High-flow O2 making intubations riskier?

[Colorado outliers]

Question for the more experienced folks...
Do you feel that he use of high-flow O2 (Optiflow, Vapotherm, etc) has actually made intubations riskier?

Over the last few years we have dramatically increased our use of these high-flow cannula devices. They're great if they can prevent intubation, which they sometimes do.
However, I've noticed (anecdotally) in some patients, they are sustained longer on these devices (compared w/ a nonrebreather) and simply get intubated 1-2 days
later. At this point, they are profoundly hypoxemic, desatting quickly during RSI, and making intubations much riskier than if they been intubated earlier while they were
on the facemask. Even w/ bag-valve mask ventilation, getting them up to 90 can be difficult.

Has anyone else noticed a similar trend? If it's just me I'll chalk it up to our institution or my poor judgement =)

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[jdh71]

What really need in critical care is a crystal ball.

I'd also like to use it to prognosticate on strokes.

 

[Hernandez]

You’re probably correct but at the end of the day sometimes the right thing to do is to aggressively avoid riding the plastic rodeo. If it were easy it would be called the intensive babysitting unit not intensive care unit.

It all comes down to patient selection and having the crystal balls to handle it when things go cattywompus.

 

[deleted547339]

Yea. It’s tough. When a patients spo2 is 90 on hfnc and a nrb, you need to be quick on the draw. This is about the only time I get nervous around an airway now - I don’t know if my fellows appreciate the gravity of the situation.

 

[Hernandez]

Yea. It’s tough. When a patients spo2 is 90 on hfnc and a nrb, you need to be quick on the draw. This is about the only time I get nervous around an airway now - I don’t know if my fellows appreciate the gravity of the situation.

I’ve gotten to where I have a very low threshold for using glidescope on these pts when I do finally tube them. Especially if the minute ventilation is >20L/min.

 

[jdh71]

You’re probably correct but at the end of the day sometimes the right thing to do is to aggressively avoid riding the plastic rodeo. If it were easy it would be called the intensive babysitting unit not intensive care unit.

It all comes down to patient selection and having the crystal balls to handle it when things go cattywompus.

The tube is really the beginning of the problems for these patients, not the end.

 

[jdh71]

I’ve gotten to where I have a very low threshold for using glidescope on these pts when I do finally tube them. Especially if the minute ventilation is >20L/min.

Hell. If I have time to plan I ask anesthesia to do it. I’m no hero.

 

[Colorado outliers]

I’ve gotten to where I have a very low threshold for using glidescope on these pts when I do finally tube them. Especially if the minute ventilation is >20L/min.

Same here. My first instinct in these patients is to use a C-MAC and have a bougie ready to go so I don't waste any time. Not going to pretend that I have the DL skills of an anesthesiologist, especially in these patients where you basically have 10-15 seconds to intubate before they rapidly desat.

I've also noticed that even when they are quickly intubated, bagged, and placed on the vent w/ high PEEP, they often desat (even with clamping tube during transfer), and it can take 1-2 hours for them to level out. It's definitely a change from our usual 'place on the vent and their sats immediately go up'.

Thinking like a scientist, just makes me wonder if there is a way to risk-stratify these patients and identify the high-risk group so that simply get intubated earlier rather than staying on Optiflow for 1-2 days before getting ultimately getting tubed. That might be impossible, though.

TimesnewRoman, I STILL get nervous around airways, even after doing this for 3-4 years. Lol. Not sure if that will ever change.

 

[alpinism]

Are you keeping them on high flow during intubation?

Elevating the head of bed also helps to prevent desaturation.

 

[deleted547339]

Same here. My first instinct in these patients is to use a C-MAC and have a bougie ready to go so I don't waste any time. Not going to pretend that I have the DL skills of an anesthesiologist, especially in these patients where you basically have 10-15 seconds to intubate before they rapidly desat.

I've also noticed that even when they are quickly intubated, bagged, and placed on the vent w/ high PEEP, they often desat (even with clamping tube during transfer), and it can take 1-2 hours for them to level out. It's definitely a change from our usual 'place on the vent and their sats immediately go up'.

Thinking like a scientist, just makes me wonder if there is a way to risk-stratify these patients and identify the high-risk group so that simply get intubated earlier rather than staying on Optiflow for 1-2 days before getting ultimately getting tubed. That might be impossible, though.

