new airway disaster

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B-Bone

B-Bone

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Let's hear some thoughts about this one:

This afternoon I was CA-2 on airway backup. I was called by the MICU to emergently intubate a patient. Went to MICU. Found 315 lb male patient with copious blood coming from mouth and nose (some on the ceiling)-massive upper GI bleed. Pulm/CC consultant was attempting DL with Mac 4 blade. Patient had very small mouth opening. RT was unable to mask ventilate. Sats were I the mid 70’s. I immediately asked for intubating LMA and placed it. Moving air, improved sats to low 90’s. Whew... Time to breathe, so I called the backup airway consultant. He arrived and we placed 8.0 ETT through intubating LMA with fiberoptic bronchoscope guidance. Tube in place, confirmed with ETCO2, chest rise, improved sats and FOB. Sats brough to mid 90’s. Lots of pulm edema coming from ETT, suctioned. ETT secured. Primary team planned emergent upper GI scope to locate source of bleeding. I left.

An hour later I was called by MICU senior because pt has “cuff leak” and they want me to take a look. EGD has not been performed yet. I go to MICU. MICU fellow demands that I change out ETT over exchange catheter immediately due to “poor oxygenation”- O2 sat is 89% at this point and holding steady. I respond that we currently have a patent airway and I am not sure I could reintubate this dude if we lose it. I call backup airway consultant and get Cook airway exchange catheter ready. I examine ETT pilot balloon. It is inflated. RT responds that it is only inflated because they "keep adding air to it" and they’ve put about 40 cc in, but insists there’s a leak. There is obvious air leaking out with each ventilation. I confirm endotracheal placement of ETT with FOB. ETT is ~2 cm above carina. Backup airway consultant arrives. We eval and he notes that ETT pilot balloon is inflated. We are urged to exchange ETT. We place Cook catheter down ETT, but are unable to get it down very far-only down to 22 cm at the teeth, but meet lots of resistance-it will go no farther. We carefully attempt exchange and get old ETT out with significant difficulty. On extubation ballon is intact and inflated to large size ~ 40 cc air. Place 6.5 ETT over cook catheter, remove catheter, attempt ventilation. Very difficult to hear BS, but we do get CO2 on detector. However, definitely hear gurgling over stomach. Catheter wasn't deep enough and ETT is in estomogo. Pull out ETT and attempt mask ventilation. Moving some air, but can only get sats to 70%. Call ENT and take one look with DL. Patient fighting DL-paralyzed with 100 mg sux. Still fighting, decide to replace intubating LMA. Attempt to place 8.0 ETT over FOB through intubating LMA again-unsuccessful this time. Can ventilate through LMA with good chest rise and holding sats at 70%, but massive pulmonary edema coming out LMA. Bag until ENT arrives. They perform emergent cricothrotomy and place 8.0 wire spiral ETT into trachea. Positive ETCO2, chest rise, confirm placement with FOB. ETT sewn into place. Sats remain at 70% without any improvement. MICU plans emergent EGD again. With things "stable" and my "services" no longer needed, I jet outta there.

I think the crux of this is that there seemed to be air leaking around ETT cuff despite what appeared to be an inflated pilot balloon. When we took ETT out, the cuff was blown up to like 40 cc. I think the cuff was blown up so much it kind of herniated up towards the cords and had an air leak. I can't think of another way to put this together. If this ever happens again, I'm gonna make damn sure to deflate the cuff and reinflate it to make sure what the F is going on. Another lesson: that Cook exchange catheter is by no means a 100% surefire way to switch out a tube. I've seen problems with it before. Most important lesson: never take out a patent ETT if you aren't pretty sure you can get another one in.

So let's hear it. Any thoughts?
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You've already answered all of your questions.

The one constructive criticism I can add is never, ever get talked into something that goes against your gut by a medicine dude who knows nothing about airway management and thinks exchanging an endotracheal tube on a beached whale is as easy as walking into a convenience store and buying some Skittles. In the blue package, not the purple.
 
very tough case (they seemed to be happening in bunches on this forum lately)..I really hate to be critical because this is such a tough situation...The only thing that I would say is that if in a situation with a tough airway, I would make sure that ENT was at the bedside and was prepped and draped prior to trying the tube exchange (especially given that the sats were stable before the exchange)....this would give you some control in a fairly uncontrollable situation...jet is also right....however, to me it sounds like you felt that the tube needed to come out at some point and that you were not completely bullied (correct me if I am wrong)... otherwise I totally agree with your thought process...keep your head up because this was a tough one.....
 
