia, but you MUST have the neck prepped and draped for a cric. They shouldn't have been fumbling for a cric tray after multiple failed intubation attempts. They probably ruined any chance at latter intubation by the multiple attempts (increased swelling).

Also what kind of ER doc can't do a trach?

Someone should tell this ER doctor not to post his/her negligence of a blog.

 

[Planktonmd]

This whole thing sounds too dramatic to me.
They made the decision to intubate based on the CT scan results although there was no indication that the patient was in distress clinically.
Then although they seem to have thought the guy has impending airway obstruction they still decided to go ahead and put him to sleep!
Then after they put him to sleep they didn't have any difficulty mask ventilating him which makes me question that he had any airway obstruction to start with.
After that they messed around the airway for what appears to be a very long time (hours maybe), then they post a picture of edematous oral cavity (not very surprising).
This whole story seems like someone was acting then thinking, it's always better to do the thinking before acting.

 

[Idiopathic]

"This was my first time dealing with a truly difficult impossible airway (and I did anesthesia prior to emergency medicine...AND I trained at a Level I trauma center in Los Angeles!!)..."

say what? what do you think he means by "did anesthesia". Ive "done anesthesia" for about a year now and seen more than 1 airway disaster.

With my limited training, I (obviously) keep this guy awake, give ketamine for sedation, and awake scope him. More than likely, he gets intubated pretty easily (I mean, THEY COULD STILL BAG HIM!!!) on the first attempt. I cant think of the scenario where I would put this guy to sleep to look in his throat and risk everything that comes with that

 

[dienekes88]

I loved the CRNA-cheerleader's comment:

"I find it hilarious that you think the CRNA isnt as good as any Anesthesiologist, afterall, the ones doing al the tubes and work in the OR ARE the CRNAs. Too bad your lack of understanding that there isnt a difference caused the delay in a real airway expert looking and treating."
-M (a.k.a. CRNA4Lyfe)

 

[SleepIsGood]

What's done is done.

What if you were the anesthesiologist that showed up AFTER the drugs were all pushed? What wouldyou have done?

I think getting an ENT stat is obviously wise. THe dude is asleep already (knowing ER docs where I'm at they all push Vec so you're screwed for atleast 30min). I say, put in an intubating LMA. Take a look with the fiberoptic. Tke the scope out and vent him through the iLMA if he desats. Keep looking with the Fiberoptic.
Maybe even try threading the tube through the iLMA.

What would you do in a situation like this when you are the consultant that shows up?

 

[rsgillmd]

What's done is done.

What if you were the anesthesiologist that showed up AFTER the drugs were all pushed? What wouldyou have done?

I think getting an ENT stat is obviously wise. THe dude is asleep already (knowing ER docs where I'm at they all push Vec so you're screwed for atleast 30min). I say, put in an intubating LMA. Take a look with the fiberoptic. Tke the scope out and vent him through the iLMA if he desats. Keep looking with the Fiberoptic.
Maybe even try threading the tube through the iLMA.

What would you do in a situation like this when you are the consultant that shows up?

You don't have to take out the fiberoptic while you went through the ILMA if you attach a bronchoscopy adapter (called a swivel adapter in my institution). One attending had me do this in my CA-1 year for educational purposes. I did it once in my CA-2 year on a difficult intubation during a code. This technique has also been published in textbooks/journals so it is not something new.

 

[Planktonmd]

What's done is done.

What if you were the anesthesiologist that showed up AFTER the drugs were all pushed? What wouldyou have done?

I think getting an ENT stat is obviously wise. THe dude is asleep already (knowing ER docs where I'm at they all push Vec so you're screwed for atleast 30min). I say, put in an intubating LMA. Take a look with the fiberoptic. Tke the scope out and vent him through the iLMA if he desats. Keep looking with the Fiberoptic.
Maybe even try threading the tube through the iLMA.

What would you do in a situation like this when you are the consultant that shows up?

This is a situation of inability to intubate (for whatever reason) but adequate mask ventilation, so you have all the time on earth to do whatever method you are most comfortable with.
My approach would be:
1- Take control of the airway and make sure that mask ventilation is adequate.
2- Minimize the number of people present in the room.
3- Suction very well.
4- Optimize position.
5- Take a look with a MAC 4 (most likely that's all i will need).
6- If DL is not successful at least I will know if the problem is pre-existing anatomy or iatogenic airway edema caused by multiple intubation attempts.
7- If the problem is swelling then I will push the tube through the area where I think the glottic opening should be under DL.
8- If I think that the guy has bad anatomy then oral fiberoptic intubation.
What's funny is that these guys kept extubating the guy several times because they were not sure where the tube was, I thought CO2 detectors are available everywhere these days.

 

[CambieMD]

This is a good case to discuss. I realize that I wasn't there and the ER doc made a point of saying how difficult it was to get ENT to come in. I would have started trying to get an ENT at the bedside much earlier. This guy needed to be seen by ENT right when he hit the door. The pt should not have been put to sleep. This is an intubation for the OR with a surgeon present to cut the neck if the need arises.

I appreciate the ER doc taking the time to share his story with the rest of us. We can learn from it.

Cambie

 

[Jeff05]

he should have NEVER put this guy to sleep. he was doing fine just sitting with a bit of obstruction.

i would have given ABX, steroids, inhalational racemic epi and waited for ENT.

this guy should have had an awake FO.

a cric set should have been open with a Jet Vent ready to go.

an LMA would not be very useful in this case - as there is lots of supraglottic swelling.

 

[2ndyear]

I agree it's a great case to discuss, and could happen to any one of us at any time. Hindsight is always 20/20, but it seems that if the patient was stable, despite what the CT showed, rounding up consultants before the fact is the right thing to do. The first step in managing airways is determining if it is anticipated to be difficult. Awake fiberoptic is easier if the pt is awake, and sitting up. Asleep, supine, after multiple intubation attempts is not an easy rescue with a scope. Hopefully the case prompted some discussion of call responsibilities for consulants. General surgeons should be able to do trachs. Similarly, if an anesthesiologist is in house they should be easy to reach. If they're busy, there should be someone on backup call from home available in a reasonable amount of time.