Intubation Blues

MedicineMan975

MedicineMan975

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Hey there, . I'm writing cause I seek an opinion on an intubation I performed about five months ago.

First a little background on myself :
I'm pretty much fresh out of medic school. I've been on the job for close to 5 months now, was doing my orientation ride time before they cut me loose on a 24hr truck. So far, I hadn't had any thing thrown at me that I couldn't negotiate my way through.Until this happened, that is.

As for the call:
We rolled to the extended care facility for a report of a seizure. We get there and we find a 50 yo male c a Hx of epilepsy and previous CVA's, postictal p suffering a seizure for approx 2-3 mins prior to our arrival. His ABC's were checked and found to be patent s impedance. So, we kick into gear. High flow O2, suction (b/c there were some gastric contents apparent on his chest), IV access, EKG, etc.
We moved him to our stretcher and he started to seize again. I hit him c 2mg Diazepam to little effect. Another 3mg smoothed him out. After getting him in the unit, and faced c maybe a 2 min transport time to the ER. I performed a quick 2 Survey: Fixed stare to the left, pupils limited in their reactivity, respirations clear @ 16/min, BP 148/82, Sinus Tach @ 124, skin W/D and a GCS of 11.

Like I said, so far just your run of the mill action/reaction EMS call. Well, once in the ED the doctor makes the decision to RSI the patient and asks me if I would like to intubate. Seeing as how he is also my med control(and has known me since I was a kid) I stepped up to the challenge and said "You bet." Now here comes the kicker.

The intubation went off s a hitch. I go in quickly once he was down, visually verified the tube passing the vocal cords, attached the color metric CO2 detector and watched it turn sunshine, and began ventilating so auscultation could confirm placement. Lung sounds were clear bilaterally, but diminished to the LEFT. So, the tube was retracted 1cm and lung sounds became clear and equal bilaterally. I was in.

Soon there after, a call came in and we had to spilt. About 30 min later, I see the doc and a respiratory guy going into the room of my SZ patient. Come to find, his breath sounds had become nearly absent on the LEFT once again and lung compliance was almost non existent. So the decision was quickly made to extubate and re-intubate.:unsure:

Needless to say, I immediately started questioning myself and what I could have possibly done to cause the complication. So, the doc extubates and gets back in. Breath sounds became equal bilaterally and the problem is solved. When I asked the doc what went wrong, he's baffled. X-rays confirmed tube position, I had encountered no obstructions during intubation, and he had used the very same tube I had used before. Question marks were doing cartwheels in my mind.

The doctor was very reassuring saying it was not a problem that obviously couldn't be corrected and that I had nothing to feel ashamed about. He was as just as confused about the whole thing as I was and told me not to worry about it. He wrote it off as possible bronchospasm.

But as you can see, I'm still perplxed by the whole affair. I like to consult outside sources when facing a quandary of some importance because, distance from a problem is the best way to be objective about a solution. At least that's my opinion. So if ya'll could give me an informed opinion on the intubation situation, I'd be very appreciative.
__________________
 
Could be that someone moved him or tube and it pushed in further??
 
Possible. But tube placement was confirmed twice by x-rays. One right after intubation, and one right before extubation. Your guess is as good as mine. Thanks for the post.
 
Was the doc who reintubated the patient the one that talked to you and didn't give a reason or explain?

Your intubation was successful if initial BS confirmed placement with the addition of ETCO2 detection, CXR and breath sounds.

Not knowing what the CXR showed as far as cardiomegaly, atelectasis, pneumo etc, puts the armchair quarterback at a disadvantage.

Also what size and what type of tube was used?

Was a dicision made to change to another tube for oral secretions and possibility of more than 24 hours on the ventilation? By our Vent PNA protocols we will sometimes elective switch the tube to one with a subglottic suction port.

If the doctor "assumed" it was bronchospasm, was a bronchodilator challenge done?

Was a basic level portable ventilator used in the ED or was it an ICU ventilator actually capable of giving a compliance value? Waveforms?

Or was the patient decompensating rapidly from "nonexistent" compliance and the decision to try something was made quickly?

Was the reintubation done with a hand held bronchoscope to check for mucus plugging or other obstruct that can not be seen on CXR?

Sometimes mucus does accumulate quickly around an ETT almost forming a cast that really messes things up. Sometimes reintubation will knock that off the tube and while the mucus will still be in the lungs, it can be broken up easier pharmacologically andor by lavage.