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good case.
1 ett cuff leaks are very, very, very uncommon. 9/10 cuff is overinflated and/or over the cords. 2.changing tube over exchange catheters is not a walk in the park as you found out. 3. Look for other causes of low SpO2; .ie. aspiration, pna, etc. PT and medicine sucked you into thinking it was the cuff, while it was bad lungs.4) as jet said; you are the airway expert. don't back down. walk out and let them deal with it themselves.
 
also, don't be afraid to take pt to OR for airway exchange. in the past I've done that. with techs, rns, ent etc on stand by. i make an event out of it. its fun.🙂
 
The cause of this leak was likely that the ETT was pulled out. The TIP of the ETT was in or just at the tracheal opening, but the CUFF was in the pharynx. (I have seen this a number of times visually- you of course, did not have the opportunity to see it on this case as visualization would have ben rather difficult). Ventilation was occurring (poorly) with no seal. MAYBE you could have replaced the ETT using a FOB as a guide- the blood probably would have precluded this though. Tough case, you did your best.
 
kmurp said:
MAYBE you could have replaced the ETT using a FOB as a guide- the blood probably would have precluded this though.
Click to expand...

How? You have to take the old tube out. You have to have the new tube on the scope when you go in to take a look. I'm just curious if there is some techinque I don't know about; please let me know.

And, B-Bone, as I was reading your case I was trying to think about the next step and figure out what I would've done differently as you developed it. There was nothing.

The only thing I might have tried was to bring a Glidescope in and try to take a look directly at the cords.

And, although exceedingly rare in a non-trauma situation, this guy might have had a tracheoesphageal rupture (hence the blood and "pulmonary edema" in the lungs) and this is why you kept hearing "gurgling" noises even though the tube was in place. Along with that, I also disagree with kmurp's supraglottic theory, especially if you used the FOB correctly. When you look back down the tube you can easily measure how high you are off of the carina. Plus, you can get an idea about how far the reinforced ETT is hanging out as to whether or not you are supraglottic. I think this is a less-likely cause, especially if you were getting ETCO2 and decent tidal volumes. When I got called back to the bedside, though, I would've taken the FOB back out, gone back down the tube, deflated the cuff, and re-advanced to confirm position before grabbing the Cook exchanger. Also, when you use a Cook exchanger, it helps to put a direct laryngoscope (like a MAC 4) in the oropharynx while using it (don't know if you did that or not) to facilitate tube exhange.

-copro
 
P.S. And, no matter how you slice it, this guy was facocta. It never ceases to amaze me sometimes in the hospital how we routinely interfere with nature taking its proper course.
 
when you said obvious air leak...by auscultating an air leak, vent readings...or both?

also, unless that patient was really volume resuscitated, maybe that pulm edema was just blood and GI contents. I think aspiration would be the rule, not the exception when you find blood on the ceiling.
 
Last edited:
coprolalia said:
How? You have to take the old tube out. You have to have the new tube on the scope when you go in to take a look. I'm just curious if there is some techinque I don't know about; please let me know.

And, B-Bone, as I was reading your case I was trying to think about the next step and figure out what I would've done differently as you developed it. There was nothing.

The only thing I might have tried was to bring a Glidescope in and try to take a look directly at the cords.

And, although exceedingly rare in a non-trauma situation, this guy might have had a tracheoesphageal rupture (hence the blood and "pulmonary edema" in the lungs) and this is why you kept hearing "gurgling" noises even though the tube was in place. Along with that, I also disagree with kmurp's supraglottic theory, especially if you used the FOB correctly. When you look back down the tube you can easily measure how high you are off of the carina. Plus, you can get an idea about how far the reinforced ETT is hanging out as to whether or not you are supraglottic. I think this is a less-likely cause, especially if you were getting ETCO2 and decent tidal volumes. When I got called back to the bedside, though, I would've taken the FOB back out, gone back down the tube, deflated the cuff, and re-advanced to confirm position before grabbing the Cook exchanger. Also, when you use a Cook exchanger, it helps to put a direct laryngoscope (like a MAC 4) in the oropharynx while using it (don't know if you did that or not) to facilitate tube exhange.

