weird intubation

[IFNgamma]

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today I had a guy come in for a TKA.

So I do DL, the cords are right there, grade 1 view, I stick the tube in. There's should be no doubt right? Wrong! My attending ascultates and hears no BSs, no EtCO2.

So he thinks I didn't intubate the trachea, since obviously I suck since I'm a 1.5 month old CA1.

So he intubates. Same thing happens, no BSs, no EtCO2. So he pulls the tube out again, and repeats the intubation.

This time, there's some BS, w/ wheezes and there's also EtCO2.

What the hell was that? weird. I'm thinking it could be bronchospasm or bronchoconstriction.

The guy does have a long smoking history and he claims to have quit for years.

any thoughts?

 

[Planktonmd]

today I had a guy come in for a TKA.

So I do DL, the cords are right there, grade 1 view, I stick the tube in. There's should be no doubt right? Wrong! My attending ascultates and hears no BSs, no EtCO2.

So he thinks I didn't intubate the trachea, since obviously I suck since I'm a 1.5 month old CA1.

So he intubates. Same thing happens, no BSs, no EtCO2. So he pulls the tube out again, and repeats the intubation.

This time, there's some BS, w/ wheezes and there's also EtCO2.

What the hell was that? weird. I'm thinking it could be bronchospasm or bronchoconstriction.

The guy does have a long smoking history and he claims to have quit for years.

any thoughts?

You answered your own question: Bronchospasm.

 

[apma77]

had this happen to me for a peds T&A...it was no etco2 due to bronchospasm and later developed diffuse wheezing

 

[videolectures]

A hyper-reactive airway enticed with a foriegn body (ETT) leading to severe bronchospasm...resulting in inadequate ventilation:

remove the ETT hoping (to dear god) that the stimulus is removed and therefore the bronchospasm resolves?

or

keep the ETT in and battle with high airway pressures and elevating PaCo2 values and crashing sats?

 

[leaverus]

I'm curious why you're asking here...didn't you and your attending discuss what happened? He provided no insight on the matter??

 

[IFNgamma]

I'm curious why you're asking here...didn't you and your attending discuss what happened? He provided no insight on the matter??

yes we discussed it. Apparently he hasn't seen this happen before and was kinda puzzled himself, but he thought it was bronchospasm. I'm asking here to get more opinions as to what the problem was.

 

[Teillard]

he thought it was bronchospasm. I'm asking here to get more opinions as to what the problem was.

What did the bag feel like?

 

[Pooh & Annie]

today I had a guy come in for a TKA.

So I do DL, the cords are right there, grade 1 view, I stick the tube in. There's should be no doubt right? Wrong! My attending ascultates and hears no BSs, no EtCO2.

So he thinks I didn't intubate the trachea, since obviously I suck since I'm a 1.5 month old CA1.

So he intubates. Same thing happens, no BSs, no EtCO2. So he pulls the tube out again, and repeats the intubation.

This time, there's some BS, w/ wheezes and there's also EtCO2.

What the hell was that? weird. I'm thinking it could be bronchospasm or bronchoconstriction.

The guy does have a long smoking history and he claims to have quit for years.

any thoughts?

Did you try bagging between intubation attempts? I guess you would have had minimal air exchange.

 

[LongSnow]

I had this happen to me too before.

Happens more frequently in smokers, especially when not enough Diprivan in used.

 

[IFNgamma]

What did the bag feel like?

don't know, I didn't get to squeeze the bag

 

[Laurel123]

Sounds very much like bronchospasm - I have definitely had this happen to me before. The patients have all been heavy smokers. After intubation and visualization of the tube through the cords, I will bag these patients and the bag won't seem excessively stiff (though it is usually because the pop-off valve is partially open )- but there is no end tidal and minimal chest movement. I will crank up the sevo (bronchodilater!) redose some propofol and just hand bag. The patient will deepen and broncodilate but once I switch them over to the vent - it will show that nice obvious upward end tidal CO2 slope of obstructive lung disease. It is also a good indicator that you will need to make the proper preparations for extubation - cause they are likely to bronchospasm again if they are emerged improperly.

 

[coprolalia]

Ummm... If you are in the trachea, it's a really bad idea to remove the ETT. You can usually use positive pressure to get past the spasm. And, you can treat through the tube (i.e., albuterol).

You lose the tube, you lose the airway. And, this might be really hard to get back making a bad situation even worse.

Don't pull the tube. This spasm usually resolves quickly, especially when the patient has a sympathetic response and treats themself with catecholamines.

