High-flow O2 making intubations riskier?

[deleted547339]

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.

I’ve seen them suggest things pretty close to that absurd....I tend to consult them fairly rarely, but I do consult for the things you said. Unfortunately we have a few autoconsults/antibiotic restrictions that I think are absurd.

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[deleted547339]

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

Yea, sending a CRNA or PGY2 is always encouraging.

 

[jdh71]

I’ve seen them suggest things pretty close to that absurd....I tend to consult them fairly rarely, but I do consult for the things you said. Unfortunately we have a few autoconsults/antibiotic restrictions that I think are absurd.

Luckily I can order any antibiotic I want. For now.

I like to joke with the residents:

Q: What’s the difference between a monkey and a critical care doctor?

A: A monkey can name more than two antibiotics!!! (Vanco and Zosyn)

 

[chocomorsel]

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

I hear you. That is terrible practice.

 

[McPoyle]

I hear you. That is terrible practice.

I somewhat agree. Just by sheer volume, a CRNA and even CA2 (pgy3) has performed the technical skill more times than any ER resident and likely most faculty (unless they are intubating patients 2-5x/day). But it does look bad, and I do think faculty should be present if another service is worried enough to be asking for our help.

This isn’t magic, it’s a technical skill that we’ve proven even monkeys (midlevels) can perform. The vast majority of airways are not difficult, and there is no shame in asking for others to be involved in case of difficulty (I ask my CT colleagues to be present when inducing sick hearts/lung tx, or my ENT colleagues to be present for some difficult airways). Like someone else said, in the unit it’s not the difficulty in performing the skill but the fact that simply inducing can kill the patient.

 

[chocomorsel]

While the CRNA and PGY3 may be better than an ER resident and or faculty, the attending anesthesiologist should not send them there alone. What if even they can't get an airway and don't have a back up. That's completely unprofessional in my opinion. Two hands are better than one and the attending anesthesiologist should be the final call.
Before the slash trach that is.

 

[McPoyle]

While the CRNA and PGY3 may be better than an ER resident and OR faculty, the attending anesthesiologist should not send them there alone. What if even they can't get an airway and don't have a back up. That's completely unprofessional in my opinion. Two hands are better than one and the attending anesthesiologist should be the final call.
Before the slash trach that is.

I agree, my discomfort is not in having a junior resident or CRNA responding rather in the department that refuses to send attending coverage along as well. I remember well in residency intervening when an ER attending was about to do something dangerous (just pulling an airway and assuming he’d be able to DL). Bear in mind this was a junior attending and I was a pgy4, which made the politics of speaking up difficult. It would have been a lot nicer to have another attending there for political reasons (and patient care).

 

[SurfingDoctor]

I remember CA3 being the first line for airways at the teaching, undeserved hospital with no attending backup for codes and be like "what is this?"

That being said, I also remember having PICU fellows trial an airway a couple of times and as I take one look being like "Call Anesthesia" and they roll in and I'm happy to manage the patient whilst they manage the airway, instead of more monkeying around.

I also remember an anesthesiologist rolling up a 2 year old who told me "this patient is about to code" who evidently was in pulseless VTach on the elevator ride...

Or being called for a pediatric code in the OR...

We all have our skill sets and at the end of the day... if we all recognize our limitations and do what is best for the patient, there is no blame to lay.

Personally, I call Anesthesia for every kid with mucopolysaccharidesosis and mediastinal mass because... I know my limitations...

I've been doing this stuff for 15 years and I'll be damned if an airway on a desaturated kid doesn't get my pucker factor high. That decompensated kid doesn't care ago one's ego... ICU, Anesthesia or otherwise...

 

[deleted547339]

While the CRNA and PGY3 may be better than an ER resident and or faculty, the attending anesthesiologist should not send them there alone. What if even they can't get an airway and don't have a back up. That's completely unprofessional in my opinion. Two hands are better than one and the attending anesthesiologist should be the final call.
Before the slash trach that is.

And yet I’ve never seen an attending anesthesiologist respond to an emergency airway.

 

[chocomorsel]

That’s terrible. It clearly happens in some places but that should not be the norm. It’s not best for the patient and it makes us look bad and lazy.
I always respond to emergent airways. As should places with MD/DOs in charge of an ACT model. Although I do remember going with attendings sometimes in residency to airway calls, I can’t say I see it often where I am now.

 

[McPoyle]

And yet I’ve never seen an attending anesthesiologist respond to an emergency airway.

It certainly doesn’t happen enough. I feel like in training half my attendings made a real effort to respond to all non-OR airways, an even smaller percentage actually accomplished this. The other half... well they couldn’t be bothered. The way I view it is we are being consulted for a procedure by another service (ICU, ED, medicine or surgery on the floor). If this were any other procedure, the resident or mid level would staff it with their attendings who would then have to attest to being present during critical portions of said procedure. This should be no different and faculty should be present.

