intubation of morbidly obese patients--have tips?

[gugal]

I'm encountering a huge number of obese patients for gastric bypass--Would love any tips, tricks or hints on what you do to increase your success with intubations of these patients.

[Tenesma]

wintermute: i think epidurals are a wonderful thing for bariatric patients... but unfortunately for some of the 700 pounders we just don't have long enough needles!!!!

as far as predicting difficulty of intubation, i firmly believe that most of the literature still hasn't figured it out... primarily because when we expect a difficult intubation we modify our technique/positioning so as to increase our odds, and in a study it is difficult to make up for that bias...

and i am sure others can agree... there are two types of difficult intubations: 1) planned and 2) unplanned.... and #2 sucks big time

[zambezi, BSN, RN]

Suzanne and Yoga...I was wondering if you could elaborate more on blindly nasally intubating someone who is awake. Instinctively, this sounds like a very uncomfortable procedure to me. Would you give some kind of sedation before performing this procedure? What drug would be optimal for a procedure that requires the pt's cooperation?

How do you talk a pt. through a procedure like this? Just HOW do you talk a pt. into "inhaling" an ET tube????? Wouldn't this at least trigger a gag reflex? I'm not sure what the incidence of getting the tube into the esophagus vs. the trachea is, but how in the heck do you talk the patient into giving the procedure another shot when the tube just went down the wrong way?

Although I have shadowed CRNAs before applying to school (and I realize I have A LOT to learn), I have never seen this procedure performed nor did the subject come up.

In the coronary care unit that I work in, we have a cardiac surgeon that seemingly only does nasal intbations (he only intubates if he is on call and the patient is requiring reintubation, not prior to surgery). The doc uses lidocaine gel...sticks it on a couple of Q-tips, numbs up the nares and the ET tube...cetacaine spray is also used. We sedate the patient with a little versed and morphine if we need it...by the time we call the doc for bad gases, manage the airway with whatever means necessary until he arrives 10 minutes later (usually we bag...) the patient needs to be intubated and, though the procdeure is quite uncomfortable looking, the patients I have seen this done with have a decreased level of consciousness and don't seem to fight too much (but it does look horribly uncomfortable...)

[suzanne4, RN]

Working in ICU, have you ever had to place an Ewald tube? Or have you ever watched an EGD? Where the patient has to literally swallow that big tube? Whether you are inserting a tube into the esophagus or the trachea, you still have to get past that gag reflex. The endo-tube is actually smaller than the Ewald. Same idea. Sure techniques may be different but you still have to get down the back of the throat.....................

[Tenesma]

suzanne

i agree that the size difference is considerable, my point revolved around the autonomic/sympathetic reflexes. Trachea is extremely more sensitive --- i have seen far more people code from having their trachea stimulated from intubation compared to esophageal tube placement

[suzanne4, RN]

suzanne

i agree that the size difference is considerable, my point revolved around the autonomic/sympathetic reflexes. Trachea is extremely more sensitive --- i have seen far more people code from having their trachea stimulated from intubation compared to esophageal tube placement

Thanks, but I thought that she had been asking how you talk a patient into

swallowing a tube while awake................I was just trying to put it into perspective, not from the anesthesia side, but from just nursing pronciples.

:balloons:

[KSCRNA]

The key to intubation, especially of the morbidly obese is position. Getting a good sniffing position, not just the head elevated is key. Using just a pillow as we do with a small patient is inadequate. You need to build a ramp of blankets on either side of midline until you get a good sniffing position. The ramp needs to be open in the middle to accomodate the fat role that is between the shoulder blades. Compression of this fat role will displace the airway anteriorly.

A good way to provide upper airway local anesthesia for awake intubation is with a nebulizer. With the patient in a sitting position and their nose held shut. Have the patienr inhale through a nebulizer with 4cc of 4% xylocaine. The mist is drawn down into the upper airway.