-copro
Click to expand...

not quite sure what you mean by that. an esophageal rupture due to wretching? you don't mean a tracheal rupture as well i dont think...but i'm not clear
 
jetproppilot said:
You've already answered all of your questions.

The one constructive criticism I can add is never, ever get talked into something that goes against your gut by a medicine dude who knows nothing about airway management and thinks exchanging an endotracheal tube on a beached whale is as easy as walking into a convenience store and buying some Skittles. In the blue package, not the purple.
Click to expand...

Agree with the Jeti Master completely (as usual). Never get talked into making a controlled situation an uncontrolled situation. You are the expert. They manage Sjogren's disease...we manage airways.

I always take my junior residents up with me to airway adventures or codes. It can be unsettling because you have to think of EVERYTHING. Take NOTHING for granted. One of the things I tell the juniors is to count how many assassins and prostitutes we encounter.

One single recent evolving disaster:
Assassination attempts:
1. Yes the suction works - no canister even in room
2. Yes this is a free flowing IV - KCL infusion piggybacked to Alaris
3. Bolusing NS now - it was actually the maintenance D51/2NS with 20K

Prostitute solicitations:
1. Can't find the pulse ox cable...can't you just intubate without one...?
2. Patient is really wiggling...can't you just give a little etomidate....?
3. Out of succ...needs to come from pharmacy...can't you just use vec?

The only thing I would have done differently would be to have called trauma or ENT and have the cric in the room. Good call with the FasTrach LMA. Good post.
 
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agree with most points

1) airway leaks w/ 8.0 ETTs are usually because the ETT/cuff is above the cords

2) i would have done the FOB - deflated the cuff, advanced it to the carina, inflated the cuff and pulled back by 2 cm and then re-attempted ventilation

3) i strongly would have recommended this be done in the OR (for many reasons)
 
jetproppilot said:
You've already answered all of your questions.

The one constructive criticism I can add is never, ever get talked into something that goes against your gut by a medicine dude who knows nothing about airway management and thinks exchanging an endotracheal tube on a beached whale is as easy as walking into a convenience store and buying some Skittles. In the blue package, not the purple.
Click to expand...

Actually, this is a good point. It is lamentable that they don't include a month of anesthesia in the IM curriculum. Especially since hospitalists and MICU teams often cover codes and are inadequately prepared for airway disasters. Even just knowledge of using an LMA in cases where you cannot tube or bag would be helpful, but not even this is not taught to our budding IM jedi's.
 
coprolalia said:
How? You have to take the old tube out. You have to have the new tube on the scope when you go in to take a look. I'm just curious if there is some techinque I don't know about; please let me know.

What I meant was to pass the FOB through the existing ETT which was likely just above the glottic opening and hoping to see enough to advance the existing ETT back into the trachea. With all the fluids down there I don't know if this would have worked.
Click to expand...
 
of course it works - meaning using FOB to reimplant the ETT

however, to optimize the technique - have the other airway person place a large MAC under the tongue and give some lift with a yankauer right next to it... that way you get 1) less secretions 2) a lot of light 3) you can now navigate the FOB a lot better...

i wish they could make a FOB that acts like an exchange tube - ie: you can screw off the handle - slide off the yucky ETT , slide on a new one, screw the handle back on and have a good view...
 
Tenesma said:
of course it works - meaning using FOB to reimplant the ETT

however, to optimize the technique - have the other airway person place a large MAC under the tongue and give some lift with a yankauer right next to it... that way you get 1) less secretions 2) a lot of light 3) you can now navigate the FOB a lot better...

i wish they could make a FOB that acts like an exchange tube - ie: you can screw off the handle - slide off the yucky ETT , slide on a new one, screw the handle back on and have a good view...
Click to expand...

Why hasn't someone made an airway device like that? With the advent of cheap and small fiberoptics (think of the C-trach, it has a screw off part), I'm surprised nobody is marketing this yet. I guess the device manufacturers are stuck on supraglottic devices for now.
 