-copro

 

[IFNgamma]

Ummm... If you are in the trachea, it's a really bad idea to remove the ETT. You can usually use positive pressure to get past the spasm. And, you can treat through the tube (i.e., albuterol).

You lose the tube, you lose the airway. And, this might be really hard to get back making a bad situation even worse.

Don't pull the tube. This spasm usually resolves quickly, especially when the patient has a sympathetic response and treats themself with catecholamines.

-copro

well, it was assumed that I screwed up the intubation during the 1st attempt, since it was me, a CA1, doing it, so the ETT was removed, even though I said I see the cords clearly and I put the tube into the trachea.

But yes, you're right, my attending, who said he clearly put the tube into the trachea the 2nd time, should not have pulled it out and intubated a 3rd time.

 

[jetproppilot]

.

 

[jetproppilot]

Ummm... If you are in the trachea, it's a really bad idea to remove the ETT. You can usually use positive pressure to get past the spasm. And, you can treat through the tube (i.e., albuterol).

You lose the tube, you lose the airway. And, this might be really hard to get back making a bad situation even worse.

Don't pull the tube. This spasm usually resolves quickly, especially when the patient has a sympathetic response and treats themself with catecholamines.

-copro

You're making it sound really easy to leave an endotracheal tube in place when you see no ETCO2 waveform, Cop.

With all due respect to your badas s self I'll disagree with you....

well....uhhhh....I'm not disagreeing with you about leaving the tube in place if its in the right spot, but unless you perform laryngoscopy to check your tube placement, with no ETCO2, you're risking an unrecognized esophageal intubation.....which if unrecognized even for a cuppla minutes can be catastrophic.

I think we all agree it was bronchospasm but to the beginner and veteran alike its really easy to say to yourself "I know it went in" when, even though you may be right, you may be wrong too.

I've had this same scenario happen more than once.

And I've done exactly what the OP's attending did....pull the tube and replace it....only to have the same result the second time...but the second time since I was concentrating so hard I knew the tube went thru so was confident proceeding with treatment of bronchospasm....albuterol, deepening of anesthetic with volatile, IV epi, whatever you gotta do...

Ever locked your car.....(or maybe you didnt)....an action you perform every day of your life..... say, two seconds previous..... and in your rush say to yourself "uhhhhh....DID I LOCK THE CAR?"

Then walk back in range of your car thinghy just to make sure you hear the chirp signaling the doors are locked, even though you're almost sure you locked it?

Intubation when you do it all day long is no different.

You do it over and over and over, expecting the same result.....but when some subsequent parameter looks different, are you sure it went through the cords? Are you sure you hit the "lock" button on your remote?"

Don't assume anything in this business.

If you dont see ETCO2 if you arent 100% sure its through, just take a look again.

Sometimes we arent the laryngoscopist, Cop.

And sometimes even when we are the laryngoscopist its hard to be 100% sure, kinda like locking your car.

If you don't wanna pull the tube and start over you're obligated (by me ) to at least take a look with your blade to ensure proper tube placement in the event of no ETCO2 tracing.

That act, if you feel so strongly about pulling the tube and starting over, will verify its in the right spot....which.....being in the right spot, even though theres no end tidal, well, you've gotta be ABSOLUTELY SURE.

Which is sometimes difficult.

Unless you verify with a second look.

Didja guys get my point?

Make sure the tube is in by looking with a blade if ya dont wanna pull it out? Don't assume its in?

Ok.
Just trying to keep you outta court....

Nice post, IFN.

Thanks for sharing.

 

[Planktonmd]

If you are not sure your tube is in the trachea put your stethoscope on the stomach and listen (assuming you have a stethoscope) 😉

 

[Laryngospasm]

You're making it sound really easy to leave an endotracheal tube in place when you see no ETCO2 waveform, Cop.

With all due respect to your badas s self I'll disagree with you....

well....uhhhh....I'm not disagreeing with you about leaving the tube in place if its in the right spot, but unless you perform laryngoscopy to check your tube placement, with no ETCO2, you're risking an unrecognized esophageal intubation.....which if unrecognized even for a cuppla minutes can be catastrophic.

.

Yes jet, but the difference here is that the bag feels like someone has their finger over the end of the tube, no compliance with high pressures, unlike the esophagus, and no epigastric gurgling. This happened to me as a resident on a peds case with severe asthma, my staff was freaking out and yelling at me, I told her it was in or the bag wouldnt feel like that. Slowly the CO2 returned.

