Long time lurker, decided to post to get some expert advice. I finished residency last June and took a private practice job. Called today to the ICU for urgent intubation. Pt is 400 lbs, no neck , on BiPAP with sats in the high 80's , she is awake/alert. how to proceed ? Induce and paralyze or play it safe and try to do awake FOB?
Looking for pearls of wisdom
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It all depends on your comfort level with the airway, if you are the only anesthesiologist around and you feel that the airway scares you then please DO NOT induce GA and try to intubate!
You are just starting your career and you should not take unnecessary risk.
This might be an excellent opportunity for you to fine tune your strategy to manage a difficult airway, do a great topical anesthetic, do some airway blocks, and do an awake FOB.
You are just starting your career and you should not take unnecessary risk.
This might be an excellent opportunity for you to fine tune your strategy to manage a difficult airway, do a great topical anesthetic, do some airway blocks, and do an awake FOB.
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not quite an expert yet - but my humble 2 bits...
complete your airway assessment - sure you did this in practice, but mentioning it here will aid in answering your question. assuming your assessment predicts difficult mask ventilation and possible difficult intubation:
keep her at 45deg, place shoulder roll, optimize positioning. topicalize her airway - this should give you an idea as to how fast she's gonna desat when you take the bipap off. awake look c glidescope - if she appears straightforward - RSI, tube. if the view is tough, awake FOB via pink oral airway.
however, she prolly won't tolerate awake FOB without bipap for long - you'd have to be quick about it..
curious to hear how it went..
complete your airway assessment - sure you did this in practice, but mentioning it here will aid in answering your question. assuming your assessment predicts difficult mask ventilation and possible difficult intubation:
keep her at 45deg, place shoulder roll, optimize positioning. topicalize her airway - this should give you an idea as to how fast she's gonna desat when you take the bipap off. awake look c glidescope - if she appears straightforward - RSI, tube. if the view is tough, awake FOB via pink oral airway.
however, she prolly won't tolerate awake FOB without bipap for long - you'd have to be quick about it..
curious to hear how it went..
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i think youve probably got to keep her awake regardless, you have zero reserve, a paCO2 thats likely higher than her paO2 and a suspected difficult intubation - the last thing you want to do is take away her only tether to this world, in my humble opinion.
I used to joke in residency that I would much rather come upon this patient in a code situation as I am pretty sure I could intubate most anyone when I didnt have to think about it...but man I hated to come upon these situations where people are alive and talking to you and act to change that. At least people thought i was joking
I used to joke in residency that I would much rather come upon this patient in a code situation as I am pretty sure I could intubate most anyone when I didnt have to think about it...but man I hated to come upon these situations where people are alive and talking to you and act to change that. At least people thought i was joking
I will tell you guys how it went but you are absolutely right, her sats would drop to the 50s withing 30 seconds of taking the BiPAP off ! Do you think it would be safe to induce/paralyze if you take an awake look with the Glidescope and the pt had a decent view or the collapse of the soft tissue after induction could turn it into a difficult airway ?
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I'm sorry, but you're an attending and posing this? It's not that difficult a question. If she looks like a candidate to tolerate awake FOB, check it out, otherwise, if she can't even tolerate that, go for the induction and glide.
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Dude.. it's all good. Thanks for posting. Sats dropping to the 50's with removal of bipap is pretty nasty. Cuz of the reasons idiopathic described, I also like to keep these whales breathing. If you took an awake look with the glidescope and saw the pot of gold, then take it without any other help. Leave the relaxant at home.
gentle induction with prop/ketamine and DL...if you cant see anything, slap the Bipap back on until she wakes up...
my question is: would bipap w a proper seal and good chin lift provide enough oxygenation to the pt while she still sleeping?
my question is: would bipap w a proper seal and good chin lift provide enough oxygenation to the pt while she still sleeping?
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Are you willing to put that to the test by giving propofol to a potentially difficult-to-intubate patient?
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If you don't feel confident about an airway, especially if you are a young guy with limited experience, then there is no reason on earth why you should induce GA!
The patient is breathing spontaneously and not dying so you don't need to create an emergency and then attempt to fix it.
The patient is breathing spontaneously and not dying so you don't need to create an emergency and then attempt to fix it.
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Being a CA-3 I still fear this the most, but here is my plan of action. This is what make us experts in what we do 
1. Call for help, ideally another colleague and better yet have ENT or Surgery on stand by. Of course these airways always show up at 3 A.M.