TimesnewRoman, I STILL get nervous around airways, even after doing this for 3-4 years. Lol. Not sure if that will ever change.

I make my fellows intubate these folks with VL and they all take it as a sign of mistrust, not that I care.

The funny thing is that the data suggests VL may take longer, but that doesn’t seem to be the case clinically.

 

[deleted547339]

Are you keeping them on high flow during intubation?

Elevating the head of bed also helps to prevent desaturation.

Yes and yes.

 

[Hamhock]

Intubating with them basically sitting up helps.
Consider awake or "ketamine awake"/DSI intubation using the bronch, if you are comfortable with it.
I never "bag" these patients. Waveform etCO2 in line with the ventilator is set up...as RT is inflating the cuff, I am attaching my ventilator with high PEEP and FiO2. The ventilator is far superior at "bagging" patients (especailly paralyzed patients).

HH

 

[deleted547339]

Intubating with them basically sitting up helps.
Consider awake or "ketamine awake"/DSI intubation using the bronch, if you are comfortable with it.
I never "bag" these patients. Waveform etCO2 in line with the ventilator is set up...as RT is inflating the cuff, I am attaching my ventilator with high PEEP and FiO2. The ventilator is far superior at "bagging" patients (especailly paralyzed patients).

HH

That’s interesting, maybe I’m just not as facile with the bronch but I don’t find that’s faster. Bipap prior to induction is definitely a nice move.

 

[jdh71]

That’s interesting, maybe I’m just not as facile with the bronch but I don’t find that’s faster. Bipap prior to induction is definitely a nice move.

Reckon I'm more facile with a bronch than most posting in this thread and I agree. Weingart detailed BiPAP intubation a number of years ago with a slow induction with Ketamine and I've used this a lot. I mean if you have "max sats" for that patient with the bipap why take it off and mess around with anything else. Slow ketamine with the Bipap on, paralyze, remove bipap when effort stops, tube with VL.

 

[deleted547339]

Reckon I'm more facile with a bronch than most posting in this thread and I agree. Weingart detailed BiPAP intubation a number of years ago with a slow induction with Ketamine and I've used this a lot. I mean if you have "max sats" for that patient with the bipap why take it off and mess around with anything else. Slow ketamine with the Bipap on, paralyze, remove bipap when effort stops, tube with VL.

I won’t even slowly induce. I’ll RSI. Our vents do NIPPV too, so I can set it up so they keep getting tidal volumes.

 

[jdh71]

I won’t even slowly induce. I’ll RSI. Our vents do NIPPV too, so I can set it up so they keep getting tidal volumes.

Slam it or don’t.

 

[tartesos]

I make my fellows intubate these folks with VL and they all take it as a sign of mistrust, not that I care.

The funny thing is that the data suggests VL may take longer, but that doesn’t seem to be the case clinically.

Might take a few seconds longer for a fellow but it increases first pass success for me.
I have the portable bronchoscope ready just in case to use as a fancy mobile bougie for those chubby ones.

 

[engineeredout]

Literature supports, and I personally trust myself, to be faster with DL than VL.

And why are people calling anesthesia for these situations? We are far more experienced intubating patients who are severely hypoxemic and with less physiologic reserve available than they are.

 

[jdh71]

Literature supports, and I personally trust myself, to be faster with DL than VL.

And why are people calling anesthesia for these situations? We are far more experienced intubating patients who are severely hypoxemic and with less physiologic reserve available than they are.

You mean the study from France where they handed second year residents a VL or DL? All the “literature” before found them equivocal or VL “better”. The literature is always interesting but almost never reproduces our practice environment. Reach for what you are best at or more confident with.

I do call folks who put in the most tubes regardless if I have the time. Feel no shame about that. When it comes to RSI in those few seconds it matters little from the perspective of just securing an airway how sick the patient is. I want tube in and oxygen going. Like any procedure numbers of procedure done is the big game in town from where I’m sitting. And if my patient needs me to not be the chest thumping airway hero, my ego is ok with that.

We all may evaluate this differently.

 

[deleted547339]

You mean the study from France where they handed second year residents a VL or DL? All the “literature” before found them equivocal or VL “better”. The literature is always interesting but almost never reproduces our practice environment. Reach for what you are best at or more confident with.

I do call folks who put in the most tubes regardless if I have the time. Feel no shame about that. When it comes to RSI in those few seconds it matters little from the perspective of just securing an airway how sick the patient is. I want tube in and oxygen going. Like any procedure numbers of procedure done is the big game in town from where I’m sitting. And if my patient needs me to not be the chest thumping airway hero, my ego is ok with that.

