Question for the AW gods........

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Have you ever had to use a manual resuscitator with an attached nebulizer (racemic epi) to reduce AW edema in a pt with no spontaneous effort during a difficult intubation?

Here's the scenario, frequent flyer comes into the ED about 0300 after ODing (ETOH and ??) and calling 911 (again). Initially EMS states she's A&OX3, but she becomes unresponsive about 1 minute out. Small rural hospital with fairly busy ED. PA and I are only people in-house at this time of night who intubate. PA tries twice unsuccessfully. This will be the Pt's third intubation in 2 weeks. I perform the laryngoscopy, and I can't see a thing. MDA had been paged, but is about 15 minutes out. So now thanks to all the trauma to her airway and complete loss of muscle tone, I'm having "great difficulty" ventilating. After mucho repositiono I'm able to establish a BLS airway and continue to bag her until anesthesiologist arrives. Only afterward did I think of rigging a neb to the ambu. I guess I'm looking for any experiences, insight, or suggestions.

BTW - Dr. Sleepytime had some difficulty as well.

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Why not? cannot hurt, you are breathing for them after all.

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I think the key is to try not to get yourself in difficult situations in the first place. The more people that muck around in the airway, the more edema the pt. will have. Did you and the PA anticipate her being a difficult airway? If she was intubated 2 weeks ago, did they have trouble intubating her at that time as well? Why were you having so much difficulty ventilating? Was it just her anatomy (was she fat?) or was she in bronchospasm? You could have tried to place an LMA to see if you could ventilate her better that way, or if your facility has FastTrac LMAs, you could have tried to intubate her that way. Dexamethasone is useful for airway edema, although this certainly would not have helped immediately. Did the anesthesiologist wind up doing a fiberoptic? The can't intubate/can't ventilate scenario is every anesthesia provider's worst nightmare, especially when you don't have a surgeon in the hospital who can do an emergency trach!!

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Have you ever had to use a manual resuscitator with an attached nebulizer (racemic epi) to reduce AW edema in a pt with no spontaneous effort during a difficult intubation?

Here's the scenario, frequent flyer comes into the ED about 0300 after ODing (ETOH and ??) and calling 911 (again). Initially EMS states she's A&OX3, but she becomes unresponsive about 1 minute out. Small rural hospital with fairly busy ED. PA and I are only people in-house at this time of night who intubate. PA tries twice unsuccessfully. This will be the Pt's third intubation in 2 weeks. I perform the laryngoscopy, and I can't see a thing. MDA had been paged, but is about 15 minutes out. So now thanks to all the trauma to her airway and complete loss of muscle tone, I'm having "great difficulty" ventilating. After mucho repositiono I'm able to establish a BLS airway and continue to bag her until anesthesiologist arrives. Only afterward did I think of rigging a neb to the ambu. I guess I'm looking for any experiences, insight, or suggestions.

BTW - Dr. Sleepytime had some difficulty as well.

What type of airway did you use? You stated a BLS airway, what type?

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i think the key is to try not to get yourself in difficult situations in the first place. i coudn't agree more! (un)fortunately i wasn't the one drinking and popping fist full-o-narcs lol! the more people that muck around in the airway, the more edema the pt. will have. that was the main issue here. did you and the pa anticipate her being a difficult airway? yes, paged anesthesia almost immediately if she was intubated 2 weeks ago, did they have trouble intubating her at that time as well? i had tubed her twice in the 6 weeks prior to this third overdose with relative ease. why were you having so much difficulty ventilating? was it just her anatomy (was she fat?) or was she in bronchospasm? the pt is a smoker, so i'm sure there was some bronchospastic component there, however like i posted earlier, lots of edema and loss of muscle tone = no aw patency. you could have tried to place an lma to see if you could ventilate her better that way, or if your facility has fasttrac lmas, you could have tried to intubate her that way. i had'nt thought of an lma, we don't use them outside of the or here. that is a good suggestion however. dexamethasone is useful for airway edema, although this certainly would not have helped immediately. did the anesthesiologist wind up doing a fiberoptic? yes, we actually use one in the ed. he did have some difficulty but got it. the can't intubate/can't ventilate scenario is every anesthesia provider's worst nightmare, especially when you don't have a surgeon in the hospital who can do an emergency trach!!

yes, it's also an rt's worst nightmare when anesthesia isn't in-house! lol! i was able to ventilate her unitl mda arrived, but it was close. we have done emergency bedside trachs (perhaps tracheal dialator?) before, but the pa was hesitant to do so. i just thought of the neb/ambu combo from my ems days, and i was wondering if anyone had used it in this context.

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What type of airway did you use? You stated a BLS airway, what type?

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I inserted an OPA.

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