 

[jetproppilot]

Yes jet, but the difference here is that the bag feels like someone has their finger over the end of the tube, no compliance with high pressures, unlike the esophagus, and no epigastric gurgling. This happened to me as a resident on a peds case with severe asthma, my staff was freaking out and yelling at me, I told her it was in or the bag wouldnt feel like that. Slowly the CO2 returned.

Are you willing to bet the life of the patient on how the bag feels?

Anesthesia mortality has been minimized because of our care and because of our monitors.

What if the dude was a really hard mask airway pre-intubation resulting in alotta air in the stomach? Whaddya think the bag would feel like then if you inadvertently tubed the esophagus?

I've had a cuppla difficult intubation cases where all the air in the stomach from aggressive mask ventilation made it difficult for us to mask ventilate...i.e. very high gastric pressure.......passed an oral NG tube and all is well again as far as ventilation...yeah, thats not what you'd expect from mask ventilating rokkstarrs but....well....s hit happens, even amidst the elite...

And the myth that you can be absolutely sure with auscultation...over the chest and over the stomach....I'd like to dispell as well...

How many five-foot-eight, 300 pound dudes have you put to sleep?

ALOT? YEAH?

OK, great.

So hear me out:

LISTENING WITH A STETHESCOPE ON THE CHEST OF AN ORCA, THEN LISTENING TO THE STOMACH THROUGH A PANNUS TWICE THE SIZE OF MY GIRLFRIEND'S ENTIRE BODY WILL YIELD NONDEFINITIVE CONCLUSIONS.

YEAH THE ABOVE IS A REALLY LONG SENTENCE SO REREAD IT....TAKE YOUR TIME...

Please don't ever become comfortable with a subjective conclusion (i.e. "I KNOW THE TUBE IS IN") when presented with OBJECTIVE EVIDENCE (i.e. no ETCO2) that you are wrong.


Am I doubting your clinical prowess Laryngospasm?

Absolutely not.

My point is you should never get too comfortable with yourself.

My Dad was an airline pilot....in an industry that relies on redundancy, checklists, and cockpit communication to keep people alive...

and yet people still die in airplanes because the pilots doubt their instruments, their checklists, and their crew and try and rely on their "expertise" even though their instruments/checklists/crew are providing objective information, and the pilot's "feeling" is subjective...

I will still continue to broadcast the same message:

Don't get too comfortable with yourself. Don't rely on "how the bag feels" to ensure endotracheal intubation.

Yeah, Laryng, that time you were right.

But the stars could not have been aligned, maybe intragastric pressure couldve been really high because of aggressive mask ventilation giving a tight "feel" of the bag even though you're in the esophagus....and you've talked yourself into the fact that "I know I'm in even though my monitors don't say so," you sit on your decision a little too long....

OR,

switch to the aviation industry, pick your favorite human error airline disaster... pilot ignoring copilot's comments about the downward-spiraling altimeter on approach to MIA.....pilot has like 15,000 hours, he's a rokkstar....casts aside the rookie-copilot's worries....plane becomes a big LAWNDART in the everglades....

JFK Junior in his Saratoga....its dark, he's trying to find his destination, he experiences spatial disorientation, doesnt trust the artificial horizon which-means-he-can't-level-the-wings-and-instead-he-listens-to-his-incorrect-inner-ear.....and in doing so he makes his plane another LAWNDART....or more accurately, a WATERDART...

ARE YOU DUDES HEARING ME? HUH?

Don't get comfortable with subjective conclusions.

"YEAH BUT HOLD ON JET.....THE BAG FEELS DIFFERENT IF YOU INTUBATE THE ESOPHAGUS.....

I'm not willing to bet the patient's life on that clinical observation.

I'm hoping you won't either.

 

[JASS92]

Are you willing to bet the life of the patient on how the bag feels?

Anesthesia mortality has been minimized because of our care and because of our monitors.

What if the dude was a really hard mask airway pre-intubation resulting in alotta air in the stomach? Whaddya think the bag would feel like then if you inadvertently tubed the esophagus?

I've had a cuppla difficult intubation cases where all the air in the stomach from aggressive mask ventilation made it difficult for us to mask ventilate...i.e. very high gastric pressure.......passed an oral NG tube and all is well again as far as ventilation...yeah, thats not what you'd expect from mask ventilating rokkstarrs but....well....s hit happens, even amidst the elite...

