During intubation, any liquid in the mouth that obscures the view of larynx not only hinders visualization, it risks aspiration. We’re used to being able to rapidly suction the mouth clear or secretions, blood, or vomit and then have a clear view of the larynx. But sometimes, either because of continued profuse bleeding or massive emesis, fluid continues to accumulate while we’re watching. How can you manage this situation and successfully intubate?
The year was 1982. The patient was an 18 year old girl on the liver transplant list. She had end stage cirrhosis due to what at the time was called “non A- non B” hepatitis. She had been admitted to the ICU that day to be worked up for a stable upper GI bleed. The most likely etiology was her esophageal varices: superficial esophageal veins that have become abnormally distended due to portal hypertension in end stage liver disease. So far she had been rock stable — that was about to change.
When I, the ICU fellow, reached the bedside, the patient was coughing and sputtering blood onto the bed sheets and there was blood everywhere. Her varices were bleeding profusely and she was going to drown in her own blood if we didn’t intubate her now. Her blood pressure was 80/50 and her pulse was 150.
I ordered the crash cart and asked for blood to be brought from the blood bank while we were giving her a bolus of crystalloid. We kept her on her side, in trendelenburg position until the last possible moment to allow the blood to drain out of her mouth. Once ready, I administered an induction dose of ketamine and succinylcholine. Ketamine would help to maintain her blood pressure.
As the drugs took effect we laid her flat, still in steep trendelenburg. This position usually lets the blood pool up and away from the larynx allowing the intubator to see the landmarks. All I could see was a puddle of blood welling up. Sucking the blood through the yankauer catheter could not clear the mouth fast enough to keep it clear. Intubation was impossible under these conditions; something needed to be changed, quickly.
We turned her onto her left side and placed the open end of the suction tubing itself into her mouth to allow it to suction continuously. The side position allowed the blood to drain out as fast as it entered her mouth and let the tongue fall to the left, where I wanted it to go anyway. I was able to intubate her.
After resuscitation with 9 units of blood, 4 units of FFP and a 6 pack of platelets plus about 5 liters of normal saline, the bleeding slowly stopped and we stabilized her. She eventually went on to successful transplant.
Afterward, I and the entire team went down to employee health for gamma globulin shots because we were covered in her blood and thus exposed to non-A, non-B virus.
As I ran into the ICU to intubate during a cardiac arrest resuscitation effort, I knew immediately that this was not going to be easy. The nurses at the head of the bed were suctioning huge volumes of emesis out of the patient’s mouth. The patient was flat on her back and no one at the time was ventilating because they were afraid to stop suctioning to apply the mask.
I took a quick look with my laryngoscope but could see nothing but emesis.
Normally I would turn the patient left side down to let the emesis drain out and intubate with the patient on her side. However, I couldn’t turn the patient lateral without stopping chest compressions. I quickly put the bed into steep trendelenburg to get the emesis to puddle up and away from the airway as best I could. I then placed the bare suction tubing into the back of the throat where it could suck emesis as soon as it appeared. I turned the patient’s face as far to the left as possible to let things drain.
I gave the patient several breaths with the ventilation bag, satisfied that the liquid was being removed and that little was going down the trachea. These days I often bring the glidescope with me when I go to an airway emergency because you never know if the patient you’ve been called to help has a difficult airway, or is in a difficult position, such as on the floor. With an emergency intubation, minimizing repeated intubation attempts and rapidly establishing an airway can prevent further loss of patient stability.
With the patient still in steep trendelenberg and with my helper holding the suction catheter, ready to move it or remove it if I needed them to, I quickly used the glidescope to intubate.
We could now ventilate the patient. The hospitalist was ultimately able to establish a rhythm and eventually stabilized the patient.
Managing Blood or Other Secretions In the Airway
Active bleeding in the airway makes intubation very challenging: airway bleeding, in both the acute trauma and postoperative settings, means that the anatomy may be altered and landmarks difficult to identify; hemodynamic instability makes choice of sedative/hypnotic agents and muscle relaxants problematic; and usually, the patient has a stomach full of blood ready to aspirate.
