Clinical Case 081: Intubation Procrastination
This is my first Clinical Case on the podcast. So hope you like the format – it is a bit mixed media.
Here is what I want you to do – first listen to the podcast below, take your time to think it over and then give me your opinion.
Either write a comment on the comment section or (and) click on the option in the poll below that best describes your preferred plan.
If you are still procrastinating – then check out the Cricon post from Scott W at Emcrit
Great way to plan your approach and get the team ready
OK – a week or so later and the results are in! Here is what the 41 people who took the poll said they would do –
Click here to view the survey results. As you can see the vast majority waned to get control of the airway and do a planned, NO DESAT type induction – which is reflective of the practice in big hospitals (I suspect the readers).
What would I do [what have I done in this scenario]:
I was one of the 3 respondents who decided to stick it out with the NIV and get him through the night. Of course we also needed to plan for the worst – had the kit and team briefed for a difficult airway etc
So I called off the RFDS / evacuation team and we optimised the NIV and medical therapy, minimised oxygen consumption.
And we had a win – weaned off the NIV 12 hours later.
Not a popular call, but I think a good outcome for all concerned. As Kurt would say: ” and so it goes…”
Casey
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About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
I’d add a free text option to the poll.
If intubation planned in this case, I’d seriously consider a pre-emptive cannula in the neck or additional person ready to perform an infraglottic technique.
I’ve made some assumptions about equipment ( no scope) and assume that a MAC type blade was used for the hernia operation. Having a difficult blade such as Glidescope, D blade or Kingvision may help and an awake look may be useful.
This scenario is not uncommon for rural docs in Australia and is a tricky dilemma
Call the retrieval service and talk it through. You have outlined the risks well of ‘watch n wait’ vs semi-elective early RSI
Assume it is safest to get him the hell out of dodge (I’d want to see good evidence of improvement before I considered waiting it out – and I do not get the ‘sniff’ of this from the podcast. So let’s assume he is going to be transferred.
Be clear I would not want to have this guys on NIPPV in an aircraft
Whilst waiting for the retrieval team to arrive is not unreasonable (more hands, more experience), your game plan should be to anticipate need for definitive airway early BEFORE they arrive
How to do it?
Group huddle, have teleconf with retrieval (you have time)
Wait for extra hands ideally
Do as a staged semi-elective procedure rather than peri-arrest tube
I would mark his CT membrane and probably needle it
Standard NO DESAT approach, nasal cannulae, all the DAE gear ready to go (BTW, what DO you have?)
Have ONE look with DL – perhaps the previous intubator was a novice…
I would be using bougie, of course
If fails, VL and pass bougie
If fails, I would use iLMA to rescue ventilate then use as a conduit with a malleable stylet (do you have?) or AmbuAscope2 (do you have?)
If fails, cut cut the neck
Double set up, one person to do surgical airway, another to do RSI
Of course, having a needle pre-placed and ability to oxygenate through that whilst intubaing and using NODESAT technique will increase your margin
I would not attempt AFOI
I would not attempt a ‘wing and a prayer’ RSI
Minh will chip in with a more detailed response, I am sure…
It all gets back to WHAT KIT and WHAT PLAN do rural docs have in their location?
This case makes one consider a not unreasonable case.
I agree with Pierre about having a free text response option!
Perhaps what might be more worthwhile is instead of podcasting just me and you Casey but invite Pierre and Tim on as well, please?
They key in the retrieval setting to this case is optimising this patients condition as much as possible to avoid invasive ventilation. If he is on maximal NIPPV settings and not clearly getting better or looking tired then a plan for intubation and ventilation must be put in place.
Discuss with retrieval team and make a plan. One thing to consider is that doing it early whilst physiology is better may be prudent rather than waiting for retrieval team to arrive and then everyone having a much deteriorated patient to try to do a v difficult intubation on. Paradoxically salbutamol infusion may worsen oxygen consumption by tachycardia and lactic acidosis. In other words leaving the patient on it the longer you wait, may give you a much worse situation when you finally need to secure the airway.