If compliance was "nonexistent", did that mean they had to hand bag as the patient was not tolerating the ventilator? That is a serious problem and if all other factors are ruled out then a mechanical problem with the tube must also be ruled out.

Who secured the ETT?

How was the tube secured? At what cm mark and what what the patient's height?

Where was the "RT guy" while you were intubating?

Was the problem resolved after reintubation?

Passing the "tube successfully through the cords" is just one phase of airway management. For a QA, I have a hundred more questions but they would be directed at the "RT guy". He had better have some good documentation and explanations. Did he check placement before placing the patient on the ventilator? Was the tube adequately secured to his policy? If no to either, he'd be jockeying O2 tanks and not touching a patient for many months until he did some remedial training.
 
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Ditto to what Vent pointed out. I see mucus plugs causing several problems, something that is almost impossible or near impossible to diagnose without CXR.

Again, Vent pointed out most of the problematics.

R/r 911
 
I apologize for all the typos in my earlier post. My caffeine level was not yet therapeutic.

There is another situation that can occur but was probably not the case in the original post.

Sometimes immediately after intubation someone (doctor, RN, RRT) will say "bag real fast" to blow off the accumulated CO2. Thus someone will bag "real fast" and vigorously with big volumes. Air will usually follow the path of least resistance which will usually be the right side. That right lung will become hyperinflated and literally shift everything toward the left. Thus, there may be diminished breath sounds on the left. Air trapping will occur if one does not pay attention to the I:E ratio and the CO2 may actually rise and not decrease. Hemodynamics will suffer also. It both lungs become hyperinflated, hemodynamics can be greatly affected.

If I, as an RRT, do increase the ventilatory rate, I also watch the tidal volume by chest rise and auscultation. I rarely will increase the ventilatory rate to or more than 20. If the rate is 20 then a 1:2 ratio or 3 second cycle by bagging will be maintained. On a ventilator, I can control various factors and will be able to monitor gas flow delivery to the lungs. Each patient and circumstance will be different. If the patient is going to be on an ARDS protocol, you may see the RRT set the ventilator at a small VT and with a higher rate. Other lung protective stategies may be applied according to disease process or injury mechanism. In the hospital, ventilator management protocols must take into consideration the CXR, ABG, lactate level as well as other labs, hemodynamics, age, height and disease/injury processes previous and present.

The above was a little of track but as I mentioned before, putting a tube through the cords is just one phase of the airway management process. There are many paramedics that want to "manage" ventilators on transports either interfacility or from 911 EMS calls. Many associate the ATV and a couple of knobs with all there is to mechanical ventilation. Even those little ATVs can get one into a bad situation quickly if a few assessment steps are not taken.
 
He didn't have a mild seizure after placement did he? Although I’m assuming you would have noticed the bite marks on the tube.
 
mikeylikesit said:
He didn't have a mild seizure after placement did he? Although I’m assuming you would have noticed the bite marks on the tube.
Click to expand...

Hopefully the "RT guy" and the doctor are not that unobservant to not notice the patient is biting the tube. If that is the case, they have no business messing with any airway.

One should not see bite marks on an ETT. The material they are made from these days is designed to withstand even the most clamped teeth. Rarely do the front teeth come down perfectly together but will slip over the tube. If taped by the molars, the broad teeth will not be able to "slice" through the tube. If the front teeth do strike perfectly together, the teeth may break and I have seen that but not frequently. If a person is clamping or has seizure a tube guard or bite block should be placed. If that can not be done safely during a seizure, I wait for pharmacological intervention to kick in if I can not open the mouth by other safe maneuvers.

The one part of the tube that is vulnerable to bite marks and can be severed is the small pilot balloon tube. For that reason if should never be included in the tape with to and next to the ETT. That puts it next to another surface to use as a "cutting board" by the teeth. Another reason not to secure plastic to plastic is a chance of "tromboning" as you have not made a complete ciricle around the ETT itself but have placed something else next to it.

The other thing to consider is the position of the ETT at the time the CXR was done. Some people leave the bag hanging on the tube as they step away for the CXR. The vent circuit may also be left hanging or pulled off the chest to put traction on an ETT especially if the ETT has not be secured per policy for the ICU. This can pull the ETT out a cm or two. So, if you pulled back 1 cm later, you may actually have been two cms too low when the tube returns to neutral.