We all may evaluate this differently.

I find that my colleagues in anesthesia are more technically proficient but often lack significant urgency.

 

[jdh71]

I find that my colleagues in anesthesia are more technically proficient but often lack significant urgency.

Which is why if it’s a “crash and burn” situation it’s arguably better for those of us more familiar with the chaos to give it a go in my opinion. This then trumps numbers. We are playing chess.

 

[CCM-MD]

I am quick to call anesthesia in an anticipated technically challenging airway, but not necessarily for a severely hypoxemic patient who needs intubation.

I've had to do 2 emergency trachs/crics thus far - not a fun situation but I found that doing my own elective perc trachs definitely made me more comfortable in those situations. Anesthesiologist was not helpful in those 2 situations - trauma/ENT would have been helpful but patient may have been dead by the time they arrived.

 

[chocomorsel]

Literature supports, and I personally trust myself, to be faster with DL than VL.

And why are people calling anesthesia for these situations? We are far more experienced intubating patients who are severely hypoxemic and with less physiologic reserve available than they are.

Yeah. Ok. While I don't claim to know the skills of everyone in the whole profession, we in general actually tube patients who are hypoxic frequently and are quite quick with it.
But sure. No need to call the airway experts/specialists. Play hero while your patient crumps.

 

[CCM-MD]

"Respecting" the airway is important. I feel like some of that has been lost since VL has become so widely available, probably because the technical barrier to intubating has reduced. Some shops have RTs tubing patients.

Being prepared, calling people for help before getting into trouble, becoming familiar with "back-up" tools like LMAs and experience with placing a surgical airway is helpful. Many fellowships train fellows to do trachs, which will probably help with the latter.

 

[engineeredout]

Yeah. Ok. While I don't claim to know the skills of everyone in the whole profession, we in general actually tube patients who are hypoxic frequently and are quite quick with it.
But sure. No need to call the airway experts/specialists. Play hero while your patient crumps.

As an intensivist (not to mention a board certified emergency physician), we are airway experts.

 

[CCM-MD]

As an intensivist (not to mention a board certified emergency physician), we are airway experts.

And if we weren't, the standard of care would be to have every intubation done by an anesthesiologist. Clearly that is not the case.

 

[chocomorsel]

And if we weren't, the standard of care would be to have every intubation done by an anesthesiologist. Clearly that is not the case.

But yet we get called when the ICU and the ED can’t get an airway. Unless of course egos get in the way.
Umm ok.
That part about “get some help”, you should try and listen to your own advice.

 

[chocomorsel]

As an intensivist (not to mention a board certified emergency physician), we are airway experts.

We get called to the ED sometimes when the ED docs can’t get an airway. What’s that about?

 

[CCM-MD]

I think its funny how anesthesiologists get territorial when it comes to airway management - often leading these types of discussions degenerating into chest thumping. Sorry but you're not the only ones intubating patients - EM, CCM physicians (and non-physicians) are on a daily basis and we aren't killing people. I have not come across any literature comparing anesthesia to non-anesthesia critical care physicians, but below are studies that compare anesthesiologists to EM. Credit to WCI.

Is anesthesia the superior "intubator" of critically ill patients and lead to better patient outcomes? Since they do it every day, one would think they PROBABLY are. But aside from anecdotes like "we get called to the ICU when they can't get an airway" as far as I know there isn't great evidence that supports that claim.

If anesthesiologists intubating in the ICU results in better patient outcomes, publish it, and let's make it the standard of care for them to do all intubations. I'll happily to hand over all of my ICU intubations. At the end of the day, I want my patients to do better.

​

Ann Emerg Med. 2004 Jan;43(1):48-53. Related Articles, Links ​

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Alternating day emergency medicine and anesthesia resident responsibility for management of the trauma airway: a study of laryngoscopy performance and intubation success.​

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Levitan RM, Rosenblatt B, Meiner EM, Reilly PM, Hollander JE.​

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Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. [email protected]​