 

[Robotic Wis-Hipple]

In response to the OP question I think it makes perfect sense that those patients whom you’ve been able to delay intubation with HFNC who subsequently fail and require an ETT/MV will be potentially riskier. These are patients that have ridden as close to the razors edge of falling off the O2-Hb dissociation curve as possible. Someone else called this a physiologically difficult airway and that’s exactly what it is, their PaO2 is in the 50’s on 60-80% FiO2 and they likely have any number of physiologic insults, mechanical/metabolic resp failure, atelectasis, inadequate ability to pull appropriate tidal volumes, airspace disease, not to mention anatomic considerations such as obesity or tracheal stenosis/malacia etc.

These patients will not tolerate apnea at all, they will crash, and they will take time to recover to their recent baseline SpO2. All you can do here is to know it’s coming, be prepared, and have all the tools and airway adjuncts as well as hands available to you that you can and get the tube in as efficiently as possible. As far as how many patient days of MV saved for every resultant urgent intubation you’re comfortable with I think that’s a fantastic question but it’s clearly outside my expertise.

And I also agree that anesthesia shouldn’t be necessary, this is your realm and I completely trust that intensivists in my hospital can perform this task perfectly. In my institution our SICU/CTICUs do call for anesthesia help occasionally and an attending anesthesiologist is happy to be there. I do wish we could get beyond the EM/CCM/Anesthesia nitpicking, especially the fallacy that we only tube ASA1,2, and 3s in elective scenarios only.

 

[coffeebythelake]

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

I would never send a solo CRNA to an off site airway with limited airway resources
just asking for trouble

 

[coffeebythelake]

And yet I’ve never seen an attending anesthesiologist respond to an emergency airway.

when i'm on-call
unless i am absolutely stuck in the ORs
I go to all airways where patient is suspected to be atypical intubation or physiologically high risk.
I discuss airway cases for all but the simplest cases, and virtually all airways performed by the residents without my presence have known airway histories
When necessary, e.g., difficult airway, peri-arrest due to respiratory failure, I perform the intubations myself.
My colleagues have the same policies when on-call.
i work at a quaternary care teaching hospital
maybe you should see how things work in other places before you make a blanket statement to denigrate another medical specialty.

 

[coffeebythelake]

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.

A lot of the data you refer about DL vs VL to is biased because they specifically exclude predicted difficult airways, the exact situations where a VL would be most useful.

 

[Hernandez]

I would never send a solo CRNA to an off site airway with limited airway resources
just asking for trouble

Let me tell you if the time I watched an anesthesiologist pass the laryngoscope to the crna and said “here, you do more of these than me”

 

[coffeebythelake]

Let me tell you if the time I watched an anesthesiologist pass the laryngoscope to the crna and said “here, you do more of these than me”

1. what kind of place do you work in?
2. and sadly, anesthesiologists with such horrible skill atrophy exist

like any other field of medicine these physicians make up a tiny percent but sure makes for a good story for some people
frankly saying stuff like this sets a bad precedent. god knows how many horribly mismanaged cases exist under intensivist care, but I don't go spouting it on a public forum for jollies.

 

[jdh71]

Is this the point in any SDN airway thread where we get to start really crapping on every other specialty doing airway?!??

Can it be that time nao?!???

 

[jdh71]

when i'm on-call
unless i am absolutely stuck in the ORs
I go to all airways where patient is suspected to be atypical intubation or physiologically high risk.
I discuss airway cases for all but the simplest cases, and virtually all airways performed by the residents without my presence have known airway histories
When necessary, e.g., difficult airway, peri-arrest due to respiratory failure, I perform the intubations myself.
My colleagues have the same policies when on-call.
i work at a quaternary care teaching hospital
maybe you should see how things work in other places before you make a blanket statement to denigrate another medical specialty.

That is a fantastic way to practice I think. It helps you are at a teaching hospital I think. Some folks are working a bit father away from the ivory tower. I personally work with fantastic anesthesia colleagues and maybe this is why I like calling them. I hope you can understand maybe some of our critical care colleagues have had a different experience and thus their cynicism. Obviously doesn’t make a whole specialty bad or weak or sloppy. I think everyone knows this. Some of this is venting and blowing off steam. And I’m sure you have seen more than one mayday mayday!! Airway from an intensivist who made it all bloody and swollen. I would salute anyone stepping into that situation with ice in their veins and placing that very important tube.

If there is one thing we can all agree on perhaps its that ortho is just the worst!!! Amirite?!??

 

[Hernandez]

1. what kind of place do you work in?
2. and sadly, anesthesiologists with such horrible skill atrophy exist

like any other field of medicine these physicians make up a tiny percent but sure makes for a good story for some people
frankly saying stuff like this sets a bad precedent. god knows how many horribly mismanaged cases exist under intensivist care, but I don't go spouting it on a public forum for jollies.

That was were I did fellowship, and needless to say I had a poor opinion of their gas program. Bad precedent. Hardly. while I’m glad you take your job serious, what you suggest seems more like the exception than the rule. Gas at my current shop won’t show up to emergencies even when asked.