Leaving the bag hanging on the ETT as the patient is being moved is also one of the leading causes of inadverent extubation. If your hands are not on the bag, the bag should not be on the tube.

There are no "accidental" extubations. The causes are due to oversight of precautionary measures and not being attentive or observant.
 
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Thanks for the tips Vent...always good do hear your input.
 
VentMedic said:
Was the doc who reintubated the patient the one that talked to you and didn't give a reason or explain? (Yes. The one and the same.)

Your intubation was successful if initial BS confirmed placement with the addition of ETCO2 detection, CXR and breath sounds.

Not knowing what the CXR showed as far as cardiomegaly, atelectasis, pneumo etc, puts the armchair quarterback at a disadvantage. (To the best of my knowledge, the chest x-ray yielded no abnormal findings. The series that were taken didn't show any signs of complications. That was the baffling part about the whole thing.)

Also what size and what type of tube was used? (A Rusch 7.5, cuffed with stylet.)

Was a dicision made to change to another tube for oral secretions and possibility of more than 24 hours on the ventilation? By our Vent PNA protocols we will sometimes elective switch the tube to one with a subglottic suction port.(Not as I understood it. I know of no protocols within the RT department like those you described.)

If the doctor "assumed" it was bronchospasm, was a bronchodilator challenge done? ( No. He made the decision to extubate then and there.)

Was a basic level portable ventilator used in the ED or was it an ICU ventilator actually capable of giving a compliance value? Waveforms? (The latter.)

Or was the patient decompensating rapidly from "nonexistent" compliance and the decision to try something was made quickly?

Was the reintubation done with a hand held bronchoscope to check for mucus plugging or other obstruct that can not be seen on CXR? ( No. A laryngoscope and the same ETT were used for the re-intubation.)

Sometimes mucus does accumulate quickly around an ETT almost forming a cast that really messes things up. Sometimes reintubation will knock that off the tube and while the mucus will still be in the lungs, it can be broken up easier pharmacologically andor by lavage. ( I don't think that was the case. Ease of ventilations started immediately after re-insertion.)

If compliance was "nonexistent", did that mean they had to hand bag as the patient was not tolerating the ventilator? That is a serious problem and if all other factors are ruled out then a mechanical problem with the tube must also be ruled out. ( My chronology may have been a little skewed in my previous post. The usual course of event when a patient is to receive RSI is thus: Doctor calls the order out, respiratory is paged, & equipment/meds are gathered. Once the RT person arrives the ball starts rolling. Now as for the vent, it has been known to happen where a RT has to manually bag for 30-45 min before someone in his/her department can shag one for them.)

Who secured the ETT? ( I did.)

How was the tube secured? At what cm mark and what what the patient's height? ( With a Thomas ETT holder. 22 cm and my best estimation would be 5'6"-5'8")

Where was the "RT guy" while you were intubating?

Was the problem resolved after reintubation? (Immediately. As soon as the patient was extubated and re-intubated, the problem disappeared as quickly as it had appeared.)

Passing the "tube successfully through the cords" is just one phase of airway management.(Point taken. I saw it as a practice opportunity, in a pretty controlled environment. Heck, outside of the 20 odd intubations required during my surgical rotation for school, I've only had the call for intubating 5 times at the most.) For a QA, I have a hundred more questions but they would be directed at the "RT guy". He had better have some good documentation and explanations. Did he check placement before placing the patient on the ventilator? Was the tube adequately secured to his policy? If no to either, he'd be jockeying O2 tanks and not touching a patient for many months until he did some remedial training.
Click to expand...


I hoped that I answered most of the variables that were associated with this little episode. I hope it helps with the problem solving. Thanks guys.
 
( No. A laryngoscope and the same ETT were used for the re-intubation.)
Click to expand...

Do you mean the same ETT? Or another 7.5 clean tube?

Sometimes mucus does accumulate quickly around an ETT almost forming a cast that really messes things up. Sometimes reintubation will knock that off the tube and while the mucus will still be in the lungs, it can be broken up easier pharmacologically andor by lavage. ( I don't think that was the case. Ease of ventilations started immediately after re-insertion.)
Click to expand...

The mucus plugging around the tip of the ETT or even near the left main bronchus is the most logical explanation and easy bagging is what happens once the plug is knocked off or dislodged and possibly broken up.
 
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MedicineMan975 said:
Hey there, . I'm writing cause I seek an opinion on an intubation I performed about five months ago.