It is tempting to maintain a fairly stable situation and try to keep NIPPV going for the aeromedical transfer. THis is feasible and I have a study waiting publication in Air Med J on our experience of using NIPPV in aeromedical retrieval. The important lesson learnt from my study was that if the patient is clearly not improving on the NIPPV, no matter how long its been on for, then it is unfavourable to try to put them in an aircraft!
So this patient scenario sounds like we are in a holding pattern on NIPPV that is keeping things just stable but the patient is not clearly improving. He needs to be in an ICU and only way to get there practically is to fly him. Ergo, the best overall plan is to secure his airway and ventilation, albeit ventilation might be tricky!
Now he is a known difficult airway, at least in terms of orotracheal intubation using DL. He is critically hypoxic and likely to not tolerate being off NIPPV for very long at all. Preoxygenation is suboptimal at best.
There are recent articles reporting intubation via the NIPPV mask whilst maintaining spont breathing and PEEP. The equipment and skill to do this I would say is unlikely to be present in this setting.
These conditions of hypoxia, known difficult intubation, poor preoxygenation are the perfect storm for an AIRWAY CLEAN KILL.
Any attempt to rapidly intubate or even place a supraglottic airway is fraught with high risk.
The safest approach is to maintain spont breathing and NIPPV as this ensures at leastthe current stability of sufficient oxygenation to maintain alertness.
Any sedation, even with ketamine to facilitate airway techniques is dicey.
AS TIm and PIerre have stated, my preferred approach here is to explain to patient clearly that we need to put him on a breathing machine via a tube into his windpipe otherwise he will die. To do so, the safest method is to
This is the free text section. 🙂 The polling software only allows a line.
Podcast sounds good – on the PHARM?
I will tell you my approach. But it is very context specific – not for all locations. C
to reiterate, DSI is not overly helpful here. We know he is difficult to intubate, DSI does not change that!
Sorry Minh
You are correct. DSI might be required if he is not tolerating the mask.
What he needs is a NO DESAT if you decide you are going to intervene
Do you want to get rid of the IV salbutamol?
C
DSI ?
He needs a cuffed tube in his trachea and then transfer.
I would not attempt any direct laryngoscopic intubation. You have evidence that this is impossible or at best very difficult. You are going to get yourself in a position where you are likely to need to rescue an already desaturated patient with a surgical airway, which would have been stressful enough in a saturated patient.
Then it comes down to what kit do you have and what are you most experienced with.
Awake nasal fibreoptic intubation may be possible but probably not in the time that it is going to take him to desaturate; so this is out.
If they managed to ventilate him previously on the intubating LMA then you could go for this and then try to intubate him with a fibrescope through this, but this depends on you having that kit and being confident you can ventilate through an LMA (not a given)
I think I would plan to go for an awake cricothyroidotomy with him sat up. Ketamine analgesia 1mg/kg, bupivacaine and adrenaline to the anterior neck, inject some 2% lidocaine through a cannula into the trachea and nebulise 5ml through the NIV. Aim to pass a size 6 tracheostomy tube through the cricothyroid membrane, this will then require high pressures to ventilate through, but will be a cuffed tube in his trachea and can be changed at his destination.
I’d be wanting to get him out but agree with the dilema that this then obligates intubation where as if you waited it may be avoidable. I’d be guided by his clinical decline and any elevation in C02 on ABGs as sign of fatigue. Once this occurs its ETT time. I’d be readying for cricothyroid airway but plan for retrograde wire intubation semi -electively. ( Never done but have read about and invisage this would be a great way to got. ).
Retrograde wire? Personally I dont reckon this would be place to try, if never done before…
Agree needs cuffed tube in trachea
Sooner not later
If novice intubator described first ‘grade IV’ then would consider
– prophylactic needle in neck under local
– NODESAT apnoeic preox
– single look DL with bougie, then VL with briefed collague calling time
(If prev intubation by experienced intubatir using DL only, straight to VL as first)
– if fail, place iLMA SGA and rescue ventilate, then fibreoptic assisted ETT via iLMA
– if cant place ILMA or ventilate, just cut the neck having pre-prepared and briefed anaes or srgucal colleague and kit ready to fo
So….what did you do?