The sad reality is not everyone is a team player. Not every specialty fulfills the sdn stereotype. I personally look at the doc, not the credentials. There are plenty of docs I wouldn’t trust for anything and some that have great skills beyond their specialty.

 

[Colorado outliers]

Is this the point in any SDN airway thread where we get to start really crapping on every other specialty doing airway?!??

Can it be that time nao?!???

Lol at this thread escalating into trashing each other's specialties. That was not the intent at all.

Robotic-wis-hipple, I appreciate your insight. I assume you are an anesthesiologist. I wish I could have done many more DL intubations
as a fellow...no one can DL and intubate as quickly as you guys. One of our anesthesia residents told me it took him about 200-300 DLs to feel
'competent'. I'm not buying that 50 DLs really makes anybody competent to intubate critically ill patients, which is what most of our fellows
get before they come to the ICU. Maybe different numbers for VL.
I like the term 'physiologically difficult airway' also - going to start using that now (will pretend that I came up with it, haha)

At our quarternary care hospital, if anesthesia is called, it's usually a 2nd or 3rd year resident, or CRNA that shows up. If the intensivist
can't intubate with VL + bougie or with a bronch, the patient usually gets an LMA until a surgical airway is established. Obviously this may depend
on the experience level and comfort of the intensivist/fellow.

 

[Robotic Wis-Hipple]

Lol at this thread escalating into trashing each other's specialties. That was not the intent at all.

Robotic-wis-hipple, I appreciate your insight. I assume you are an anesthesiologist. I wish I could have done many more DL intubations
as a fellow...no one can DL and intubate as quickly as you guys. One of our anesthesia residents told me it took him about 200-300 DLs to feel
'competent'. I'm not buying that 50 DLs really makes anybody competent to intubate critically ill patients, which is what most of our fellows
get before they come to the ICU. Maybe different numbers for VL.
I like the term 'physiologically difficult airway' also - going to start using that now (will pretend that I came up with it, haha)

At our quarternary care hospital, if anesthesia is called, it's usually a 2nd or 3rd year resident, or CRNA that shows up. If the intensivist
can't intubate with VL + bougie or with a bronch, the patient usually gets an LMA until a surgical airway is established. Obviously this may depend
on the experience level and comfort of the intensivist/fellow.

I am in fact an anesthesiologist, and I agree with you that I wouldn’t think 50 DLs qualifies anyone as competent let alone an expert. But sadly, in this era (I sound like a cantankerous old dude yet I’m only a few years out of fellowship) everyone is being pulled in many different directions and the numbers are likely decreasing overall as “mid-levels” are being groomed for the, let’s say, “hands-skills”. As an example I’ve worked in 2 completely different academic systems that have begun credentialing PAs or DNPs for central line placements, and the line in the sand for number of lines before being deemed competent was 15 at one and 25 at the other. Really? I put 2+ central lines in a day and I still run into lines occasionally that don’t go smoothly.

Add to that the improvement in technology and VL is basically everywhere and it makes the average formerly semi-difficult airway look so easy. I’m not naive enough to believe that I’ll ever be as good at direct laryngoscopy as most of the old grey hairs that practiced 20-30yrs without glidescopes or fiberoptic bronchoscopes.

But back to my point about being pulled in many directions, when I’m not in the heart rooms I’ll typically have 3 ORs running, and my department is not unique and this is why I fear many of your ICUs or offsite airway calls receive residents or CRNAs, because I can’t really be 2+ floors away with that many ORs running (typically). Does it happen? Sure, but when a call comes overhead or direct to the charge anesthesiologist it’s up to them to triage who can respond. At my site the ICUs know to call the charge early if there’s someone that looks difficult or is known difficult that they expect may either be extubated or need to be intubated sometime in the shift so that we can plan ahead a bit.

And lastly, I know I’m rambling, and this isn’t meant to be inflammatory, but I would think you guys/gals should be able to get a tube in via fiber optic bronch at least. You guys certainly do more diagnostic/therapeutic bronchs than I do (and I do a fair number post long pump run or for DLT placement and OLV). I would think if failed DL/VL a FOB intubation would be right up your alley. Of course this is barring complete respiratory failure like in scenarios such as the OP or something like a supraglottic/glottic mass or post trach tracheal stenosis expected to require a tube too small to go over the bronch but in those cases (the anatomic pathologies) I wouldn’t put em to sleep.

 

[deleted171991]

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 =)

It's not the HFNC. It's the critical care attending.

HFNC is a trial/bridge therapy. If it works, one can see it relatively fast (and should then keep on checking that the patient keeps moving in the right direction). If it doesn't (initially or later), one should have another conversation with the patient. It doesn't take a genius to judge the difference, and to decide that an intubation will be unavoidable. When about unavoidable intubations, sooner is better/safer than later.

Obviously, if one only sees one's patients once a day, and relies on trainees' hearsay for the other 20+ hours, one will get nasty surprises. Don't blame the HFNC for that (and for dumb trainees).