2. Consider Benzocaine Spray if possibly or Lidocaine Aromatizer
3. DL with Glidescope awake and if you see the airway Attempt to gently place the tube or directly topicalize. Have someone ready to push Prop or Etom and a NMBD as soon as the tube goes passes.
4. If no view is present, now you maybe in some serious trouble. This is where having someone comfortable with Trachs ends up being helpful. Because even if you consider awake FOB, you will most likely will not have enough time. However, if the airway is somewhat topicalized you mine as well take a look.
Keep in mind this lady may end up getting trached at some point in her life anyways.
5. Last option make the patient DNR/DNI and go back to bed
1. Call for help, ideally another colleague and better yet have ENT or Surgery on stand by. Of course these airways always show up at 3 A.M.
2. Consider Benzocaine Spray if possibly or Lidocaine Aromatizer
3. DL with Glidescope awake and if you see the airway Attempt to gently place the tube or directly topicalize. Have someone ready to push Prop or Etom and a NMBD as soon as the tube goes passes.
4. If no view is present, now you maybe in some serious trouble. This is where having someone comfortable with Trachs ends up being helpful. Because even if you consider awake FOB, you will most likely will not have enough time. However, if the airway is somewhat topicalized you mine as well take a look.
Keep in mind this lady may end up getting trached at some point in her life anyways.
5. Last option make the patient DNR/DNI and go back to bed
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1. Topicalize.
2. Take an awake look with Glidescope.
3. If easily obtainable view, induce and intubate.
4. If no view, AFOI.
2. Take an awake look with Glidescope.
3. If easily obtainable view, induce and intubate.
4. If no view, AFOI.
Devil is in the details. How would you topicalize someone on BiPAP? Do you just sneak in the atomizer every 30 secs? Or can you set up lido neb with BiPAP on?
Another alternative, induce, spontaneous breathing, intubating LMA, fiber.
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Lma/fiber is good here but if you're giving GA you may lose the airway. I'd keep him awake and induce w Brutaine and use a Glide or DL. If really necessary I'd give 14mg etomidate but nothing else. The key is positioning...the grade view is likely 1 or 2 as in most of these obese people.
The key shift in thinking for me is that this is not a nice clean elective OR case where I don't want to emotionally and literally traumatize the patient; this is a life-saving measure. So screw the comfort and class, just get the airway while pt is spontaneously breathing bc otherwise losing this airway is very possible. Too tricky (although not impossible) to topicalize w bipap and poor sats.
Also..many times these people really wanna get tubed. They know you're trying to help them breathe and that air hunger is a real motivator.
The key shift in thinking for me is that this is not a nice clean elective OR case where I don't want to emotionally and literally traumatize the patient; this is a life-saving measure. So screw the comfort and class, just get the airway while pt is spontaneously breathing bc otherwise losing this airway is very possible. Too tricky (although not impossible) to topicalize w bipap and poor sats.
Also..many times these people really wanna get tubed. They know you're trying to help them breathe and that air hunger is a real motivator.
First we tried to topicalize. We would take the BiPAP off for a few seconds, sats drop then back up again. Took a look with a Glidescope , it was an okay view (grade II) but the pt didn't tolerate that for long, started to desat and didn't tolerate the glidescope or passing the tube. We tried again after giving 2 mg of versed but same thing happened, pt is too awake.
Then we decided to give 30 of propofol to see if we have her relax a little bit but still too awake, we pushed total of 100 mg of propofol ,then pt starting biting down , and COUDN"T OPEN THE MOUTH OR VENTILATE!! sats now in the 50s , then we pushed sux and got the tube in !
I don't if I would have induced from the get go , what are the chances of neither being able to intubate or ventilate ! I also had LMA handy just in case!
Any comments
Then we decided to give 30 of propofol to see if we have her relax a little bit but still too awake, we pushed total of 100 mg of propofol ,then pt starting biting down , and COUDN"T OPEN THE MOUTH OR VENTILATE
!! sats now in the 50s , then we pushed sux and got the tube in ! I don't if I would have induced from the get go , what are the chances of neither being able to intubate or ventilate ! I also had LMA handy just in case!