First a little background on myself :
I'm pretty much fresh out of medic school. I've been on the job for close to 5 months now, was doing my orientation ride time before they cut me loose on a 24hr truck. So far, I hadn't had any thing thrown at me that I couldn't negotiate my way through.Until this happened, that is.

As for the call:
We rolled to the extended care facility for a report of a seizure. We get there and we find a 50 yo male c a Hx of epilepsy and previous CVA's, postictal p suffering a seizure for approx 2-3 mins prior to our arrival. His ABC's were checked and found to be patent s impedance. So, we kick into gear. High flow O2, suction (b/c there were some gastric contents apparent on his chest), IV access, EKG, etc.
We moved him to our stretcher and he started to seize again. I hit him c 2mg Diazepam to little effect. Another 3mg smoothed him out. After getting him in the unit, and faced c maybe a 2 min transport time to the ER. I performed a quick 2 Survey: Fixed stare to the left, pupils limited in their reactivity, respirations clear @ 16/min, BP 148/82, Sinus Tach @ 124, skin W/D and a GCS of 11.

Like I said, so far just your run of the mill action/reaction EMS call. Well, once in the ED the doctor makes the decision to RSI the patient and asks me if I would like to intubate. Seeing as how he is also my med control(and has known me since I was a kid) I stepped up to the challenge and said "You bet." Now here comes the kicker.

The intubation went off s a hitch. I go in quickly once he was down, visually verified the tube passing the vocal cords, attached the color metric CO2 detector and watched it turn sunshine, and began ventilating so auscultation could confirm placement. Lung sounds were clear bilaterally, but diminished to the LEFT. So, the tube was retracted 1cm and lung sounds became clear and equal bilaterally. I was in.

Soon there after, a call came in and we had to spilt. About 30 min later, I see the doc and a respiratory guy going into the room of my SZ patient. Come to find, his breath sounds had become nearly absent on the LEFT once again and lung compliance was almost non existent. So the decision was quickly made to extubate and re-intubate.:unsure:

Needless to say, I immediately started questioning myself and what I could have possibly done to cause the complication. So, the doc extubates and gets back in. Breath sounds became equal bilaterally and the problem is solved. When I asked the doc what went wrong, he's baffled. X-rays confirmed tube position, I had encountered no obstructions during intubation, and he had used the very same tube I had used before. Question marks were doing cartwheels in my mind.

The doctor was very reassuring saying it was not a problem that obviously couldn't be corrected and that I had nothing to feel ashamed about. He was as just as confused about the whole thing as I was and told me not to worry about it. He wrote it off as possible bronchospasm.

But as you can see, I'm still perplxed by the whole affair. I like to consult outside sources when facing a quandary of some importance because, distance from a problem is the best way to be objective about a solution. At least that's my opinion. So if ya'll could give me an informed opinion on the intubation situation, I'd be very appreciative.
__________________
Click to expand...

Since I know both the medic and the med control... not to mention the RT dept and work there, I'll chime in.

Bro, first off you weren't there when things went ''hinky''. Things happen. Yes, breath sounds may have gone absent. There's a good chance the tube just got pushed in a bit. If Doc said you were in, then you were in. Don't sweat it.

Remember, ya'll pulled it back only 1cm to get BS equal. That's not much. 2 would have probably been better.

You were in. Good job.
 
Mike, I told him that on my first post this morning but I don't think he believed me.

VentMedic said:
Your intubation was successful if initial BS confirmed placement with the addition of ETCO2 detection, CXR and breath sounds.
Click to expand...


Maybe my questions scared him a little but that's nothing compared to some of the inquiries we do on problem intubations for our inhouse staff. It's too bad the some of the same questions are posed to some EMS teams.
 
Don't think you ''scared'' him per se. He's intelligent and skilled. Intelligent enough not to get that dreaded ''Para-god'' Syndrome. I do, however, need to give him a swift kick in the pants for doubting himself;)
 
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MSDeltaFlt said:
Don't think you ''scared'' him per se. He's intelligent and skilled. Intelligent enough not to get that dreaded ''Para-god'' Syndrome. I do, however, need to give him a swift kick in the pants for doubting himself;)
Click to expand...

Aww, shucks Mikey. You're making me blush:blush:. Thanks for everybody's posts. Like I said, it has been bothering me for a bit and I figured this was as good as any place to get a little more feedback on the subject. And let me tell y'all, it was very helpful.
 
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