We have just finished another round of Critical Event Training for my hospital’s Anesthesia and OR staff. One of the scenarios we ran was how to manage a failed airway: the dreaded “can’t intubate-can’t ventilate” scenario.
As an instructor, it’s important for me to set the stage realistically. The more real the scenario, the more the providers will learn and be able to apply the information should they ever find themselves in a comparable situation. I must observe as the trainees respond to the emergency, and then help the trainees self-analyze what went well — or not so well — during the scenario. Of course, discussion of how things went during a training scenario always leads to sharing of examples from past real life scenarios. And after 37 years of practice I’ve had a lot of sharable experiences.
One past case we discussed is particularly appropriate for those students around the country who are just beginning to learn airway management because the solution rested in basic airway management techniques. This case, involving an intubation in an ICU patient that turned into a “can’t intubate/can’t ventilate” emergency demonstrates how returning to the basics of airway management can sometimes be the way to save your patient from harm. All illustrations from Anyone Can Intubate 5th Edition.
The patient was a 50 yo, 5’ 10”, 110 kg male suffering from respiratory failure from sepsis. The intensivist was preparing to intubate and had asked me, as the anesthesiologist on the code team that day, to come over to the ICU to provide an extra pair of hands in case the intubation proved difficult. However, as I entered the ICU it was clear that the situation had clearly changed for the worse. The intensivist had tried and failed the intubation and had then been unable to ventilate. He was just setting up for an emergent cricothyrotomy. The oxygen saturation was 50. A nurse was unsuccessfully attempting to ventilate the unresponsive patient.
I had brought a glidescope with me and I rushed to the head of the bed, intending to attempt another intubation to establish an airway. However, the first thing I saw was that the nurse, in her anxiety, was pushing the face mask down over the face and in the process, forcing the chin down over the neck. The whole head was bent steeply downward.
I quickly took over the airway, tilted the head back into the sniffing position and inserted an oral airway. I grabbed both jaw angles and pulled upward. The patient had a large round face and a thick neck which made keeping the mask seal challenging with one hand. I instead made the seal with both hands and asked the nurse to squeeze the bag. We were immediately able to ventilate and the saturation rose over the next minute into the mid 90s. Everyone in the room took a deep breath. I was then able to intubate using the Glidescope. Disaster was averted.
In this particular airway emergency, the lesson learned was to always start with the basics of airway management. Links are provided below to previous blog articles with greater detail on each topic. I recommend reading to the end for the big picture and then returning to the links for more in depth discussions.
Don’t Be Afraid To Ask For Help
Our intensivist called for assistance early. Rarely will you be in a situation where you are the only person trained in intubation. Never hesitate to ask for help. That help can be getting equipment ready, aid in holding the head or neck in position, or asking someone else to intubate.
The faster that help can arrive, the better off you (and your patient) are. Ask early and apologize later if you don’t need the help. If I’m anticipating a potentially difficult intubation I will often ask a colleague to stand by as an extra pair of hands. I also make sure I have back up equipment like bougies, supraglottic airways, and videolaryngoscopy.
A common error if you’re having trouble intubating is to keep trying the same thing over and over again. Change your blade from a curved MAC to a straight Miller blade or the reverse. Alter the patient’s head position, try cricoid pressure, have someone else try. Sometimes it’s your technique that’s making the intubation difficult.
Bear in mind, however, that the more laryngoscopies you perform, the more likelihood there is of increasing laryngeal edema or bleeding. This can worsen the airway and ultimately make ventilation difficult. Unless you quickly see evidence of impending success, it’s often better to switch to an alternative method of intubation like videolaryngoscopy when you can.
Of course, if the intubation is elective, such as for elective surgery, then you can always abort the intubation attempt and awaken the patient to perform an awake intubation.
This is a true emergency. Without the ability to ventilate, you have only minutes until life-threatening complications occur, including brain damage and death. You must always be prepared for loss of the airway because it can occur unexpectantly.
First, Open the Airway
The most common cause of airway obstruction is the collapse of tongue and soft tissue at the back of the throat over the larynx. Tilting the head and pulling the jaw upward lifts this tissue off the larynx and opens the airway.
Use the head tilt, chin lift maneuver or the triple airway maneuver. Even if you’re using cervical spine precautions (and keeping the head in a neutral position with the neck) you should still pull the jaw upward.These maneuvers lift the tongue, epiglottis and soft tissue upward and off the glottic opening.