​

STUDY OBJECTIVE: We compare laryngoscopy performance and overall intubation success in trauma airways when primary airway management alternated between emergency medicine and anesthesia residents on an every-other-day basis. METHODS: Data on all trauma intubations during approximately 3 years were prospectively collected. Primary airway management was assigned to emergency department (ED) residents on even days and anesthesia residents on odd days. Emergency medicine residents intubated patients who arrived without notification or who needed immediate intubation before anesthesia arrived. The study was conducted in an inner-city, Level I trauma center with approximately 50,000 ED patients and 1,800 major trauma cases a year. Main outcomes were success or failure at laryngoscopy and the number of laryngoscopy attempts needed for intubation. RESULTS: Six hundred fifty-eight trauma patients were intubated during the study period. Laryngoscopy was successful in 654 of 656 cases. Two (0.3%) patients underwent cricothyrotomy after failed laryngoscopy, and 2 (0.3%) patients had awake nasal intubation without laryngoscopy. The specific number of laryngoscopy attempts was unknown in 6 cases (3 from each service), resulting in 650 cases for laryngoscopy performance analysis. Overall, 87% of patients were intubated on first attempt, and 3 or more attempts occurred in 2.9% of patients. Laryngoscopy performance by service (broken down by 1, 2, and >or=3 attempts) was as follows: emergency medicine 86.4%, 11%, and 2.6% versus anesthesia 89.7%, 6.7%, and 3.6%. Analysis by service was done by using Wilcoxon Mann-Whitney testing (P=.225). CONCLUSION: There were no differences in laryngoscopy performance and intubation success in trauma airways managed on an every-other-day basis by emergency medicine versus anesthesia residents.​

​

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J Trauma. 2001 Dec;51(6):1065-8. Related Articles, Links ​

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Role of the emergency medicine physician in airway management of the trauma patient.​

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Omert L, Yeaney W, Mizikowski S, Protetch J.​

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Department of Surgery, Allegheny General Hospital, South Tower, Pittsburgh, Pennsylvania 15212, USA.​

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BACKGROUND: A Level I trauma center recently underwent a policy change wherein airway management of the trauma patient is under the auspices of Emergency Medicine (EM) rather than Anesthesiology. METHODS: We prospectively collected data on 11 months of EM intubations (EMI) since this policy change and compared them to the last year of Anesthesia-managed intubations (ANI) to answer the following questions: (1) Is intubation of trauma patients being accomplished effectively by EM? (2) Has there been a change in complication rates since the policy change? (3) How does the complication rate at our trauma center compare with other institutions? RESULTS: EM residents successfully intubated trauma patients on their first attempt 73.7% of the time compared with 77.2% ANI. The overall success rates, i.e., securing the airway within three attempts, were 97.0% (EMI) and 98.0% (ANI). The airway was successfully secured by EMI 100% of the time while a surgical airway was performed in two ANIs. CONCLUSION: EM residents and staff can safely manage the airway of trauma patients. There is no statistically significant difference in peri-intubation complications. The complication rate for EDI (33%) and ANI (38%) is higher than reported in the literature, although the populations are not entirely comparable.​

​

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Acad Emerg Med. 2004 Jan;11(1):66-70. Related Articles, Links ​

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A comparison of trauma intubations managed by anesthesiologists and emergency physicians.​

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Bushra JS, McNeil B, Wald DA, Schwell A, Karras DJ.​

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Department of Emergency Medicine, Temple University Hospital and School of Medicine, Philadelphia, PA 19140, USA. [email protected]​

​

Although airway management by emergency physicians has become standard for general emergency department (ED) patients, many believe that anesthesiologists should manage the airways of trauma victims. OBJECTIVES: To compare the success and failure rates of trauma intubations performed under the supervision of anesthesiologists and emergency physicians. METHODS: This was a prospective, observational study of consecutive endotracheal intubations (ETIs) of adult trauma patients in a single ED over a 46-month period. All ETIs before November 26, 2000, were supervised by anesthesiologists (34 months), and all ETIs from November 26, 2000, onward were supervised by emergency physicians (12 months). Data regarding clinical presentation, personnel involved, medications used, number of attempts required, and need for cricothyrotomy were collected. Study outcomes were: 1) successful intubation within two attempts, and 2) failure of intubation. Failure was defined as inability to intubate, resulting in successful intubation by another specialist, or cricothyrotomy. Odds ratios (ORs) with 95% confidence intervals (95% CIs) were used to compare results between groups. RESULTS: There were 673 intubations during the study period. Intubation within two attempts was accomplished in 442 of 467 patients (94.6%) managed by anesthesiologists, and in 196 of 206 of patients (95.2%) managed by emergency physicians (OR = 1.109, 95% CI = 0.498 to 2.522). Failure of intubation occurred in 16 of 467 (3.4%) patients managed by anesthesiologists, and in four of 206 (1.9%) patients managed by emergency physicians (OR = 0.558, 95% CI = 0.156 to 1.806). CONCLUSIONS: Emergency physicians can safely manage the airways of trauma patients. Success and failure rates are similar to those of anesthesiologists.​

 

[jdh71]

And if we weren't, the standard of care would be to have every intubation done by an anesthesiologist. Clearly that is not the case.

