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

Exhaling During Manual Ventilation Is As Important As Inhaling

Exhalation during manual ventilation is as important as inhalation. 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.

Illustration showing the parts of a bag-valve-mask device, using a self-filling bag as an example.

Common parts for bag-valve-mask devices, In this case a self-inflating style bag. The reservoir bag, when present, allows near 100% inspired oxygen if allowed to fill.

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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

Difference in Manual Ventilation: Self-Inflating Ventilation Bag vs. a Free Flow Inflating Bag

Manual ventilation 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 will discuss the differences in ventilation technique for self-inflating vs free-flow ventilation bags. Understanding those differences is important for successful manual ventilation of your patient. Continue reading

Alert: We May All Be Over-Inflating Our LMA Cuffs!

 

Since its invention, the Laryngeal Mask Airway, or LMA, has become quite valuable as a surgical airway alternative to intubation. When I first started in anesthesia, the only way to avoid intubation during surgery was to manually assist ventilation with a bag-valve-mask attachment. Cases that went on for hours often resulted in cramped fingers, and sometimes progressively poorer ventilation over time as the hand holding the mask became overly tired. A poor mask seal could potentially cause the stomach to distend with air, pushing up the diaphragms, limiting tidal volume, and increasing the risk of aspiration. The LMA has changed anesthesia so much that residents now find it challenging to find cases to practice their masking skills.

However, the 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. Continue reading

Mask Ventilation: Avoiding Hand Fatigue

Hand fatigue during mask ventilation can cause  loss of the ability to maintain a good mask seal. Those of us who mask ventilate patients have all been there. We’ve been mask 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.

As an anesthesia provider I often ventilate patients with bag-valve-mask devices. Of course we need to know how to manage the airway during emergency situations in the ICU or emergency room. When we administer general anesthesia, we mask ventilate both at the beginning and at the end of a case.

For some surgical procedures we may even allow the patient to breathe anesthetic gas spontaneously through a mask during the entire surgical procedure, requiring us to hold the airway open, assist ventilation as needed, and stay out of the surgeon’s way. Laryngeal mask airways are often used these days for such cases, but in the old days the choice was either mask ventilation or intubation.

With mask ventilation, it’s important to know how to open the 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. When I’m working with a new student, and when appropriate to the case, I often have them hold the mask during the entire anesthesia because it helps them improve their skills. So how do you effectively and efficiently ventilate while minimizing hand fatigue? Let’s look at the steps to follow. Continue reading

Potential Tongue Ischemia with LMA Supreme

When we place anything in the mouth, be it an endotracheal tube, oral airway or LMA, we are typically extremely careful to protect the teeth. We take care to avoid cutting the lips with the teeth. But we often take the safety of the tongue for granted. I recently recognized a potential problem while using an LMA supreme that could have caused tongue ischemia if not corrected. Let we show you what happened so you can be on guard with your own patients.  Continue reading

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. However, I often see that providers have more difficulty trying to assist ventilation of a patient who is still breathing spontaneously.

The typical inexperienced provider will try to provide large, slow breaths just as they were taught in ACLS. Unfortunately these breaths are often out of synch with the patient’s own breathing. Squeezing the bag while the patient is exhaling means that your inflation pressure must not only overcome the diaphragm, but also reverse the passive outflow of air, the elastic recoil of the lungs, and the rebound of the chest wall combined. The vocal cords may be closed. Ventilating out of synch with the patient won’t be as effective. The breath you deliver will take the path of least resistance to enter the stomach or escape from the mask. It often makes the patient cough.

Even worse,  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. Let’s see why. Continue reading

LMA Supreme: Great Invention But Insert It Gently

I really like the LMA Supreme, which is a next generation LMA, or laryngeal mask airway. 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. However, if you’re a fan of using alternative placement techniques for inserting the the Unique LMA, or its reusable version the Classic LMA, it can be a little challenging to use. Also, if you aren’t careful you can give your patient a nasty cut on the lip during insertion. How does the Supreme differ from the Unique? Continue reading