Tongue Fallback/Airway Obstruction

[maddy_w]

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I am a masters engineering student pursuing a project in the patient monitoring/anesthesiology space. I have come across the problem of tongue fallback obstructing the airway in non-GA procedures (i.e.: awake surgeries).

Has anyone ever experienced this problem? How often does it happen? How critical is it? How satisfied are you with current methods to mitigate the problem?

Additionally, how much time does it take to mitigate this problem?

Thank you! Any and all commentary is appreciated.

 

[Mman]

it is a critical problem in usually large sleep apnea patients that we are attempting to sedate for a procedure without using an airway device. The patients desire to be amnestic to what is going on around them but still spontaneously breathing. Most common work around (other than just giving them a jaw thrust) IMHO is using a nasopharyngeal airway, though those are not always easy to place or well tolerated.

 

[nimbus]

It’s an age old problem. Many ways to deal with it from telling the patient to take a deep breath, an entire gamut of oral and nasal airways, manual maneuvers we do with our hands, to intubation.

 

[deleted875186]

This is the primary reason an anesthesiooogist rather than any other doctor or nurse should be the only one to provide deep sedation.

Lots of solutions, either providing less sedation, or providing more sedation and using some sort of airway.

 

[migm]

yes only an anesthesiologist can figure out an NP airway, jaw thrust, positioning or securing an airway

 

[vector2]

yes only an anesthesiologist can figure out an NP airway, jaw thrust, positioning or securing an airway

To be fair, pretty much everyone outside of an anesthesiologist, midlevel anesthesia provider, occasional CCM/ER doc, or surgeon who can cric is pretty bad at getting oxygen into a patient who's not getting enough oxygen.

Have you ever seen an RT bag a coding ICU patient? Most of the time they could be in an instructional video on exactly what not to do

 

[woopedazz]

I am a masters engineering student pursuing a project in the patient monitoring/anesthesiology space. I have come across the problem of tongue fallback obstructing the airway in non-GA procedures (i.e.: awake surgeries).

I'm sure you already know this, but just in case you didn't I've attached an image to show what the two main contributers of sleep apnoea/airway obstruction during sedation/"swallow their tongue during seizure"/etc are: The soft palate and the tongue. More as an illustration as to how the frenulum linguae keeps the deceptively large "tongue muscles" mostly in place even when it's obstructing. Yes, the tongue loses tone and obstructs the airway, but it doesn't really "fallback" or "swallow" or "twist back" on itself. It just shifts posterior in the oral cavity. Just in case you were concerned that tongues were actually being "swallowed" and that this was the issue you were trying to avert.
I'm sorry if that was patronising, but sometimes people get confused by the layman's nomenclature.

1. Has anyone ever experienced this problem?
2. How often does it happen?
3. How critical is it?
4. How satisfied are you with current methods to mitigate the problem?
5. Additionally, how much time does it take to mitigate this problem?

1. Yes. Everyone has.
2. Happens relatively frequently with larger patients who have OSA.
3. It's critical if there are non-airway trained personnel caring for the patient. Patients can suffer morbitity/mortality due to obstruction, but relatively infrequently in controlled anaesthesia environments. This is because it's relatively benign if someone properly trained is in charge. The reason it is relatively benign is because there are numerous ways to mitigate/treat the issue as others have already stated. Obviously sometimes things just don't work out how you want them to and you run into issues.
4. Pretty satisfied.
5. Timewise: Resolves within 1 second of tapping the patient on the forehead and asking them to take a deep breath. Or 5 seconds if they don't wake up and you've over-sedated them and you need to do a manual manoeuvre/re-position. Or 5-15 seconds if that doesn't work and you need to grab an airway adjunct.

Anecdote time: That all being said... I've responded to a Code Blue and observed the pronunciation of death in scope suite secondary to obstruction; poorly equipped room, on a different floor to the operating theatres, no difficult airway equipment outside of theatre, undertrained staff, etc: Huge fatty with known OSA, THRIVE applied for several minutes but SpO2 remained below 95%, attending gave a bit of fentanyl with 40mg of propofol, immediately obstructed, failed adjuncts including LMA (which was wrong size because scope suite...), respiratory arrest, attempt to tube = difficult airway --> immediate decision for surgical airway --> they couldn't find a scalpel, dead.