To be fair . . . “Standard of care” is defined as the standard practice in an area. It isn’t decided by necessarily the (arguably) BEST person be involved in every instance. Intensivists are also a kind/type of airway physicians but are we “experts”? I don’t know. Define “expert” right? Airways are in my wheelhouse as they are in yours. Not every airway needs/requires an “airway expert” - hell most don’t. And what we are talking about here is an airway that needs to ensure first pass tube. My practice is if I have time to plan, and sometimes we don’t, but usually we do in that patient on 1.0 with slowly dropping sats, is to ask anesthesia to put in the tube. I’m not personally suggesting anyone who assesses this differently is wrong. There isn’t only one way to do much of anything in the ICU. I will strongly suggest this is a very reasonable approach. At the end of the day we all stand in the gap - a gap we all chose to stand in but it can a lonely gap with a lot of responsibility and hard decisions.

I think it also helps I trust most of my Anesthesia colleagues. YMMV where you work.

 

[CCM-MD]

To be fair . . . “Standard of care” is defined as the standard practice in an area. It isn’t decided by necessarily the (arguably) BEST person be involved in every instance. Intensivists are also a kind/type of airway physicians but are we “experts”? I don’t know. Define “expert” right? Airways are in my wheelhouse as they are in yours. Not every airway needs/requires an “airway expert” - hell most don’t. And what we are talking about here is an airway that needs to ensure first pass tube. My practice is if I have time to plan, and sometimes we don’t, but usually we do in that patient on 1.0 with slowly dropping save, is to ask anesthesia to put in the tube. I’m not personally suggesting anyone who assesses this differently is wrong. There isn’t only one way to do much of anything in the ICU. I will strongly suggest this is a very reasonable approach. At the end of the day we all stand in the gap - gap we all chose to stand in but it can a lonely gap with a lot of responsibility and hard decisions.

I don't disagree with pretty much everything you have said. I think it is reasonable to have anesthesia intubate potentially challenging patients if the situation allows. I am quick to call them in certain situations and won't attempt if there is time.

What I am saying is, if anesthesiologists are truly better at managing the airway of a critically ill patient, maybe they should be managing all of the airways. As far as I know, there is no evidence that says that. In fact, we have evidence that EM physicians achieve similar outcomes in the studies I quoted above.

 

[jdh71]

I don't disagree with pretty much everything you have said. I think it is reasonable to have anesthesia intubate potentially challenging patients if the situation allows. I am quick to call them in certain situations and won't attempt if there is time.

What I am saying is, if anesthesiologists are truly better at managing the airway of a critically ill patient, maybe they should be managing all of the airways. As far as I know, there is no evidence that says that. In fact, we have evidence that EM physicians achieve similar outcomes in the studies I quoted above.

I mean that is one thing you can suggest, that anesthesia be the only ones to do airways and there are a few places I know of that do that. But they are like many things in the hospital a resource often best used elsewhere for the zero sum game. And we both know most airways don’t need to have an anesthesiologist and I don’t doubt that @chocomorsel would agree.

 

[CCM-MD]

I mean that is one thing you can suggest, that anesthesia be the only ones to do airways and there are a few places I know of that do that. But they are like many things in the hospital a resource often best used elsewhere for the zero sum game. And we both know most airways don’t need to have an anesthesiologist and I don’t doubt that @chocomorsel would agree.

My point was there is no evidence to suggest that anesthesiologists achieve better outcomes for ICU/ER intubations. If there is, then perhaps there should be a push for anesthesiologists doing all the intubations, everywhere. Or EM/CCM docs need better airway management training.

 

[jdh71]

My point was there is no evidence to suggest that anesthesiologists achieve better outcomes for ICU/ER intubations. If there is, then perhaps there should be a push for anesthesiologists doing all the intubations, everywhere. Or EM/CCM docs need better airway management training.