About the other thing: a glidescope intubation takes me about 30 seconds in 90+% of the patients (plus 30 seconds for the meds to kick in). Anybody who can't intubate in that timeframe had better not attempt a solo intubation in sick lungs. These are not healthy thin well-preoxygenated patients with 7 minutes worth of O2 in their FRC (and with easy apneic oxygenation from the HFNC); these are sick dudes with barely a minute worth of oxygen in their crappy lungs. They WILL desat by the time the tube is in, even in expert hands.

 

[Undisclosedlurker]

It's not the HFNC. It's the critical care attending.

HFNC is a trial/bridge therapy. If it works, one can see it relatively fast (and should then keep on checking that the patient keeps moving in the right direction). If it doesn't (initially or later), one should have another conversation with the patient. It doesn't take a genius to judge the difference, and to decide that an intubation will be unavoidable. When about unavoidable intubations, sooner is better/safer than later.

Obviously, if one only sees one's patients once a day, and relies on trainees' hearsay for the other 20+ hours, one will get nasty surprises. Don't blame the HFNC for that (and for dumb trainees).

About the other thing: a glidescope intubation takes me about 30 seconds in 90+% of the patients (plus 30 seconds for the meds to kick in). Anybody who can't intubate in that timeframe had better not attempt a solo intubation in sick lungs. These are not healthy thin well-preoxygenated patients with 7 minutes worth of O2 in their FRC (and with easy apneic oxygenation from the HFNC); these are sick dudes with barely a minute worth of oxygen in their crappy lungs. They WILL desat by the time the tube is in, even in expert hands.

Great troll post!

 

[deleted171991]

Great troll post!

Yours? Indeed.

Your first post was much better. So I'll give you the benefit of the doubt. I was not trolling.

The main value I see in HFNC is decreased dead space and 3 cm H2O of PEEP. It's like a castrated low-pressure CPAP, especially in mouth breathers. Hence, I don't expect miracles from it (but it can buy just enough time for a turnaround in some patients). If I want miracles from NIV (such as avoiding intubation in pulmonary edema), I'll go the BiPAP way (in the appropriate patients). Any NIV is a bridge therapy, hence it needs frequent followups; the backup plan should be intubation, while the patient still has some decent reserve.

 

[deleted547339]

It's not the HFNC. It's the critical care attending.

HFNC is a trial/bridge therapy. If it works, one can see it relatively fast (and should then keep on checking that the patient keeps moving in the right direction). If it doesn't (initially or later), one should have another conversation with the patient. It doesn't take a genius to judge the difference, and to decide that an intubation will be unavoidable. When about unavoidable intubations, sooner is better/safer than later.

Obviously, if one only sees one's patients once a day, and relies on trainees' hearsay for the other 20+ hours, one will get nasty surprises. Don't blame the HFNC for that (and for dumb trainees).

About the other thing: a glidescope intubation takes me about 30 seconds in 90+% of the patients (plus 30 seconds for the meds to kick in). Anybody who can't intubate in that timeframe had better not attempt a solo intubation in sick lungs. These are not healthy thin well-preoxygenated patients with 7 minutes worth of O2 in their FRC (and with easy apneic oxygenation from the HFNC); these are sick dudes with barely a minute worth of oxygen in their crappy lungs. They WILL desat by the time the tube is in, even in expert hands.

Eh, I got pretty comfortable keeping people on HFNC for a long time with marginal sats. We had a robust lung transplant program and those folks would stay on HFNC with NRB for weeks with spo2s in the 80s for weeks.

 

[deleted171991]

Eh, I got pretty comfortable keeping people on HFNC for a long time with marginal sats. We had a robust lung transplant program and those folks would stay on HFNC with NRB for weeks with spo2s in the 80s for weeks.

Another proof that one shouldn't treat numbers, but patients.

 

[jdh71]

Another proof that one shouldn't treat numbers, but patients.

We all come at this with unavoidable clinical bias based on who we are usually treating, and in the usual SICU/CTICU setting I can see your argument regarding HFNC more strongly applied - folks with otherwise "ok enough lungs and heart for surgery in the first place" get acute hypoxemic, that is something that needs to be decided "tube or no tube" pretty quickly, but in the chronic disease, old people, bad lungger, bad heart, population most commonly seen in the MICU, mechanical ventilation is too often the beginning of the problems not the end of them. I'm in the camp of "Hell, if they are hanging in there on hi flow, what aint "broke" (heh) don't need to be fixed." Of course setting realistic expectations and talking intubation status, communicating with patient and or decision makers goes without saying.

 

[Undisclosedlurker]

It's not the HFNC. It's the critical care attending.

HFNC is a trial/bridge therapy. If it works, one can see it relatively fast (and should then keep on checking that the patient keeps moving in the right direction). If it doesn't (initially or later), one should have another conversation with the patient. It doesn't take a genius to judge the difference, and to decide that an intubation will be unavoidable. When about unavoidable intubations, sooner is better/safer than later.