In addition, the patient is at risk of aspiration. Hypoxia and even asphyxiation is possible if the airways are filled with blood and not oxygen. There is risk of inducing shock with induction agents. Finally, the providers are going to be exposed to the risk of any blood born pathogens.
Know how to deal with this dangerous and demanding situation.
- Consider awake intubation, although that may not be an option. That wasn’t possible in either of the above cases. Also, fiberoptic bronchoscopy with massive fluid in the airway is extremely challenging. However, I have performed awake direct laryngoscopy in a patient in shock.
- Always pre-oxygenate when you can, especially if you’re patient is awake. Your patient will b better able to tolerate longer periods of apnea.
- You will need helpers, but they need you to direct their efforts to assist you. Think out loud, don’t make them guess your next move or possibly get in your way! Tell your helpers what you plan to do, what you’re worried about, what you need them to do, and when you need them to do it.
- Place a helper, each with a suction, on either side of the patient .
- They need to suction while you are intubating but they also need to avoid hitting your hand or obstructing your view.
- Consider placing a orogastric or nasogastric tube before you start and suction it completely if possible
- Consider placing the bed in steep trendelenburg — this will not interfere with chest compressions if in progress
- On the positive side, Trendelenburg allows fluid to puddle and drain away from the airway.
- On the negative side, Trendelenburg decreases functional residual capacity (the patient’s reserve “oxygen tank”) thereby decreasing how long they can hold their breath. It also shifts the larynx and tongue upward, which may potentially make intubation a bit more challenging.
- Turn the patient onto the side if you can — left side is optimal since the tongue will shift out of the way of your laryngoscope blade. If you can’t, sometimes turning the face to the left side allows sufficient liquid to drain.
- SUCTION IS KEY! You must ensure adequate suction. This may mean using unguarded suction tubing. If so, make sure your assistant keeps it open as it will tend to suck up against the tongue and obstruct
- Choose your induction medications wisely. Inducing shock is a real potential risk.
- Be prepared for emergent cricothyrotomy.
- Have the equipment and your helper ready to go.
- Know when to stop intubation attempts. Failure to promptly recognize the failed airway leads to disaster!
- Consider using your video laryngoscope if you have one, however be aware that the camera lens can be easily blocked by secretions. Direct laryngoscopy is often the best method
- Protect yourself and your crew! Don protective gowns, wear a mask and eye protection. Wash well afterward and consider changing if your clothes are soiled.
What about an LMA?
Could you use an LMA in a can’t-intubate-can’t-ventilate scenario with massive amounts of blood or emesis in the airway? Its definitely not optimal because of the aspiration risk and it depends on the source of bleeding.
- If you’re dealing with a massive nose bleed, an LMA, especially if it’s an LMA with a gastric suction port like the LMA Supreme, could be used to protect the airway. In this case the blood is not within the channel of the LMA so ventilation is possible and you can suction the stomach through the gastric port.
- If the bleeding is pulmonary, obviously the blood is coming from a source inside the LMA and an LMA would not be protective.
- With bleeding gastric varices or massive emesis you could argue that placing a device like the LMA Supreme would allow you to vent the liquid away from the airway, allowing you to ventilate with some protection and perhaps even use the LMA’s channel to intubate.
Cricothyrotomy would be the more optimal way to proceed in the can’t intubate can’t ventilate scenario with massive airway hemorrhage as it definitively protects the airway. However, cricothyrotomy may or may not be an option depending on the equipment available and the skill set of the providers involved. If the choice is ventilation with a continued risk of aspiration vs. not ventilating at all, then by all means try an LMA.
Patients in shock frequently vomit, sometimes profusely. Trauma, nose bleeds, or esophageal varices can produce massive bleeding in the oropharynx. You need to be prepared at all times to deal with liquid in the airway.