How To Open The Airway

How to open the airway is an essential skill that every health provider should know. Of all the airway skills, it’s the easiest to master and the most likely to save lives in respiratory distress and failure. This article details recognizing airway obstruction, techniques to open the airway, and insertion of Read More …

Preventing Airway Emergencies

I’m in Egypt at the 35th International Conference Egyptian Anesthesia 2019. I was given the great honor of presenting my article on the 10 Rules For Approaching Difficult Intubation: Always Prepare For Failure. Preparation, Decision Making, Teamwork and Communication are key to preventing airway emergencies. Read More …

PostObstructive Pulmonary Edema

Patients with postobstructive pulmonary edema (or P.O.P.E.) develop sudden, unexpected and potentially life-threatening pulmonary edema after relief of airway obstruction.  It can be mild or severe. My first experience with it was in 1983. The Case In 1983, we didn’t have pulse oximetry, end-tidal carbon dioxide monitoring or even automated Read More …

Difficult Intubation In A Newborn

The unanticipated difficult neonatal intubation in L&D greatly complicates neonatal resuscitation. This discussion highlights the approach to difficult ventilation & intubation in the newborn. #FOAMED Read More …

Intubation During Cardiac Resuscitation

Intubating patients during cardiac resuscitation is often challenging because of the circumstances surrounding the intubation. Excitement and apprehension accompany this life saving effort. In addition, The patient is often in a less than optimal position while chest compressions are in progress. You usually find the patient in one of two awkward positions: on the ground or in a bed. This article discusses techniques to better manage intubation during cardiac resuscitation, especially with the patient in an awkward position. Read More …

Not All Airway Emergencies Need Intubation

An emergency department physician I met the other day shared with me an experience from her hospital  that offers a good example of the fact that there are many different ways of managing an airway emergency in a child that don’t involve intubation. Medical management can sometimes avoid some of the risks of losing the airway that intubation might impose. Read More …

Remember That Respiratory Failure Is Not Always Due to Lung Failure

While assisting ventilation and protecting the airway are first priorities to stabilize a patient, treating the cause of the respiratory failure may require more than just ventilation and/or intubation. In fact, treating the cause can sometimes help you avoid the progression of respiratory distress to respiratory failure. If you don’t consider a potential problem or cause, you’re not going to be able to diagnosis it. This is a case of respiratory failure caused by hypovolemic shock and hypoglycemia in a child. Read More …

Communication In A Crisis: A Case of Respiratory Depression In A Child:

When I’m teaching airway management to my Perioperative/OR nurses, I often recount the story of management of a young child’s postoperative respiratory depression. In addition to illustrating the importance of evaluating ventilation in addition to oxygenation, this case shows how good communication makes management of a critical event more effective. Read More …

Airway Emergency: Start With The Basics of Airway Management

A case of “can’t intubate- can’t ventilate is discussed which illustrates the importance of always using good techniques of basic airway management. Read More …

Intubation With Airway Bleeding and Massive Emesis

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? This article discusses two prior cases and offers suggestions on intubation when massive emesis or blood interfere with visualization. Read More …

Anticipated Difficult Intubation: Should I Intubate The Patient Awake?

When facing any intubation, you must decide whether the intubation is safer to be performed asleep or awake. Many providers are uncomfortable with performing awake intubations and leave it as a last resort. There are a variety of reasons for this discomfort, including lack of experience and/or the fear that the patient will remember the intubation and think poorly of their care. However, awake intubation can be a safe and comfortable strategy in many clinical situations. This article discusses some of the criteria for deciding when to do an awake intubation. Read More …

Apneic Oxygenation: Increase Your Patient’s Margin Of Safety During Intubation

Breathing room air, oxygen saturation drops precipitously to below 90% within about a minute of the start of apnea in the average healthy adult. While preoxygenation is one of the most important safety measures we can use prior to induction of anesthesia and in preparation for intubation, apneic oxygenation can allow even more time for intubation to occur. Apneic oxygenation using nasal cannula can significantly delay the onset of critical hypoxia.

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Assisting Ventilation With Bag-Valve-Mask

As an anesthesiologist, I often run to emergencies where the patient is not breathing adequately and requires intubation. However, before any intubation, a patient in respiratory distress/failure needs ventilation. Providers who have passed ACLS are often able to ventilate an apneic patient well because they have practiced on the manikin.

Providers who infrequently need to ventilate an apneic patient will have more difficulty assisting the ventilation of a patient who is still breathing spontaneously. In addition, providers will occasionally hesitate to try to assist a patient’s breathing while waiting for the intubation team because they feel they don’t know how. Delay in improving ventilation can place your patient at higher risk of complication. This is unfortunate because in many ways assisting ventilation is even easier than manually ventilating an apneic patient. This article reviews the mechanic of breathing to show how to assist ventilation. Read More …

Don’t Be Afraid To Use Percutaneous Jet Ventilation In An Emergency

Needle cricothyrotomy or percutaneous transtracheal jet ventilation (PCJV) can truly be a life saving procedure. It is a fast, effective way of providing oxygen to a patient with an obstructed airway who does not respond to more conventional means of opening the airway. The “can’t intubate-can’t ventilate” scenario is a good example. PCJV is faster to perform than a surgical airway. It will buy you time to establish a more permanent airway such as an intubation or surgical airway if the patient is hypoxic.

However, PCJV carries some rare though potentially serious risks of worsening airway obstruction and cardiovascular collapse if the catheter is not correctly positioned within the trachea. Fear may prevent us from using it. In addition, most of us have never had to use PCJV in an emergency or even seen it used. Lack of familiarity with the equipment and simple lack of comfort may make us hesitate to try. We may not even think about it in the moment of crisis. So let’s look at some of the ways we can use PCJV safely. Read More …

Laryngospasm is a Life-Threatening Emergency

One of the more frightening events in anesthesia is laryngospasm: the protective, reflex, spasmodic closure of the vocal cords that occurs when the vocal cords are stimulated. This article discusses the mechanism of laryngospasm, and how to treat it. Read More …