Any comments
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There may have been time for a dex bolus and infusion as you attempted to topicalize the airway and take a look. Remi is nice as well as you can titrate to effect quickly and always push narcan in an emergency and regroup. If you had a good view when he wasn't cooperating, xxxxxx-sux-tube is a good plan. It's unlikely that the grade 2 glide view would go away when your intubating conditions and position improved.First we tried to topicalize. We would take the BiPAP off for a few seconds, sats drop then back up again. Took a look with a Glidescope , it was an okay view (grade II) but the pt didn't tolerate that for long, started to desat and didn't tolerate the glidescope or passing the tube. We tried again after giving 2 mg of versed but same thing happened, pt is too awake.
Then we decided to give 30 of propofol to see if we have her relax a little bit but still too awake, we pushed total of 100 mg of propofol ,then pt starting biting down , and COUDN"T OPEN THE MOUTH OR VENTILATE
I don't if I would have induced from the get go , what are the chances of neither being able to intubate or ventilate ! I also had LMA handy just in case!
Any comments
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guys you are either awake or not. an awake look with a glidescope buys you exactly that, a chance to intubate an AWAKE patient with a glidescope. because what do you think happens when you induce her? well ill tell you that the view wont be the same, so if you have a good awake view, topicalize the cords a little, pass a tube between them, tolerate a little coughing, induce AFTER THE TUBE IS IN THE TRACHEA, exactly as you should with awake FOI. Otherwise you go to sleep from the start and use what y ou like best.
Ive gotten burned on the awake look followed by induction follwoed by oh s*** whered my view go
Ive gotten burned on the awake look followed by induction follwoed by oh s*** whered my view go
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Jesus Christ i hope so
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First we tried to topicalize. We would take the BiPAP off for a few seconds, sats drop then back up again. Took a look with a Glidescope , it was an okay view (grade II) but the pt didn't tolerate that for long, started to desat and didn't tolerate the glidescope or passing the tube. We tried again after giving 2 mg of versed but same thing happened, pt is too awake.
Then we decided to give 30 of propofol to see if we have her relax a little bit but still too awake, we pushed total of 100 mg of propofol ,then pt starting biting down , and COUDN"T OPEN THE MOUTH OR VENTILATE
I don't if I would have induced from the get go , what are the chances of neither being able to intubate or ventilate ! I also had LMA handy just in case!
Any comments
you probably ran into trouble because she went into laryngospasm. an argument for inducing fully in these patients is that you will probably be able to ventilate. in the literature, the bolded statement is fairly rare but i think it usually assumes multiple providers (i.e. four handed mask)
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First we tried to topicalize. We would take the BiPAP off for a few seconds, sats drop then back up again. Took a look with a Glidescope , it was an okay view (grade II) but the pt didn't tolerate that for long, started to desat and didn't tolerate the glidescope or passing the tube. We tried again after giving 2 mg of versed but same thing happened, pt is too awake.
Then we decided to give 30 of propofol to see if we have her relax a little bit but still too awake, we pushed total of 100 mg of propofol ,then pt starting biting down , and COUDN"T OPEN THE MOUTH OR VENTILATE
I don't if I would have induced from the get go , what are the chances of neither being able to intubate or ventilate ! I also had LMA handy just in case!
Any comments
can you private message me.. so i can give you a smack down in private.. I heard something in this post that you need to know.. Have you done your orals yet??????????????????
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Why the private message? Share your knowledge with all of us who have orals coming up!
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michigangirl said:
One thing that leapt out at me as a potential oral-board killer was this:
Cookie said:
When you're talking about awake intubations / airway looks on the orals, an uncooperative patient is hypoxic/hypercarbic/hypotensive until proven otherwise, not "undersedated" and your awareness of this fact needs to be conveyed to the oral board examiners.
Obviously in this actual case Cookie was aware of the patient's vital signs, but a pitfall that was drilled into me by multiple oral board prep books and the course I went to was something like this ...
examiner: the patient can't tolerate your efforts
you, flirting with failure: I give more sedation
examiner: the patient still can't tolerate your efforts
you, about to fail: I give more sedation
examiner: the patient resists a little less
you, failing: I give more sedation
examiner: the patient codes (because the problem was hypoxia, not lack of sedation)
Or maybe maceo objected to
Inducing from the get go is rarely the right thing to do on an oral board scenario involving a potentially ugly airway, and may be a bit ballsy in real life too.Cookie said:
But I'd be interested in what had maceo so worked up
and don't see any reason why not to post it here.
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