Insert An Oral or Nasal Airway
Insert an nasal or an oral airway to treat airway obstruction. Nasal airways are better tolerated by semi-conscious patients. Oral airways are often used in unconscious patients to avoid the potential risk of nose bleed.
Oral and nasal airways are not mutually exclusive. If I’m having a really hard time ventilating a patient I will insert both an oral and a nasal airway. They work by different mechanisms and their function ca be additive. If the patient regains consciousness, and a gag reflex, to the extent that they are no longer tolerating the oral airway then you may have to remove it. Having a nasal airway in place helps maintain an airway that may still be somewhat precarious.
Pull The Face Into The Mask,
Never Push The Mask Onto The Face
A big mistake with ventilation is trying to seal the mask by pushing the mask down onto the face, as in this case. This maneuver invariably forces the chin downward, piling the soft tissue around the back of the tongue over the larynx and worsening airway obstruction.
To ventilate, start with a good mask seal. Always pull the face up into the mask by grasping the mandibular bone (not the soft tissue) and lifting the face into the mask to produce the seal. The face becomes sandwiched between your fingers pulling up and your thumb and forefinger sealing the mask against the face.
Note the positions of the fingers. Thumb and forefinger press mask against the face and form a “C” shape. Remaining fingers grip mandible and form an “E”. You are literally pulling the face into the face with your fingers while your thumb is applying counter pressure. This push pull action also holds the head in extension and holds the airway open.
Use Two Person Ventilation When It’s Hard To Ventilate
Use good ventilation technique, based on your knowledge of basic physiology, to ventilate effectively, as previously discussed in this blog article.
If difficulty persists, use both your hands to seal the mask. Have a helper squeeze the bag for you. Place thumbs on top of the mask, index fingers on the bottom, bunching the soft tissue of the cheeks under the mask. Pull the jaw upward with your remaining fingers by spreading them along the jaw line, underneath the angle of the mandible. Pull up forcefully, squeezing the patient’s face between the mask and your hands. Hold just the bone. Pushing on the soft tissue under the jaw can force it into the airway and worsen obstruction.
Use of both hands makes it easier to shift the mandible forward and pull the obstructing tissue up and off the larynx. Move your fingers as needed to perfect your seal. You may still sometimes need a helper to stop leaks
When someone else is squeezing the bag, it’s especially important to verify adequate ventilation — since you can no longer feel the compliance of the bag yourself. Watch the chest rise, see the air condense on the mask (if mask is clear plastic), and have someone listen for breath sounds. Make sure your helper communicates any signs of obstruction or lack of seal immediately. This technique is a team effort.
Follow this link to a video on how to open an airway, insert an oral or nasal airway and apply a mask to ventilate. Ventilation using both one hand and two hands with an assistant is also demonstrated.
If the goal is urgent ventilation, remember that intubation is only one way to ventilate. Consider changing to an alternate method of ventilation, such as use of a supraglottic airway like the Laryngeal Mask Airway . If you can ventilate though an LMA you will have time to consider what further steps need to be taken to secure the airway.
In you still can’t ventilate, you must consider surgical options such as a jet ventilator or cricothyrotomy to quickly reestablish oxygenation. The intensivist was just beginning this step when I arrived on the scene.
In the stress and chaos of an emergency, it’s a common human failing that the brain can freeze in unfamiliar circumstances. Forgetting key steps and even techniques is common. That’s one of the main reasons why we perform Critical Event Training. It’s also the reason we all have to rectify with ACLS, PALS, BLS every 2 years. It’s easy to forget the basics if you don’t use them all the time.
The more familiar we are with a scenario, the more likely we will immediately perform the steps that are needed to resolve it, especially if those crises are rare in real life. In addition, Crisis Check Lists are increasingly being used to specifically help ensure that providers use all possible options during rare critical events such as cardiac arrests, pulmonary emboli, dysrhythmias, hypoxia, and others. If your hospital doesn’t have Crisis checklists consider obtaining them. One such aide can be downloaded here.
Teamwork is also extremely important. Your team members must feel comfortable with making suggestions, pointing out potential problems, and keeping each other informed on what steps have been taken and which are needed. The value of treating patients as a team is that you can leverage the power of multiple brains in the room to solve the problem. You are much more powerful and likely to succeed as a group rather than trying to act alone.
Frequent practice, learning about how to treat those rare emergencies, and improving your ability to function as a team is important before you actually find yourself in a critical event.
May The Force Be With You
Christine Whitten MD
Author, Anyone Can Intubate 5th Edition.