Obviously, if one only sees one's patients once a day, and relies on trainees' hearsay for the other 20+ hours, one will get nasty surprises. Don't blame the HFNC for that (and for dumb trainees).

About the other thing: a glidescope intubation takes me about 30 seconds in 90+% of the patients (plus 30 seconds for the meds to kick in). Anybody who can't intubate in that timeframe had better not attempt a solo intubation in sick lungs. These are not healthy thin well-preoxygenated patients with 7 minutes worth of O2 in their FRC (and with easy apneic oxygenation from the HFNC); these are sick dudes with barely a minute worth of oxygen in their crappy lungs. They WILL desat by the time the tube is in, even in expert hands.

Prior to your post, multiple experienced attendings had posted that had noticed the same phenomenon mentioned in the OP.
Yet you arrive and conclude it must be their fault, and it 'doesn't take a genius' to avoid to judge who is responding to HFNC. That is why I called you out on trolling.

Not everyone who initially looks better on HFNC will continue to do so; it's not as black and white as you claim. They may decompensate unexpectedly in the next 1-2 days. Then they get intubated, in much worse shape then if they had gotten intubated prior to HFNC. Is the attending's poor judgement to blame? I don't think so. As someone else mentioned, some of our pre-transplant patients live on HFNC until transplant, sometimes +/- VV ECMO. I don't think the point is to blame HFNC, but to realize that we may be saving some patients from being intubated while creating riskier intubations for others despite our vigilance.

I agree with your comment about intubation. I would even decrease that to 20 seconds for many of these patients. If the fellow isn't experienced, I'll do it myself, with a bougie ready to go.

 

[deleted171991]

We all come at this with unavoidable clinical bias based on who we are usually treating, and in the usual SICU/CTICU setting I can see your argument regarding HFNC more strongly applied - folks with otherwise "ok enough lungs and heart for surgery in the first place" get acute hypoxemic, that is something that needs to be decided "tube or no tube" pretty quickly, but in the chronic disease, old people, bad lungger, bad heart, population most commonly seen in the MICU, mechanical ventilation is too often the beginning of the problems not the end of them. I'm in the camp of "Hell, if they are hanging in there on hi flow, what aint "broke" (heh) don't need to be fixed." Of course setting realistic expectations and talking intubation status, communicating with patient and or decision makers goes without saying.

I had extensive MICU training, so I understand how the HFNC is used for buying time (and I am in the same camp as you - better is the enemy of good). But, even with chronic MICU patients, one can see a trend. Any patient who needs more than 70-80% FiO2 for days would worry me. Let's also not forget that high O2 for a long time causes ALI. There is a point where the risk/benefit ratio of MV changes, and it's way before the patient cannot keep up even on 90-100% O2.

 

[deleted171991]

Prior to your post, multiple experienced attendings had posted that had noticed the same phenomenon mentioned in the OP.
Yet you arrive and conclude it must be their fault, and it 'doesn't take a genius' to avoid to judge who is responding to HFNC. That is why I called you out on trolling.

Not everyone who initially looks better on HFNC will continue to do so; it's not as black and white as you claim. They may decompensate unexpectedly in the next 1-2 days. Then they get intubated, in much worse shape then if they had gotten intubated prior to HFNC. Is the attending's poor judgement to blame? I don't think so. As someone else mentioned, some of our pre-transplant patients live on HFNC until transplant, sometimes +/- VV ECMO. I don't think the point is to blame HFNC, but to realize that we may be saving some patients from being intubated while creating riskier intubations for others despite our vigilance.

I agree with your comment about intubation. I would even decrease that to 20 seconds for many of these patients. If the fellow isn't experienced, I'll do it myself, with a bougie ready to go.

Obviously, I was not talking about lung transplant patients and other rare birds. But people have a tendency to forget that HFNC is not "just" a NC, it's more like a NRB (at FiO2 over 60%), so one should treat it with the appropriate respect and expectations.

Also, nothing "unexpected" happens over 1-2 days. I may be biased because I come from a specialty whose motto is Vigilance, but, many times, the trend is there for anybody who's looking. The problem is that some people are not really looking, except briefly once or twice a day. Hence my above rant.

I am a huge fan of minimalism and avoiding iatrogenesis, by the way, but the one thing I dislike more than an unnecessary intubation is being called to intubate a patient who may crash during intubation (when that could have been avoided).

 

[chocomorsel]

It's not the HFNC. It's the critical care attending.

HFNC is a trial/bridge therapy. If it works, one can see it relatively fast (and should then keep on checking that the patient keeps moving in the right direction). If it doesn't (initially or later), one should have another conversation with the patient. It doesn't take a genius to judge the difference, and to decide that an intubation will be unavoidable. When about unavoidable intubations, sooner is better/safer than later.

Obviously, if one only sees one's patients once a day, and relies on trainees' hearsay for the other 20+ hours, one will get nasty surprises. Don't blame the HFNC for that (and for dumb trainees).

