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.

Continue reading

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

When I’m teaching communication in a crisis to my Perioperative/OR nurses, I often recount the story of what happened during one particular child’s recovery years ago. This case, involving a 2 year old child who developed respiratory depression in the recovery room, demonstrates how good communication in a crisis, including the ability to challenge an authority figure, can improve patient safety and allow collaborative teamwork in a crisis management situation. 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

Close Call In Honduras With A Nosebleed

I recently visited Honduras with a Head and Neck surgical team where we had a close call with a potential airway obstruction due to a blood clot. The case illustrates how a provider should never make assumptions, because if those assumptions are wrong, you can endanger your patient.

After a long day in the OR, while we were packing up to leave, a nurse from the ward ran in and said that one of the patient’s who had had a septoplasty that day for chronic sinusitis was bleeding. I immediately started setting up the OR again while our surgeon went over to the ward. Continue reading

Finding PEEP In a Bottle (of Water): Thinking Outside The Box

As you read this I am flying to Honduras with International Relief Team on a head and neck surgery medical mission. I will attempt to post mission updates from the hospital compound, pending internet connections. Participating in a medical mission to the developing world is never easy.

Medical personnel trained in a high tech environment take for granted the complex monitoring devices, multiple choices of drugs, and plentiful support peronnel which simplify our job. When medical volunteers travel to the developing world they are often unprepared for the potential hazards produced by outdated technology, unfamiliar and sometimes poorly maintained equipment, poor sanitation, limited supplies, and a malnourished, often poorly educated population.

Let me give you an example of one rather exciting case from early in my volunteer experience. Continue reading

MacGyvering In Anesthesia

I used to love the old TV show MacGyver, which featured an inventive hero who frequently had to improvise some clever device from ordinary objects in order to beat insurmountable odds and save the day.  The concept was so popular that the word MacGyver became a verb. Oxford Dictionaries state that to “MacGyver” is to make or repair something “in an improvised or inventive way, making use of whatever items are at hand”.

As I have traveled the developing world on medical missions I have often had to reinvent ways to do the things I take for granted in my sophisticated operating room, such as reassembling an anesthesia machine that fell apart right after intubation (see this story here) or improvising PEEP from some suction tubing and a bottle of water. (see that story here)

But being able to improvise is just as important in the settings of the more modern hospital. Continue reading

Hair Style Can Impact Intubation

Healing Little Heroes director dressed as Darth Vader at Ronald McDonald House, San Diego

Our Healing Little HeroesFoundation  founder dressed as Darth Vader at Ronald McDonald House, San Diego

Last weekend I spent time with the charity group Healing Little Heroes at the San Diego Rady’s Children’s Hospital, and Ronald McDonald House. The mission of Healing Little Heroes Foundation is to help pediatric patients in hospitals and outpatient settings to heal emotionally and mentally by appearing as Superheroes. My good friend, and general surgeon, Justin Wu, dressed below as Darth Vader, set up the Foundation.

On this day we arrived in full Star Wars costumes to entertain the kids and their families. I’m dressed as Queen Amidala. Which brings me to the topic of today’s conversation. Can hairstyle impact your intubation or even your anesthetic management? The answer is yes. There is no question that if Queen Amidala needed emergency intubation, that her hairstyle would get in the way. Continue reading

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 airway bleeding or massive emesis, fluid continues to accumulate while we’re watching. How can you manage this situation and successfully intubate? Here I describe two cases, one involving blood and the other massive emesis, that required intubation through a large puddle of fluid. I offer tips and tricks to assist you in your future emergency management. Continue reading

Avoiding Pediatric Drug Errors

Pediatric drug errors are unfortunately common. The literature states that medication errors occur in 5% to 27% of all pediatric medication orders, a very sobering number. Considering that many of these errors occur in the smallest, and therefore most vulnerable, of our little patients, the potential impact is especially great.

For the last 3 months, I’ve been teaching critical event training classes for our OR and Perioperative RNs, Anesthesia MDs and CRNAs, and OR techs in preparation for opening our new hospital in San Diego. Several of the scenarios involved pediatric cases. As part of that process, I’ve been reviewing with my providers ways to avoid the potentially deadly problem of pediatric drug dosing errors as well as ways to avoid them. Let’s discuss some of the ways to make pediatric medication administration safer. 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

Ventilation Perfusion Mismatch

Alveolar gas exchange depends not only on ventilation of the alveoli but also on circulation of blood through the alveolar capillaries. In other words it depends both on ventilation and perfusion. This makes sense. You need both oxygen in the alveoli, and adequate blood flow past alveoli to pick up oxygen, other wise oxygen cannot be delivered. When the proper balance is lost between ventilated alveoli and good blood flow through the lungs, ventilation perfusion mismatch is said to exist.

The ventilation/perfusion ratio is often abbreviated V/Q. V/Q mismatch is common and often effects our patient’s ventilation and oxygenation. There are 2 types of mismatch: dead space and shunt.

Imbalance between perfusion and ventilation is called ventilation perfusion mismatch. This illustration compares shunt, the perfusion of poorly ventilated alveoli; and Physiologic dead space: the ventilation of poor perfused alveoli.

Shunt is perfusion of poorly ventilated alveoli. Physiologic dead space is ventilation of poor perfused alveoli.