^ That is obviously extremely unusual and was a sentinel event for that hospital. No adjunct could have helped, the patient needed to be cancelled and proper resources needed to be available. Nothing you could engineer to improve that particular case.

 

[2Fast2Des]

To be fair, pretty much everyone outside of an anesthesiologist, midlevel anesthesia provider, occasional CCM/ER doc, or surgeon who can cric is pretty bad at getting oxygen into a patient who's not getting enough oxygen.

Have you ever seen an RT bag a coding ICU patient? Most of the time they could be in an instructional video on exactly what not to do

Agree, more air is leaving the pt or going in the stomach when others are going to town. At one code the RT was asking to take over the intubation because I was having a hard time with aspiration flying out, chest compressions, difficult visualization with all that and he was like hey do you mind if I take over. In my mind I was like lol yeah okay. Eventually I got it in and suctioned out all the Ensure from the lungs.

Better to leave the **** show to those who can manage it

 

[deleted875186]

yes only an anesthesiologist can figure out an NP airway, jaw thrust, positioning or securing an airway

They are not hard to figure out, but non anesthesia providers tend to be slower to recognize the problem, and slower to resolve it.

 

[coffeebythelake]

Have you ever seen an RT bag a coding ICU patient? Most of the time they could be in an instructional video on exactly what not to do

Code situation, chest compressions in progress, patient with copious dark gastric contents pouring out from mouth, I kid you not it was overflowing. The RT bagging patient like nothing wrong. Maybe he didnt know that pushing gastric contents into the lungs is an unsuitable ventilation technique. Maybe he was pioneering a new methos of liquid ventilation?? I told the RT wtf was he doing and get me suction, while intubating patient. They returned pulses after, but predictably pt developed massive ARDS and later died.

 

[coffeebythelake]

I am a masters engineering student pursuing a project in the patient monitoring/anesthesiology space. I have come across the problem of tongue fallback obstructing the airway in non-GA procedures (i.e.: awake surgeries).

Has anyone ever experienced this problem? How often does it happen? How critical is it? How satisfied are you with current methods to mitigate the problem?

Additionally, how much time does it take to mitigate this problem?

Thank you! Any and all commentary is appreciated.

Happens all the time with sedation, especially deep sedation. As others have commented, it is usually easy to detect, by usual vigilance and ETCO2 monitoring. Treatment is lighten anesthetic, or different maneuvers such as jaw thrust, chin lift, use of oral or nasopharyngeal airways, placement of supraglottic device or intubation.

 

[pgg]

yes only an anesthesiologist can figure out an NP airway, jaw thrust, positioning or securing an airway

I'm sensing some hurt feelings here.

 

[Arch Guillotti]

yes only an anesthesiologist can figure out an NP airway, jaw thrust, positioning or securing an airway

lol bro, go over to the EM forum if you want to troll😵

 

[migm]

i just like hanging out with the elites. thanks for teaching the rest of us

 

[deleted697535]

yes only an anesthesiologist can figure out an NP airway, jaw thrust, positioning or securing an airway

 

[Noyac]

I don’t know if anyone said this already but I like to turn their head to the side when they obstruct because of the tongue. After decreasing the sedation of course.

 

[deleted697535]

I don't like to make small talk with patients for an hour during the op so I like a generously sedated patient. ²cc load prop. Slide in an oral airway. Prop at 40. Chill

I am a masters engineering student pursuing a project in the patient monitoring/anesthesiology space. I have come across the problem of tongue fallback obstructing the airway in non-GA procedures (i.e.: awake surgeries).

Has anyone ever experienced this problem? How often does it happen? How critical is it? How satisfied are you with current methods to mitigate the problem?

Additionally, how much time does it take to mitigate this problem?

Thank you! Any and all commentary is appreciated.

Basically on every second or third sedated case. Most of the time it's not critical unless you ignore it thru lack of skill or poor patient selection which is another sign of lack of skill or experience. Most yr 2 residents can handle it easily enough

Im very satisfied with his easy it is to manage, nasal or oral airway works great

 

[coffeebythelake]

Im very satisfied with his easy it is to manage, nasal or oral airway works great

How often do you place nasal trumpets in sedation cases? I'm not a big fan, especially if trauma leads to epistaxis in a supine pt with an unsecured airway.