And the myth that you can be absolutely sure with auscultation...over the chest and over the stomach....I'd like to dispell as well...

How many five-foot-eight, 300 pound dudes have you put to sleep?

ALOT? YEAH?

OK, great.

So hear me out:

LISTENING WITH A STETHESCOPE ON THE CHEST OF AN ORCA, THEN LISTENING TO THE STOMACH THROUGH A PANNUS TWICE THE SIZE OF MY GIRLFRIEND'S ENTIRE BODY WILL YIELD NONDEFINITIVE CONCLUSIONS.

YEAH THE ABOVE IS A REALLY LONG SENTENCE SO REREAD IT....TAKE YOUR TIME...

Please don't ever become comfortable with a subjective conclusion (i.e. "I KNOW THE TUBE IS IN") when presented with OBJECTIVE EVIDENCE (i.e. no ETCO2) that you are wrong.


Am I doubting your clinical prowess Laryngospasm?

Absolutely not.

My point is you should never get too comfortable with yourself.

My Dad was an airline pilot....in an industry that relies on redundancy, checklists, and cockpit communication to keep people alive...

and yet people still die in airplanes because the pilots doubt their instruments, their checklists, and their crew and try and rely on their "expertise" even though their instruments/checklists/crew are providing objective information, and the pilot's "feeling" is subjective...

I will still continue to broadcast the same message:

Don't get too comfortable with yourself. Don't rely on "how the bag feels" to ensure endotracheal intubation.

Yeah, Laryng, that time you were right.

But the stars could not have been aligned, maybe intragastric pressure couldve been really high because of aggressive mask ventilation giving a tight "feel" of the bag even though you're in the esophagus....and you've talked yourself into the fact that "I know I'm in even though my monitors don't say so," you sit on your decision a little too long....

OR,

switch to the aviation industry, pick your favorite human error airline disaster... pilot ignoring copilot's comments about the downward-spiraling altimeter on approach to MIA.....pilot has like 15,000 hours, he's a rokkstar....casts aside the rookie-copilot's worries....plane becomes a big LAWNDART in the everglades....

JFK Junior in his Saratoga....its dark, he's trying to find his destination, he experiences spatial disorientation, doesnt trust the artificial horizon which-means-he-can't-level-the-wings-and-instead-he-listens-to-his-incorrect-inner-ear.....and in doing so he makes his plane another LAWNDART....or more accurately, a WATERDART...

ARE YOU DUDES HEARING ME? HUH?

Don't get comfortable with subjective conclusions.

"YEAH BUT HOLD ON JET.....THE BAG FEELS DIFFERENT IF YOU INTUBATE THE ESOPHAGUS.....

I'm not willing to bet the patient's life on that clinical observation.

I'm hoping you won't either.

wow dude you are truly inspiring (no sarcasm). also, i find it funny that you used the airplane analogy, because i believe i just read about another commercial jetliner crash that occurred in Spain. I believe that the pilot ignored the instrument error signaling upon a first take off attempt. The result: I believe the plane exploded in midair at takeoff. What a horrible outcome from an event that could have been entirely prevented had this "expert" simply humored his own ego.

 

[jennyboo]

today I had a guy come in for a TKA.

So I do DL, the cords are right there, grade 1 view, I stick the tube in. There's should be no doubt right? Wrong! My attending ascultates and hears no BSs, no EtCO2.

So he thinks I didn't intubate the trachea, since obviously I suck since I'm a 1.5 month old CA1.

So he intubates. Same thing happens, no BSs, no EtCO2. So he pulls the tube out again, and repeats the intubation.

This time, there's some BS, w/ wheezes and there's also EtCO2.

What the hell was that? weird. I'm thinking it could be bronchospasm or bronchoconstriction.

The guy does have a long smoking history and he claims to have quit for years.

any thoughts?

First time this happened to me as a CA-1, it was a 70F with, just as you said, a smoking history. I put the tube in under direct visualization and got no EtCO2 and no breath sounds (and no stomach sounds either). So we take it out and mask (on 100% O2).

Somewhere in the middle of this we also disconnected the EtCO2 monitor and tried blowing in it -- didn't get much of a waveform, so overhead paged engineering.

However, with masking (previously a perfectly good mask and it was not a RSI) O2 sat took a dive to 85%. On repeat listening, breath sounds were present but very quiet with tight wheeze. So we turned on the volatile agent and bag-masked, bag-masked, bag-masked until she slowly climbed back up to 98%, and re-intubated her.