This article will describe how dead space is different from shunt. It will help you understand how you can use these concepts to care for your patient. Continue reading

Intubation With A Curved Blade

Direct laryngoscopy depends on being able to bring the 3 axes of the airway into alignment to see the larynx. Curved blades are commonly used, especially by beginners because they are more forgiving of less than optimal placement and provide more room to pass the tube. However, it’s important to use them correctly. This article will discuss intubation technique using a curved blade. Straight and curved blades use different techniques for bringing the larynx into view. For a discussion of how to use a straight blade click here. Continue reading

Help! My Anesthesia Machine’s Not Working!

There is nothing quite as scary as being in the middle of administering an anesthetic and having your anesthesia machine fail. In my 36 years of anesthesia practice I’ve had this happen to me a few times. Knowing how to quickly troubleshoot your machine, and knowing how to protect your patient are important, potentially life-saving skills. It helps to have thought through the steps to rescue the situation before it happens to you.

Here I describe how I learned this lesson the hard way on a volunteer medical mission to rural Honduras. When my machine failed, I was poorly prepared and this forced crisis management that I could easily have avoided with a little forethought and preparation.
Continue reading

Codeine Risk In Children, Especially Those With Sleep Apnea

Although the initial FDA warnings about potentially fatal overdose from codeine in children were released in 2012, I’m recently discovered that a few of my surgeon and nursing colleagues were still unaware of the potential risks. Therefore I thought it might be helpful to bring up the topic so people can remind their own colleagues of the risks of codeine in children.

Codeine must be used with extreme caution, if at all, in young children or pregnant women because of variants in the enzymes some patient’s use to metabolize the drug. Continue reading

Intubation: Step By Step

Learning intubation technique can be challenging. 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 of steps that flow naturally from one to the next. The trick to a smooth intubation is to allow each step to blend seamlessly into the next. The text and illustrations below are excerpted from my book Anyone Can Intubate, as well as from my upcoming book on pediatric intubation, which I’m busy writing. Continue reading

Tips To Teaching Intubation

To teach intubation skills on living patients, even those that have practiced on a manikin, can be challenging. With fall comes the new crop of trainees eager to learn how to intubate. There will also be a new group of instructors teaching their first students to intubate. It’s important to anticipate the common errors so we can safeguard our patients. Here I describe the all of the barriers, physical as well as psychological, that interfere with your student’s learning of the intubation technique. I offer tips on how to help your student conquer those barriers, while keeping your patient safe. Continue reading

Anticipated Difficult Intubation: Should I Intubate The Patient Awake?

When I was training, awake intubation for anticipated difficult airway was routine. Blind nasal intubation and fiberoptic intubation were common events. The advent of video laryngospcopy  has made the need for awake intubation much less common. Instruments like the Glidescope and the McGrath video laryngoscope have revolutionized intubation, and made the difficult intubation scenario fortunately much more uncommon.

However, awake intubation with the patient breathing spontaneously is still sometimes optimal for patient safety.  Awake intubation can be performed using standard laryngoscopy techniques, but it is more commonly done using specialty intubation techniques such as blind nasal or fiberoptic intubation.

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 and all providers should develop expertise with one or more techniques of choice — before an emergency forces them to use one.

This article will discuss how to decide when to do an awake intubation. Future articles will discuss how to do them. Continue reading

Can Changing Our Anesthesia Practice Help Save The Polar Bears?

I recently had the incredible opportunity to visit Svalbard, Norway, an archipelago above the Arctic Circle about 600 miles from the North Pole. We were lucky enough to see polar bears, including a rare sighting of a Mom with 3 cubs.

Mother polar bear with her 3 cubs, Svalbard, Norway

Mother polar bear with her 3 cubs, Svalbard, Norway

The landscape was breathtakingly beautiful. But underlying the minute to minute magic was the sober message that the climate was warming and the ice was melting.

photo showing recession of a glacier in Svalbard, Norway with Dr Whitten in the foreground.

Just five years ago, the glacier in the background extended to the point where Dr Whitten is standing in Svalbard.

We passed glacier after glacier that used to fill the fjords we were sailing through, but which now clung to the sides of the canyon walls. Our ship, the National Geographic Explorer, was able to circumnavigate the Svalbard archipelago, something that has rarely been done because the northern ice usually blocks the eastern islands. Those polar bears, and indeed our planet, are in trouble.

However, I came home comfortable in my own mind that I was already doing my part to decrease global warming: using LED light bulbs, solar power, hybrid car, turning off all electrical devices when not in use. Ironically, I soon discovered that the anesthetic gases I use every day are some of the most potent greenhouse gases on the planet.

When we administer anesthesia, we pay a great deal of attention to the concentration of nitrous oxide and halogenated agents such as sevoflurane or desflurane that our patient receives. We know that too much or too little of these gases can harm our patients. We are often less compulsive about avoiding exposure to ourselves, or even our Operating Room colleagues to waste anesthetic gases. Therefore, to remind everyone of best practices on how to protect ourselves from exposure, I’ve been part of a team collaborating with our Workplace Safety department to create a training video on how to minimize Waste Anesthesia Gas (WAG) exposure. 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

Avoiding Difficult Intubation Of The Easy Airway

It’s extremely easy to make any otherwise routine intubation difficult just by failing to properly position the patient or to use optimal technique. We’ve all done it. Let’s see how to avoid this pitfall. (All illustrations by Christine Whitten MD, Anyone Can Intubate). Continue reading