 

[Urzuz]

How often do you place nasal trumpets in sedation cases? I'm not a big fan, especially if trauma leads to epistaxis in a supine pt with an unsecured airway.

Agreed. Most of the time if a patient is obstructing it can be resolved by decreasing the sedation. For the vast majority of patients there is a sweet spot dose where they aren’t obstructing but are also not moving/forming memories.

Once in a blue moon I’ll find it necessary to put an oral airway in during a sedation case. As a general rule I never use nasal trumpets unless I’m dilating for a nasal intubation...I’ve seen patients end up with profound epistaxis from a seemingly benign placement of a nasal airway on more than one occasion.

 

[vector2]

How often do you place nasal trumpets in sedation cases?

Frequently, because I'm in the south, all my pts are super fat, and I think they're far superior and less stimulating than OPAs. I get nosebleeds probably less than 5% of the time. The key is using a 28 fr (maybe 30 for a slighter bigger person), squirt of afrin, and enough lube on the trumpet. Use a very gentle touch.

I've noticed that ppl mostly have problems with epistaxis when 1. the trumpet is too big for the naris (jamming a 34fr into a 5'2" lady), 2. the person placing the trumpet is trying to force it when the pt's turbinates just aren't having it


Note: I am using the soft PVC, fixed flange Rusch nasal airway below. The robertazzi style ones made of other materials might be significantly more traumatic.

 

[woopedazz]

Also if you're certain they're going to obstruct and you want to avoid opioids/GA entirely for whatever reason --> plop the distal third in a jug of warm water from the scrub sink just as you're about to start. Softens the tip nicely, but doesn't completely lose it's shape further up the stem leading to a narrow diameter.

That trick is mainly used for extubation for obvious reasons...

 

[maddy_w]

Hello everyone! Thank you so much for answering my questions. I have really enjoyed learning about your experiences. If anyone has a minute, I have some follow up questions:
1) How many cases annually are done under sedation that becomes deep sedation (and therefore the risk of tongue fallback is apparent)?
2) How many cases annually does tongue fallback occur in these scenarios?
3) How many cases annually have tongue fallback occurring to the degree that the procedure is switched from sedation to general anesthesia?

Thank you! Looking forward to hearing your responses.

 

[nimbus]

Hello everyone! Thank you so much for answering my questions. I have really enjoyed learning about your experiences. If anyone has a minute, I have some follow up questions:
1) How many cases annually are done under sedation that becomes deep sedation (and therefore the risk of tongue fallback is apparent)?
2) How many cases annually does tongue fallback occur in these scenarios?
3) How many cases annually have tongue fallback occurring to the degree that the procedure is switched from sedation to general anesthesia?

Thank you! Looking forward to hearing your responses.

1. millions
2. millions
3. millions

 

[coffeebythelake]

Hello everyone! Thank you so much for answering my questions. I have really enjoyed learning about your experiences. If anyone has a minute, I have some follow up questions:
1) How many cases annually are done under sedation that becomes deep sedation (and therefore the risk of tongue fallback is apparent)?
2) How many cases annually does tongue fallback occur in these scenarios?
3) How many cases annually have tongue fallback occurring to the degree that the procedure is switched from sedation to general anesthesia?

Thank you! Looking forward to hearing your responses.

When propofol is used for sedation, all 3 happens quite frequently. It is easy for the depth of anesthesia to be very deep. With versed, fentanyl, or precedex less frequently.

 

[joshmir]

May Be good to review for noobs

what’s the experience of veterans with

light dose of narcan

risks of orOpharyngeal airways

 

[nimbus]

May Be good to review for noobs

what’s the experience of veterans with

light dose of narcan

risks of orOpharyngeal airways

Sounds like a terrible idea during the middle of a case. I’ve never given narcan during a sedation case. Prefer to make the airway patent.

 

[drmwvr]

May Be good to review for noobs

what’s the experience of veterans with

light dose of narcan

risks of orOpharyngeal airways

Using any narcan, let alone a "light dose" (whatever that means) would imply the use of enough opiate in a sedation case to contribute to, at best, airway obstruction and at worst apnea...which would be absurd.

 

[sevo00]

i just like hanging out with the elites. thanks for teaching the rest of us

lol what a pathetic loser someone has to be in order to use their free time to troll another specialty online. cool story bro...why don't you go do something better with your life