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Airway Corner: Cannot Intubate, Cannot Ventilate!

Jeffrey Reitsema, MD, Joy Cook, MD, and Darren Braude, MD
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C3 Project Written Summary:Vaginal Bleeding, Pediatric Traumatic Musculoskeletal Disorders 2 MB - PDF

We kick off the July 2012 episode with a segment recalling what one might call a difficult airway case...

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prestwig1 -

This was an interesting case. I know what the guru's of airway like Dr. Walls say on this issue......However, when Jabba the Hutt with COPD and CHF with a respiratory rate of 40 and hypoxemia. Nasotracheal intubation can save a life. These patients distressed patients all but suck the tube into their tracheas. This technique is no longer taught....but it should be! A 6.5 or 7 through the nose might have saved a life. If confronted with this case I would have at least tried one shot...through the nose. If he sucks it in (as they often due) you have purchased valuable time. If not.....you are left in no worse position

Minh L., Dr -

well done team! I doubt nasal cannula apnoeic oxygenation would have done anything in this case if the CPAP was not.

So next time..double setup with best attempt of oralintubation using full RSI with cric operator setup and prepped as well?

sounds like you had enough staff for double setup?
The other trick I have done is site an needle cannula into the trachea via the cricothyroid membrane under LA , PRE RSI.
Then during laryngoscopy with your VL, someone can oxygenate via holding oxygen tubing at 15L to the cannula hub for two seconds or so at a time. It also helps as a locator for your surgical cric if need be.

Kevin M., MD -

Very difficult case. I would have paralyzed this patient every day and twice a day on Sunday's. I want the absolute best chance to intubate under these circumstances and the default, if no intubate/no ventilate, is surgical airway anyway.

Dan M., M.D. -

What a tough case! Thanks for sharing. In hindsight, this is the ideal scenario (crappy patient anatomy & physiology) for awake flexible fiberoptics. Not available in all shops, including mine, but if confronted with this airway nightmare, I would have had anesthesia come down with theirs, or if I was really on top of my game waiting alongside me with it before the patient showed up. We had a very similar case a couple of months ago and this was one of the teaching points.

Peter W. -

Brown pants case! Thanks for the review. Two thoughts:
1) the time it takes to pull a blade out while getting a good view of cords, getting a good seal on Jaba, and then ventilating someone who was already difficult to ventilate is longer than just pushing a tube (smaller than 8-0 if needed) through the cords.
2) Lots of adjuncts for airways, but if the tool used for the first quick look (C-MAC in this case) worked, the same tool with muscle memory from the same operator should be used the second time round. Changing to another device is increasing the risk of a worse outcome.

prestwig1 -

I am glad brought up fiberoptic....I will not say this again but all must think about it.....Perfect for this case is fiberoptic THROUGH THE NOSE!! Advantage....still can oxygenate through the mouth. WILL SOMEONE PLEASE EXPLAIN TO AN OLD GRAY HAIR THE RELUCTANCE TO INTUBATE NASALLY?

brendanC -

I think with the first look the boogie should have been available. Seeing the cords and passing the boogie at that time could have saved the airway. If I predict a difficult airway, that boogie is right next to me.

Virgil D., M.D. -

I tell residents that the biggest error about cric'ing a patient is waiting too long.

Sean G., M.D. -

"quick trach" (which is actually a cric) this guy.....I love them, thanks to an EMRAP peds commentator from about 2 years ago.

Matt B. -

Is fiberoptic nasal intubation considered old school? I am a 4th year resident in Philly and we at least try it first on cases like this or severe angioedema.

Aaron A. -

As a new grad, the reluctance to nasally intubate comes from never having tried it, and never having seen it done. Awake intubations sound like a great idea but are also difficult. Tough, tough case; personally, I would give myself the best chance to do what I know how to do--that is, RSI/bougie/video laryngoscope, and cric if needed. I agree with comments above, when in a peri-arrest situation a cric should be considered quickly. I've asked anesthesiologists about these types of cases because we have a lot of angioedema and they are split as to awake/nasal type techniques vs RSI. There is a significant camp that would go ahead an paralyze for the best chance of success. Great case.

Judy Peck, M.D. -

I would have done nasotracheal intubation. He would have sucked it right into his trachea. It can be exchanged for an oral ET tube after he is stabilized. However, if I had failed to secure his airway with a nasotracheal tube and I had I seen his cords on video then I would have stuck the ET tube right in, likity split. This guy has already been hypoxic for a very long time, a few more seconds won't change his long term outcome.

GoodCPR -

How about trying to pass the bougie through the LMA. I have done it twice and it worked.

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Episode 130 Full episode audio for MD edition 238:19 min - 100 MB - M4AEM:RAP July 2012 Written Summmary 1 MB - PDFC3 Project Written Summary:Vaginal Bleeding, Pediatric Traumatic Musculoskeletal Disorders 2 MB - PDF