High-flow O2 making intubations riskier?
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5-10% are going to.
This. If you’re inducing, your patient isn’t recovering respiratory drive from your induction med of choice (especially Etomidate) in a clinically acceptable timeframe regardless. And I agree, in the comorbidity you’re dealing with in patients like the OP the apnea is the island not the presence of paralytic (I’m in the always give paralytic camp).
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Here is a yet unproposed way of looking at things:
Question 1: What is the nature of the patient's respiratory failure?
Question 2: Depending on the answer to 1, what can happen or what can we do to fix this (i.e. time , rest, antibiotics, steroids, inhalers, diuresis)
Question 3: are my interventions working and if so, how quickly? (this may require bedside assessment frequently)
Once these questions are answered, or better yet, as you go through the process of answering them, you are also assessing whether hi-flow, bipap, or intubation is the best way to go.
It is especially important to have some idea about how soon after and intervention you expect the patient to start getting better.
Hi-flow and bipap are temporizing tools to avoid the negative effects of intubation and mechanical ventilation. You just need to have expectations and assess whether they are being met!
Question 1: What is the nature of the patient's respiratory failure?
Question 2: Depending on the answer to 1, what can happen or what can we do to fix this (i.e. time , rest, antibiotics, steroids, inhalers, diuresis)
Question 3: are my interventions working and if so, how quickly? (this may require bedside assessment frequently)
Once these questions are answered, or better yet, as you go through the process of answering them, you are also assessing whether hi-flow, bipap, or intubation is the best way to go.
It is especially important to have some idea about how soon after and intervention you expect the patient to start getting better.
Hi-flow and bipap are temporizing tools to avoid the negative effects of intubation and mechanical ventilation. You just need to have expectations and assess whether they are being met!
That’s a small number. If that’s the case, then I am sold!!!
Well. That’s what the literature says will fail extubation. arguably fewer than that and tubes are staying in to long and visa versa. Though it’s likely never exactly that simple.
I thought you meant 5 to 10% fail the HFNC temporization. Not extubation. In the Neuro unit that number is much higher.
I'm not aware of any data on that specific cohort, but my experience is probably around 1/3 fail extubation usually because of secretion handling - half transition of comfort, the other half to a tracheostomy - is a conversation I have prior to extubation in this cohort.
reading these posts, im anesthesia going into CCM, i almost ALWAYS use VL in ccm patients. Even if their prior airway was documented easy, I dont mess around in the CCM ever. Why make something harder, when you can make it easier (this is after doing thousands of airways).
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Yea, I make my fellows use VL almost all the time. They don’t love it (most of my colleagues allow them to DL). It makes my HR go down by probably 20 knowing exactly what view they have.
Same I always use VL when teaching. I figure most of my academic partners are giving them DL experience anyways. I just don't know how to meaningfully help someone who is struggling with DL and I can't tell if they are making progress or trouble shooting correctly.
I’m a cardiac anesthesiologist—I use VL for all patients like this. Its more reliable. There’s no need to be a hero.
I pride myself on trainee (particularly fellow) autonomy, but when I ask someone their airway plan for a debilitated, nearly dead ICU patient and it sounds something like “ehhhhh, I’ll just DL, it’ll be okay” we have a pointed discussion about the pros and cons of that approach vs. the one that has a higher first pass success rate and ICU literature backing its superiority. I don’t care if you’ve intubated thousands of patients, there are only a few reasons to turn down VL in that patient population.
agree
no sense taking a risk -- however small -- in DL when you have VL in this patient population.
doesn't take much for a physiologically complicated patient to tip off the edge.
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