About the other thing: a glidescope intubation takes me about 30 seconds in 90+% of the patients (plus 30 seconds for the meds to kick in). Anybody who can't intubate in that timeframe had better not attempt a solo intubation in sick lungs. These are not healthy thin well-preoxygenated patients with 7 minutes worth of O2 in their FRC (and with easy apneic oxygenation from the HFNC); these are sick dudes with barely a minute worth of oxygen in their crappy lungs. They WILL desat by the time the tube is in, even in expert hands.

I am glad someone said it as I was getting ready to ask after a long day of work. Why are we putting so many people on high flow and leaving them on for days at a time? Aren't we just setting ourselves up?
When I did residency about 7-10 years ago, the high flow thing was a new thing and people who looked crappy bought a tube. Unless I am actively diuresing someone or extubating them to high flow to give them a shot I don't see the need for high flow honestly.
I have regretted not putting the tube in a lot more than putting the tube in by a huge margin.

 

[jdh71]

I am glad someone said it as I was getting ready to ask after a long day of work. Why are we putting so many people on high flow and leaving them on for days at a time? Aren't we just setting ourselves up?
When I did residency about 7-10 years ago, the high flow thing was a new thing and people who looked crappy bought a tube. Unless I am actively diuresing someone or extubating them to high flow to give them a shot I don't see the need for high flow honestly.
I have regretted not putting the tube in a lot more than putting the tube in by a huge margin.

I just have to disagree with you guys. I think there is a huge role for HFNC to play in the MICU. And in many of those patients their problem really isn’t lack of a mechanical vent, especially the tough physiologic cases like asthma or pulmonary hypertension when the vent, when necessary, is really the beginning of the problems not the end of it.

 

[Undisclosedlurker]

Obviously, I was not talking about lung transplant patients and other rare birds. But people have a tendency to forget that HFNC is not "just" a NC, it's more like a NRB (at FiO2 over 60%), so one should treat it with the appropriate respect and expectations.

Also, nothing "unexpected" happens over 1-2 days. I may be biased because I come from a specialty whose motto is Vigilance, but, many times, the trend is there for anybody who's looking. The problem is that some people are not really looking, except briefly once or twice a day. Hence my above rant.

I am a huge fan of minimalism and avoiding iatrogenesis, by the way, but the one thing I dislike more than an unnecessary intubation is being called to intubate a patient who may crash during intubation (when that could have been avoided).

Patients sitting on HFNC for days are not ‘rare birds’. In the MICU (~40 bed large academic center) I attend in we have at least a handful on HFNC for greater than 3 days. In our Onc ICU, out of 12 beds, there are usually at least 2 on HFNC for several days. This is a trend over the last couple years.

Disagree w/ your second point also, of course patients can initially look better on HFNC, than unexpectedly deteriorate. Even if the deterioration is rapidly recognized the intubation will be riskier than prior to HFNC. That’s the whole premise of the OP.

It seems you either:
1. Don’t round in a tertiary/quaternary MICU
2. See a different patient population than mine (ARDS/ECMO referral center, heavy solid and BMT organ transplant center)
3. Are BSing/trolling although I’ll give you the benefit of the doubt as you gave me.

I also don’t like risky intubations...but it’s generally an unavoidable part of my job.

 

[jdh71]

Patients sitting on HFNC for days are not ‘rare birds’. In the MICU (~40 bed large academic center) I attend in we have at least a handful on HFNC for greater than 3 days. In our Onc ICU, out of 12 beds, there are usually at least 2 on HFNC for several days. This is a trend over the last couple years.

Disagree w/ your second point also, of course patients can initially look better on HFNC, than unexpectedly deteriorate. Even if the deterioration is rapidly recognized the intubation will be riskier than prior to HFNC. That’s the whole premise of the OP.

It seems you either:
1. Don’t round in a tertiary/quaternary MICU
2. See a different patient population than mine (ARDS/ECMO referral center, heavy solid and BMT organ transplant center)
3. Are BSing/trolling although I’ll give you the benefit of the doubt as you gave me.

I also don’t like risky intubations...but it’s generally an unavoidable part of my job.

I know he’s not trolling. I think it’s as I noted above a certain unavoidable clinical selection bias based on where one works and sees the most. I don’t subscribe to @FFP ’s newsletter but I strongly suspect he’s simply your typical anesthesia critical care doc - these guys get trained to be super duper serious, like a truckload of dead babies serious (and that is a very serious topic) about everything starting in residency. I’m not suggesting that is “wrong” per se, it makes me roll my eyes at times, and it is ONE way to practice but it’s more stylistic than better. Being aggressively correct is just the way these guys are. Trainjng plus self selection by personality is my guess. Anyway, I wouldn’t let it get to you too much. He’s a valuable contributor to this forum and I always appreciate his perspective. I could personally do with less “my way or the highway” but none of us are perfect.

The whole high o2 causes ALI is very likely dogma. And I’ve never seen good data to support that.

 

[SurfingDoctor]

Throwing a 9 month old on HFNC for respiratory distress typically has a lot less that can go wrong with it than intubating.

