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 …
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 …
One of my readers recently asked a very important question about ventilating a patient with a bag-valve-mask device: “Is there an outlet for the expired air of the patient?” The answer is yes. When ventilating a patient we are concentrating, and rightfully so, on watching the lungs expand and verifying that we hear breath sounds. It is just as important to verify that your patient can exhale. All ventilation devices have a built in pressure relief valve, also called a pop-off valve, which allows you to balance the force needed to expand the lungs with the ability to the patient to passively exhale. Failure to allow exhalation can lead to patient injury from barotrauma. Read More …
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 …
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 …
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 …
Ventilating with a bag-valve-mask device requires a good mask seal against the face in order to generate the pressure to inflate the lungs. But it also requires knowledge of how to effectively use the ventilation device to deliver a breath. This article discusses the difference in the use of a self-filling ventilation bag and a free-flow ventilation bag. Read More …
Fall is the time of year when new students commonly begin to learn how to intubate. My first intubation was one of the first times I literally held someone’s life in my hands. I was nervous. The anesthesiologist teaching me tried to not look too anxious as I awkwardly grabbed my laryngoscope blade, fumbled while opening the patient’s mouth, and cautiously maneuvered the endotracheal tube into the trachea. It felt like time stopped until the tube was in place, after which the three of us (me, my teacher and my patient) all took a deep breath. Since then, over the last almost 37 years, I’ve intubated thousands of people in the U.S. and, as an international volunteer, eight countries.
So I thought it would be helpful at this time of year to discuss a step-by-step approach to intubation with the commonly used curved blade. Intubation, like a dance, is composed to steps that flow naturally from one to the next. The trick to a smooth intubation is to allow each step to blend seamlessly together. The description and illustrations below are excerpted from my book Anyone Can Intubate, where you can find more detail about this and many other topics. Read More …
The laryngeal mask airway, or LMA, is so commonly used, and so apparently safe, that it’s easy to become complacent. Research is showing that it’s apparently very common for us to over-inflate our LMA cuffs — to the potential harm of our patients. This article discusses some of the risks of overinflation, the predispositions to overinflation, and some of the strategies to avoid it. Read More …
Those of us who ventilate patients have all been there. We’ve been ventilating a patient with a bag-valve-mask device during a prolonged and difficult intubation process and our hand holding the mask starts to cramp. When ventilating a patient with a mask, it’s important to know how to open and airway and provide positive pressure breaths. However, it’s also important to know how to do so in a way that conserves your grip strength. Ventilating with a mask can be very tiring to your hand. Prolonged “masking” can tire your hand to the extent that you lose grip strength and coordination — making maintenance of an open airway harder to sustain over time.
Here we discuss tips on how to ventilate effectively while avoiding hand fatigue. Read More …
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.
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 …
I often find that my students sometimes confuse oxygenation and ventilation as the same process. In reality they are really very different. Ventilation exchanges air between the lungs and the atmosphere so that oxygen can be absorbed and carbon dioxide can be eliminated. Oxygenation is simply the addition of oxygen to the body.Why do we need to understand this? Let’s look at some common examples. Along the way we will painlessly use the Alveolar Gas Equation to explain two common scenarios:
how hypoventilation causes hypoxia,
why abruptly taking all supplemental oxygen away from a carbon dioxide retainer will hurt them. Read More …
I saw a potential aspiration hazard in the OR today. How many times a day do we routinely peel plastic wrappers off of airway equipment? If I’m at the surgicenter, I might need 7 face masks, a variety of LMAs and endotracheal tubes and an oral airway or two. Take a look Read More …
Ease of insertion, presence of a gastric port, and the option for using higher ventilatory pressures make the LMA Supreme more versatile and applicable for use in higher risk patients. This article will discuss the differences between the LMA Supreme and The Classic LMA, detail how to insert the Supreme to optimize positioning in the oropharynx and provide guidance on how to avoid patient injury. Read More …
The rare “can’t intubate-can’t ventilate” scenario is frightening. It’s important to master as many techniques as possible to prepare for this possibility. The LMA Fastrach is designed specifically designed to ventilate a patient intermittently during a prolonged intubation attempt. Knowing how to use this tool could potentially save a patient’s life. Using the Fastrach is not difficult. However, there are enough steps during intubation, as well as during safe removal of the device without accidental extubation, that can make it seem intimidating. In addition to some tips and tricks that make it work, you’ll find a link below to a video clip of intubating a patient with the Fastrach. Read More …
A good anesthesiologist, or any health care provider, has to embrace the catastrophist within because our goal is to protect our patients from the unexpected. We have to constantly imagine the worst-case scenario so that if, or when, it happens we not only recognize it early, we’re ready for it. What we’re often not good at is protecting ourselves at work. We tend to be so patient focused that we often don’t even think about personal hazards. This article discusses some of the risks we face during airway management of the infectious patient. Read More …
Airway obstruction, one of the most serious and potentially life-threatening problems a patient can have, can occur in any patient given the right combination of mental and physical conditions. Respiratory insufficiency and failure from both upper or lower airway obstruction share many of the same symptoms and signs. Being able to recognize the signs of airway obstruction may save your patient’s life. Read More …
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 …
Airway obstruction can occur following uneventful thyroglossal duct excision because of removal of the hyoid bone. This article describes reasons why the anatomical change can cause obstruction and discusses a case where such airway obstruction needed treatment in the immediate postoperative period. Read More …