Difficult Intubation In A Newborn

Difficult neonatal intubation can occur unexpectedly. We’re ready to perform neonatal resuscitation in the delivery room. We may be less ready to have to deal with a difficult neonatal airway at the same time. Recently I, and my colleagues, had to manage an unanticipated difficult neonatal intubation in labor and delivery.

The Case

The baby was born extremely edematous, and in respiratory distress. Although it was easy to ventilate the baby using the NeoPuff, airway swelling prevented the neonatologist  from identifying the epiglottis and vocal cords. The anatomy was too distorted. Following protocol when faced with a difficult intubation, the neonatologist called a “Code White”, an overhead page that in my hospital summons help from anesthesia, nursing, respiratory care and pharmacy to assist with either a emergency pediatric cardiac arrest or emergency intubation.

As a responding anesthesiologist, I too was unable to see landmarks during laryngoscopy. Continue reading

Airway Emergency: Start With The Basics of Airway Management

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 emergency: the dreaded “can’t intubate-can’t ventilate” airway emergency 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. Continue reading

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

Needle cricothyrotomy or percutaneous 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, percutaneous transtracheal jet ventilation 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. Continue reading