 

[deleted171991]

.

I know he’s not trolling. I think it’s as I noted above a certain unavoidable clinical selection bias based on where one works and sees the most. I don’t subscribe to @FFP ’s newsletter but I strongly suspect he’s simply your typical anesthesia critical care doc - these guys get trained to be super duper serious, like a truckload of dead babies serious (and that is a very serious topic) about everything starting in residency. I’m not suggesting that is “wrong” per se, it makes me roll my eyes at times, and it is ONE way to practice but it’s more stylistic than better. Being aggressively correct is just the way these guys are. Trainjng plus self selection by personality is my guess. Anyway, I wouldn’t let it get to you too much. He’s a valuable contributor to this forum and I always appreciate his perspective. I could personally do with less “my way or the highway” but none of us are perfect.

The whole high o2 causes ALI is very likely dogma. And I’ve never seen good data to support that.

My previous description, before Wiseguy, also included pompous ass.

I think all of us have our own biases. Myself, I am mostly biased by the fact that up to 30% of what I was consulted on during my fellowship was iatrogenic, as in could have been avoided. So I lost a lot of respect for physicians as a group.

 

[Robotic Wis-Hipple]

.

My previous description, before Wiseguy, also included pompous ass.

I think all of us have our own biases. Myself, I am mostly biased by the fact that up to 30% of what I was consulted on during my fellowship was iatrogenic, as in could have been avoided. So I lost a lot of respect for physicians as a group.

Gotta be honest, I almost posted the popcorn GIF awhile ago. I expected better than this.

 

[deleted171991]

Gotta be honest, I almost posted the popcorn GIF awhile ago. I expected better than this.

I am getting old.

 

[CCM-MD]

An intensivist who doesn't "see the need for high flow", is a dangerous one.

Don't go around throwing tubes left and right in patients who can be supported without... especially older, chronically ill patients with multiple comorbidities (which are becoming more and more common)... you can do a lot of harm.

The TUBE & vent doesn't cure anything. It is a modality to buy time while the patient improves with other treatment or on their own. BIPAP/CPAP/HFNC can do the same thing in many - BUY time and support the patient while they improve - without some of the problems of invasive MV.

Not easy to predict who's going to fail NPPV/HFNC. Many fail, but many get better also.

I am a believer of what's already been said... the vent is often the beginning of problems.

Less is often more in the critically ill. "Don't just do something, stand there!"

 

[deleted171991]

An intensivist who doesn't "see the need for high flow", is a dangerous one.

Don't go around throwing tubes left and right in patients who can be supported without... especially older, chronically ill patients with multiple comorbidities (which are becoming more and more common)... you can do a lot of harm.

The TUBE & vent doesn't cure anything. It is a modality to buy time while the patient improves with other treatment or on their own. BIPAP/CPAP/HFNC can do the same thing in many - BUY time and support the patient while they improve - without some of the problems of invasive MV.

Not easy to predict who's going to fail NPPV/HFNC. Many fail, but many get better also.

I am a believer of what's already been said... the vent is often the beginning of problems.

Less is often more in the critically ill. "Don't just do something, stand there!"

I share a lot of your beliefs, except the emphasized part. It's not easy to predict... if one doesn't keep watching them. That's not just the nurses' job. Doctors who follow their patients frequently enough to see the movie will understand them much better than those who just see rare photos. And if one's ICU job doesn't allow one to follow one's patients closely (I look at my sickest patients every hour or more frequently, even if just from the door, between notes), one should get a better job.

So, while initially it may not be easy to predict certain things, after watching the patient in dynamic, one should be able to see a trend. As an anesthesiologist who's called to intubations, I would never fault an intensivist who watches his/her patients like a hawk for having a patient crash "unexpectedly". But, most of the time, one could have seen it coming, IF watching the movie (and not the photos).

 

[chocomorsel]

An intensivist who doesn't "see the need for high flow", is a dangerous one.

Don't go around throwing tubes left and right in patients who can be supported without... especially older, chronically ill patients with multiple comorbidities (which are becoming more and more common)... you can do a lot of harm.

The TUBE & vent doesn't cure anything. It is a modality to buy time while the patient improves with other treatment or on their own. BIPAP/CPAP/HFNC can do the same thing in many - BUY time and support the patient while they improve - without some of the problems of invasive MV.

Not easy to predict who's going to fail NPPV/HFNC. Many fail, but many get better also.

I am a believer of what's already been said... the vent is often the beginning of problems.

Less is often more in the critically ill. "Don't just do something, stand there!"

If you are talking about me, that’s not what I said. And I did not say the tube and vent fixes everything.

Maybe for pulmonary cripples that are way more common in the MICU with no endgame on the vent sure.

But there’s still CPAP so I am not exactly throwing tubes around left and right. But days and days on HFNC without improvements, maybe we need to think of palliative if we don’t want to tube them.

 

[jdh71]

If you are talking about me, that’s not what I said. And I did not say the tube and vent fixes everything.

Maybe for pulmonary cripples that are way more common in the MICU with no endgame on the vent sure.

