Presenter: Debbie Fretwell, MD, ResidentUniversity of California San Diego Authors: Debbie Fretwell, MD, Resident Dan Lee, MD, PhD (Faculty Mentor) Background The Difficult Airway and its... [ view full abstract ]
Presenter: Debbie Fretwell, MD, Resident
University of California San Diego
Authors: Debbie Fretwell, MD, Resident
Dan Lee, MD, PhD (Faculty Mentor)
Background
The Difficult Airway and its management remains challenging at times even for a well-trained and skilled anesthesiologist. First published in 1993, the ASA’s “Difficult Airway Algorithm” proposes interventions for unsuccessful intubation attempts. What about a successfully intubated patient who cannot be ventilated? Aside from a little known flow diagram published by Hosking et al in 1989 for forward military hospitals, we know of no existing established guidelines for the recommended sequence of airway interventions for “intubated, cannot ventilate” situations.
Case Description
We will present a discussion of the challenges and successes of three unique cases in which a patient was successfully intubated, but could not be adequately ventilated. Case one involves a 4 month-old burn ICU pediatric code that presented a diagnostic dilemma and took 20 minutes to resolve. Case two involves a 9 year-old patient in with Tetralogy of Fallot, post-thoracotomy hemorrhage, and progressive difficulty ventilating ultimately requiring ETT exchange. Case three explores the added difficulties of troubleshooting in a prone-positioned patient during lumbar laminectomy with acute onset of inability to ventilate that eventually required exchange to an armored endotracheal tube.
Discussion
Every anesthesiologist is likely to experience a situation in which a patient has an endotracheal tube (ETT) verified between the vocal cords, or tip visualized within tracheal rings, but who cannot be effectively ventilated. Diagnosing difficult ventilation in an intubated patient should be systematic and include mechanical versus pathological etiologies. The stakes are high and the consequences of not resolving such a situation in a timely manner are potentially devastating. We propose a novel algorithm, that could serve as an additional arm of the ASA’s Difficult Airway Algorithm, that offers guidelines to organize an efficient clinical approach to the management of the “intubated, cannot ventilate” scenario.