To be fair, your data didn’t exactly deal with what we are talking about either. I mean we can go through all the potential confounders but yes in at least the situations evaluated the best data we have suggests there may be no potential differences. Regardless I still see the either or position you are suggesting as a possibility as really unnecessary because of more practical reasons.

 

[CCM-MD]

To be fair, your data didn’t exactly deal with what we are talking about either. I mean can go through all the potential confounders but yes I’m at least the situations evaluated the best data we have suggests there may be no potential differences. Regardless I still see the either or position you are suggesting as a possibility as really unnecessary because of more practical reasons.

Thats fair. The data doesn't exactly talk about our patient on 100% FiO2 in the ICU - but one would want a "quick and slick" intubation in this situation and the data does show no difference in first attempt intubation success rate or within 2 in the last study I quoted.

While I think its reasonable to call anesthesia in this situation, it is unreasonable to say a CCM doc is "playing hero while his/her patient crumps" if he/she decides to proceed with the intubation themself.

 

[chocomorsel]

Like @jdh71 said, most airways don’t need an anesthesiologist. However the difficult ones, and or the ones who crump fast can be best served by us.

I can do a therapeutic bronch. However the @jdh71 can do them faster and with more skill and less bleeding compared to me.
I can do a pigtail, but the EM or surgical folk can do it faster than me. It’s just simple mathematics here.
I can do a subclavian, but will struggle compared to a surgeon.
So I don’t understand why people get all offended about airways here.

Especially in situations where seconds count. Who wants to be potentially coding a patient just because your ego gets the best of you?

As far as hypoxic patients without reserve, we get plenty of experience there as well. Those patients are called morbidly or super morbidly obese. Plenty of those in good old USA.

 

[chocomorsel]

That “playing hero” comment was a little tongue in cheek because in my and my colleagues experience, the MICU docs are the ones who tend to not call for help until the airway is bloody and almost unmanageable.

@jdh71 is most likely in the minority when it comes for asking for assistance early.

Funny that at both the academic institutions I have been, the anesthesia run ICUs have the airway team come and do most of the airways whereas the MICU run by Pulm/medicine/ER never call for any help from us at this institution and at my last(Pulm/medicine), they would call after multiple failed attempts and bloodied airways. First try is the best try.

In anesthesia, we are taught to always call/ask for help when the airway looks like it could be a challenge. Maybe cuz we have learned from past mistakes.

 

[deleted547339]

That “playing hero” comment was a little tongue in cheek because in my and my colleagues experience, the MICU docs are the ones who tend to not call for help until the airway is bloody and almost unmanageable.

@jdh71 is most likely in the minority when it comes for asking for assistance early.

Funny that at both the academic institutions I have been, the anesthesia run ICUs have the airway team come and do most of the airways whereas the MICU run by Pulm/medicine/ER never call for any help from us at this institution and at my last(Pulm/medicine), they would call after multiple failed attempts and bloodied airways. First try is the best try.

In anesthesia, we are taught to always call/ask for help when the airway looks like it could be a challenge. Maybe cuz we have learned from past mistakes.

Maybe. But I’ve been at my current institution (large academic MICU) and have heard of anesthesia coming to an airway exactly once in the past year. I think it’s just super rare.

 

[leviathan]

These are what some of the airway experts I trained with would call the physiologically difficult airway, rather than anatomically difficult. You might be able to get the tube in, but even if you could get it on your first pass, taking an extra 30 seconds to get the tube in could lead to some serious trouble. And if for some reason you have an unanticipated difficult airway and you cant get the tube in at all, then they may end up just arresting.

I tend to try to do them awake if the patient can cooperate, but when talking to my anesthesia colleagues locally they all say they would just do a usual RSI and just put the tube in. The concern they have raised is around causing laryngospasm when trying to pass the tube through actively moving cords.

I had a case last week where I was called for a patient on bipap who had sats in the high 70s-low 80s despite good volumes/seal with the mask and 10 of PEEP and 100% fio2. I ended up putting the high flows back on, gave ketamine and took a look with VL to pass the tube while she was still breathing spontaneously. However I spoke with some anesthesia friends and they all argued to just paralyze for the best first-pass attempt.

Good discussion as I agree, I've been seeing a lot more cases recently where people are maxed out on high flows and need intubation with zero ability to pre-oxygenate them due to how much shunt they have. Would love to hear more opinions from both ICU/EM/anesthesia.