But there’s still CPAP so I am not exactly throwing tubes around left and right. But days and days on HFNC without improvements, maybe we need to think of palliative if we don’t want to tube them.

Unless you really need the positive pressure and in most cases of HFNC you don’t, then really there is not a need to strap a mask to a patients face indefinitely. I’d definitely intubate before duct taping the cpap to a patients face. There are many more potential problems from prolonged NIPPV than high flow.

 

[jdh71]

I share a lot of your beliefs, except the emphasized part. It's not easy to predict... if one doesn't keep watching them. That's not just the nurses' job. Doctors who follow their patients frequently enough to see the movie will understand them much better than those who just see rare photos. And if one's ICU job doesn't allow one to follow one's patients closely (I look at my sickest patients every hour or more frequently, even if just from the door, between notes), one should get a better job.

So, while initially it may not be easy to predict certain things, after watching the patient in dynamic one should be able to see a trend. As an anesthesiologist who's called to intubations, I would never fault an intensivist who watches his/her patients like a hawk for having a patient crash "unexpectedly". But, most of the time, one could have seen it coming, IF watching the movie.

Even patients slowly trending the wrong direction don’t necessarily require a vent. There are a lot of variables. It’s a case by case thing.

 

[SurfingDoctor]

Not quite the same... but timely none the less...

Nasal high-flow preoxygenation for endotracheal intubation in the critically ill patient: a randomized clinical trial - PubMed

Clinical trial Submission: 7 March 2016. Registry name: Benefits of high-flow nasal cannulae oxygen for preoxygenation during intubation in non-severely hypoxemic patients: the PROTRACH study. Clinicaltrials.gov identifier: NCT02700321. Eudra CT: 2015-A00145-44. CPP: 15/13-975 (Comité de...

www.ncbi.nlm.nih.gov

Of course, the caveat being that applying it for pre-oxygenation is probably applying it too late...

 

[Mad Jack]

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 =)

We had great results with high flow in certain patients. I mean, we literally had some that could tolerate nothing else- CPAP, BiPAP, nonrebreather, high flow mask, etc- that were DNI that survived care of high flow being tried as a last resort and working. It's not perfect, but it's a useful tool when applied correctly

 

[deleted547339]

Obviously, I was not talking about lung transplant patients and other rare birds. But people have a tendency to forget that HFNC is not "just" a NC, it's more like a NRB (at FiO2 over 60%), so one should treat it with the appropriate respect and expectations.

Also, nothing "unexpected" happens over 1-2 days. I may be biased because I come from a specialty whose motto is Vigilance, but, many times, the trend is there for anybody who's looking. The problem is that some people are not really looking, except briefly once or twice a day. Hence my above rant.

I am a huge fan of minimalism and avoiding iatrogenesis, by the way, but the one thing I dislike more than an unnecessary intubation is being called to intubate a patient who may crash during intubation (when that could have been avoided).

Yea, but you don’t get called for the 80-90% who look like death but turn around. You’re not aware of your selection bias because you see the crash tubes. If we called you 12 hours earlier, you’d be unnecessarily tubing patients more to the tune of an order of magnitude.

I’ve had awful pulmonary vasculitis patients who guppy breathed while waiting for pulse dose steroids and immunosuppression to work for a couple days. Same for BMT patients waiting for count recovery. A lot of the micu folks behave like this.

The problem is that a lot of stuff in academic Micus is the weird stuff. Yea, when you have a patient with respiratory failure post-cabg, you shouldn’t let them languish, same when you have a stroke patient who is slowly aspirating, or someone already hypoxic 24h into a bout of nec panc, or hypoxic with rib fractures with adequate analgesia, but you never know when exactly these MICU folks will turn the corner - and a lot of them would be significantly harmed by a tube - think BMT folks or old, wouldn’t want to live in an LTAC but would 100% get trached if you tube them.

I agree, the patients with a clear downward trajectory without a clearly fixable issue need the tube (if it’s appropriate), but HFNC is quite helpful when you just need time on a more nebulous patient.

Edited for typo.

 

[chocomorsel]

Unless you really need the positive pressure and in most cases of HFNC you don’t, then really there is not a need to strap a mask to a patients face indefinitely. I’d definitely intubate before duct taping the cpap to a patients face. There are many more potential problems from prolonged NIPPV than high flow.

Trialing that HFNC on a patient who was extubated yesterday and looks like crap today as far as increased WOB and tachypnea with PCO2 of 28. Let's see how long she lasts.
Read more about it, found a bunch of studies on babies, only one paper on adults, and gonna keep an open mind on this one and try something different.
We have been using it on a guy for days now whom we are spot diuresing and so far so good. But those are the ones I am familiar with it working well on.

 

[nimbus]

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.

Now that sugammadex is available, you really aren’t stepping into no man’s land.

 

[jdh71]

Now that sugammadex is available, you really aren’t stepping into no man’s land.

Not as much. But in the physiological complicated airway you still definitely are.