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In this 115th episode I welcome Dr. Steven Freiberg back to the show to discuss management of the contaminated airway.
CME: https://earnc.me/lDqJUu
References:
Han, S; Fisher, J. Airway Management During Persistent Flooding Of the Oropharyngeal Airway. Anesthesiology News. 2016. March.
Joshi, R; Hypes, C; et al. Difficult Airway Characteristics Associated with First-Attempt Failure at Intubation Using Video Laryngoscopy in the Intensive Care Unit. Ann Am Thorac Soc. 2017 Mar;14(3):368-375
Stockton, E.; Lockey, D; et. al. Contamination of the airway in pre-hospital trauma patients. European Journal of Anaesthesiology. 2008. May; 25:188
Uday, J; McCunn, M; et al. Management of the Traumatized Airway. Anesthesiology. 2016, Vol.124, 199-206
I think this was a great podcast. I will definitely try to implement these techniques into my practice. I am often on call and cover emergent intubations for the hospital. So I am faced with these situations more often than I like. I would like to share some techniques that have often helped me in my practice. 1. Keeping them spontaneously breathing. This will not only give you more time but also allow you to see those bubbles of air passing through. 2. Keeping the head of bed up as high as 30 degrees then intubating from the side instead of from the back. If you feel they are going to be difficult you can immediately start with the glidescope. It am tall and therefore I am able to reach with their head up high. However if you need a step stool often times the staff will have them. I have found that even when I have the head of bed elevated at 20 degrees and I see vomit in the airway, having my team elevate the head even more has often caused the vomit to stay in the esophagus.
3. If there is an nasogastric tube in place, making sure it is working properly before induction and increasing suction if possible.
Thank you so much for this awesome podcast.
Great points, thanks for sharing them!
Great podcast, thank you both. I would like to remind listeners of a nifty rescue technique that’s suited for severely soiled airways, namely blind digital intubation, whereby an ETT (or bougie) is passed blindly into the hypopharynx with the right hand inside the mouth, using your middle finger to lift the epiglottis and feeling for the arytenoids and other landmarks with your index finger. Then you just advance the tube alongside the index finger between the cords. Can use left hand for BURP if needed. Had a similar case to the one described in the podcast just recently, massive pulmonary edema, multiple failed attempts and suboptimal BVM ventilation, obviously. Managed to intubate within 5 seconds of initiating the attempt without issues. Just important to be keenly aware of the anatomy and be lucky with the mouth size:finger length ratio. I do feel though that this is a niche technique for very specific indications, like the ones described in the podcast.
Thanks for sharing that tip!