 

[deleted547339]

These are what some of the airway experts I trained with would call the physiologically difficult airway, rather than anatomically difficult. You might be able to get the tube in, but even if you could get it on your first pass, taking an extra 30 seconds to get the tube in could lead to some serious trouble. And if for some reason you have an unanticipated difficult airway and you cant get the tube in at all, then they may end up just arresting.

I tend to try to do them awake if the patient can cooperate, but when talking to my anesthesia colleagues locally they all say they would just do a usual RSI and just put the tube in. The concern they have raised is around causing laryngospasm when trying to pass the tube through actively moving cords.

I had a case last week where I was called for a patient on bipap who had sats in the high 70s-low 80s despite good volumes/seal with the mask and 10 of PEEP and 100% fio2. I ended up putting the high flows back on, gave ketamine and took a look with VL to pass the tube while she was still breathing spontaneously. However I spoke with some anesthesia friends and they all argued to just paralyze for the best first-pass attempt.

Good discussion as I agree, I've been seeing a lot more cases recently where people are maxed out on high flows and need intubation with zero ability to pre-oxygenate them due to how much shunt they have. Would love to hear more opinions from both ICU/EM/anesthesia.

I’ll throw a NRB on during preoxygenation, then RSI - truly RSI - and go. Sometimes I’ll go bipap and leave it on with a high set rate then have it functionally bag through induction.

 

[chocomorsel]

Unless they look to be anatomically difficult, its prop, roc, tube. It's about speed really.

 

[jdh71]

These are what some of the airway experts I trained with would call the physiologically difficult airway, rather than anatomically difficult. You might be able to get the tube in, but even if you could get it on your first pass, taking an extra 30 seconds to get the tube in could lead to some serious trouble. And if for some reason you have an unanticipated difficult airway and you cant get the tube in at all, then they may end up just arresting.

I tend to try to do them awake if the patient can cooperate, but when talking to my anesthesia colleagues locally they all say they would just do a usual RSI and just put the tube in. The concern they have raised is around causing laryngospasm when trying to pass the tube through actively moving cords.

I had a case last week where I was called for a patient on bipap who had sats in the high 70s-low 80s despite good volumes/seal with the mask and 10 of PEEP and 100% fio2. I ended up putting the high flows back on, gave ketamine and took a look with VL to pass the tube while she was still breathing spontaneously. However I spoke with some anesthesia friends and they all argued to just paralyze for the best first-pass attempt.

Good discussion as I agree, I've been seeing a lot more cases recently where people are maxed out on high flows and need intubation with zero ability to pre-oxygenate them due to how much shunt they have. Would love to hear more opinions from both ICU/EM/anesthesia.

The paralysis sometimes feels like stepping out into no man’s land and I know a few of my partners still intubate without. The pretty good data on first pass with paralysis has me personally convinced. I only tube paralyzed. (Maybe there is a reason I wouldn’t paralyze I can’t think of off the top of my head??) But I think arguably the safest way with sick ICU patients is paralyzed.

 

[jdh71]

I’ll throw a NRB on during preoxygenation, then RSI - truly RSI - and go. Sometimes I’ll go bipap and leave it on with a high set rate then have it functionally bag through induction.

Seems like most of my patients are already on bipap by the time they require intubation. I’ve not seen a reason to take it off during the induction. Though I tend not to “slam” in meds because of hypotension which I’ve seen with them all going in fast in the sick sick including ketamine.

 

[Siggy]

Being prepared, calling people for help before getting into trouble, becoming familiar with "back-up" tools like LMAs and experience with placing a surgical airway is helpful. Many fellowships train fellows to do trachs, which will probably help with the latter.

I think this is the key thing. For me, there's no way that, as it stands now, a time sensitive intubation is best served with me using VL. Why? Because I can't count on at most 2 hands the number of intubations I've gotten with VL. What I need to do during my second year of fellowship is pull out the glide scope, bougie, and miller more often than going with the trusty Mac 3 or Mac 4 for the non-crash/code intubations. It doesn't matter if first rate pass for DL was 50% and VL was 100% in skilled hands (note: numbers made up) if the person doing the intubation doesn't have any experience with VL to begin with.

 

[Colorado outliers]

Reckon I'm more facile with a bronch than most posting in this thread and I agree. Weingart detailed BiPAP intubation a number of years ago with a slow induction with Ketamine and I've used this a lot. I mean if you have "max sats" for that patient with the bipap why take it off and mess around with anything else. Slow ketamine with the Bipap on, paralyze, remove bipap when effort stops, tube with VL.