When you have time...and you did when they were filling the cuff up with a lot of air...it's always good to get a CXR.

You would have seen that the tube was high, and you would have known what to do, and that was to use a fiber to direct the tube lower into the trachea.



The other thing to do when forced into a situation where you HAVE to change a tube (cuff is truly busted), is to establish some OTHER way of ventilating/oxygenating a patient.

A vessel dilator threaded through the cricothyroid membrane and connected to a jet ventilator is ideal.....keeps patient alive, and is unobtrusive enough to allow you to d ick around above the cords to replace the tube.
 
The other trick with the Fiber is to load a tube on and drive the FO into the trachea NEXT to the existing tube.

Put the existing tube, and put the new one in.
 
Agree w/most everything above.

One thing I like to do after the exchange is complete is to put the old ETT in a suction canister that is filled with water and blow the cuff up to see if there is a definitive leak. The nitwits from IM don't really understand what an endeavor this can be.

I remember when I was a CA1 I went on a tube exchange with the CA-3. I I was a relative newby but I didn't really understand why we were changing it out. Tidal volumes, peak pressures were ok and I could feel the cuff as I ballotted the pilot. But we went ahead anyway. This guy was sick as stink. He was a strapping teenager with some terrible leukemia or lymphoma who had one foot in the grave and the other on a banana peel. He was all lined up on about 5 pressors with a full scale flog in process per the familys request even though he was obviously dwindling. He was as puffed up as you can possibly imagine.

First we read the family the riot act. So we induce, roc him (after some thought), position, DL Mac 4, suction, Cook down ETT. Unfortunately at some point despite everything we were doing we lost the airway briefly (maybe we had trouble getting the new ett down, I can't really remember). Thankfully we got the tube in after a bit of mucking around. Well this guy was so far gone that this little bit of disruption let that other foot slip off the proverbial banana peel and he coded. He came back pretty quickly with some Vitamin E but I gained a whole new respect for tube changes early that AM. I don't think the cuff leaked when I checked it either.

Now I think really long and hard about these and have since turned a few of them down. I don't know if I would take someone to the OR for this or have ENT on standby unless the situation was really dire but I won't do it unless I am convinced there's a leak and I have no problem tellign family that it can be a life or death situation. Sounds kinda dramatic but we all know how fast these airways go in the crappy especially on pts. that have no reserve.
 
 
Arch Guillotti said:
Now I think really long and hard about these and have since turned a few of them down.
Click to expand...

My standard answer now is, "How 'bout we take him to the OR and do a trach?" That usually makes them think twice.

Also, FWIW, our new "standard of care" at my institution is not to use the Cook exchanger. We deepen/induce and do a DL with the "defective" tube in place. If we get a good view of the tube going through the cords, with whatever cricoid/laryngeal/positioning we have, we gently deflate the cuff, remove the old tube, and stick the new one in right away. This seems to work the best. I generally refer to the Cook exchanger as the "agent saboteur". Most people don't even hook O2 up to the end of it when they try the change over, which is what it's specifically designed for.

And, yikes... http://www.anesthesia-analgesia.org/cgi/content/citation/105/4/1174

😱

-copro
 
B-Bone said:
MICU fellow demands that I change out ETT over exchange catheter immediately due to “poor oxygenation”- O2 sat is 89% at this point and holding steady.
Click to expand...

At that time, I'd request 40 of etomidate, 120 of sux, and 100 grams of kiss my ass. I can't add much more than everyone else has said, as a Monday morning quarterback I might have considered a surgical airway. It may seem like a bit of overkill, but you could have had a bad outcome and he can live with a trach scar.

I wish our bougies were a few inches longer. They'd be a pretty good tube exchanger. Much better than the Cooks.
 
If I can't intubate, can't LMA, can't ventilate, can't return to spontaneous ventilation before something bad happens, I'm going to go to cutting their neck quickly. Sure, I could try retrograde, jet ventilation, or something else, but I think where people get in real trouble is where they delay the cric because they want to spare the patient an emergent surgical procedure. That's admirable, but not if it causes anoxic brain injury or death.
 
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