If a patient is already on Optiflow and a facemask (which is often the case), switching them to BPAP, in my experience often leads to rapid desats. Obviously that may not be the case for every patient depending on their physiology and I agree if they're already on BPAP I leave them on it until paralyzed. I'm also decent w/ a bronch, but I'm not sure for the average airway w/ a good view bronch vs VL + bougie is a big difference in time. 'Difficult airway', often go w/ bronch first.

Great to hear everyone's thoughts on this issue.

We also rarely call anesthesia in our unit. I'll never be as good as an anesthesiologist w/ DL but ability to use VL + bougie or bronch usually allows us to get the airway promptly. I truly wish I had the DL skills of an anesthesiologist, but that will never happen unless I switch careers.

 

[Hernandez]

Side discussion. What brand bougie do y'all use? The brand at my current shop doesn't do me much good as it's doesn't hold bends placed in it

 

[Hork Bajir]

And why are people calling anesthesia for these situations? We are far more experienced intubating patients who are severely hypoxemic and with less physiologic reserve available than they are.

This would be analogous to an ICU doc telling an ID doc that you are way better at prescribing appropriate antibiotics to critically ill patients than they are. Can you do it adequately 99% of the time? Sure. Are they better at it than you are? Definitely. Does that really matter most of the time? Probably not. But based on your statement it sounds like you either have a concerning level of hubris (which will ultimately lead to you getting burned), or a lack of understanding about the specialty of anesthesiology (believe it or not, we do more than just elective intubations on healthy patients all day).

I don't mean to knock the skills of anyone else here. The airway is not the exclusive realm of anesthesiologists, nor should it be... But please don't disrespect our field (which has a great deal of overlap with critical care). We can all learn from each other, and both we and our patients will be better for it.

 

[deleted547339]

This would be analogous to an ICU doc telling an ID doc that you are way better at prescribing appropriate antibiotics to critically ill patients than they are. Can you do it adequately 99% of the time? Sure. Are they better at it than you are? Definitely. Does that really matter most of the time? Probably not. But based on your statement it sounds like you either have a concerning level of hubris (which will ultimately lead to you getting burned), or a lack of understanding about the specialty of anesthesiology (believe it or not, we do more than just elective intubations on healthy patients all day).

I don't mean to knock the skills of anyone else here. The airway is not the exclusive realm of anesthesiologists, nor should it be... But please don't disrespect our field (which has a great deal of overlap with critical care). We can all learn from each other, and both we and our patients will be better for it.

Ummmm....the icu doctor is better with antibiotics in critically ill than ID. It’s not uncommon for ID to do some nonsense like say “well, they’re in 3 pressors, but the last bug they had was sensitive to ancef, so that’s all I would give them until cultures come back.”

“Get out of my icu before I stab you.”

 

[jdh71]

Ummmm....the icu doctor is better with antibiotics in critically ill than ID. It’s not uncommon for ID to do some nonsense like say “well, they’re in 3 pressors, but the last bug they had was sensitive to ancef, so that’s all I would give them until cultures come back.”

“Get out of my icu before I stab you.”

Anecdotally I’ve never seen ID suggest anything that inane in a patient. Plus we don’t consult them in almost all cases. I usually consult in bacterial endocarditis and meningitis mostly because this is regional SoC and I don’t want to to practice outside of that. ID can also help me lean on the heart surgeons. I consult in non surface/non pulmonary fungal infections, transplant patients with CMV or weird virus, viral meningitis, and HIV with weird bug or virus. This seems like the better analogy.

 

[Hernandez]

This would be analogous to an ICU doc telling an ID doc that you are way better at prescribing appropriate antibiotics to critically ill patients than they are. Can you do it adequately 99% of the time? Sure. Are they better at it than you are? Definitely. Does that really matter most of the time? Probably not. But based on your statement it sounds like you either have a concerning level of hubris (which will ultimately lead to you getting burned), or a lack of understanding about the specialty of anesthesiology (believe it or not, we do more than just elective intubations on healthy patients all day).

I don't mean to knock the skills of anyone else here. The airway is not the exclusive realm of anesthesiologists, nor should it be... But please don't disrespect our field (which has a great deal of overlap with critical care). We can all learn from each other, and both we and our patients will be better for it.

I agree with you....until y'all send CRNAs.