Written by Dr. Capwell Taylor (PGY2) and Dr. Joseph Botros (PGY2)
65-year-old male with history of prior CVA and residual right hemiparesis, CAD, HLD, HTN, DM, ESRD presents via EMS for evaluation of hypoxia from nursing home; recently discharged after hospitalization for left lower lobar pneumonia.
Initial vitals: O2 sat 74% on 15L NRB with BP of 96/68 mmHg, HR of 110, RR of 20.
On ED arrival, the patient was obtunded with tachypnea, labored respirations, and midline trachea. There was asymmetric chest rise with almost completely absent breath sounds over the right chest, with faint rhonchi over the right apical field.
Despite repositioning of pulse oximetry to multiple locations, an oxygen saturation greater than 75% was never obtained, a stat ABG was performed concurrently with obtaining IV access. Needle thoracostomy was discussed, but not performed due to the faint lung sounds present in the apex of right chest. CXR was performed immediately.
Based off the above Chest X-Ray, the etiology of our patient’s hypoxia was suspected to be secondary to mucus plugging. Orotracheal intubation and RSI were prepared, but we chose to avoid a neuromuscular blocker due to the severity of patient’s hypoxia, which despite the supplemental oxygen was not improving beyond 75%. Intubation was performed via video laryngoscopy while timing tube delivery to the patient’s respirations.
Below is the video of the intubation:
During the intubation, the patient’s cough reflex was still intact, and thus contact of the posterior oropharynx with the endotracheal tube caused the field of view to become obscured. During the initial attempt, the tube did not cover the necessary distance to insert between the vocal cords. After the field of view returned, the tube was delivered more rapidly and into the correct position while maintaining visualization during removal of the rigid stylet.
Tube placement was confirmed by color capnography. Oxygen saturation did not change despite FiO2 of 100%. Deep suctioning was performed immediately with thick secretions removed from the bronchus. Pulse oximetry rapidly improved to nearly 100% and repeat CXR was performed.
Initial ABG performed on arrival was canceled by the lab, so the true extent of the patient’s hypoxemia at presentation is unknown. They were started on fentanyl infusion, vancomycin, piperacillin/tazobactam and transferred to ICU for further treatment of hypoxemic respiratory failure secondary to pneumonia.
Cap’s Takeaways:
1)Keep an appropriately wide differential beyond pneumothorax in unilaterally absent breath sounds.
2)“Delayed sequence intubation” (DSI) should be considered in patients unable to tolerate adequate preoxygenation.
In this case, preoxygenation had failed. Maintaining the patient's own respiratory drive during the intubation was prioritized to prevent peri-intubation cardiac arrest from hypoxemia. Etomidate was given shortly after tube placement. DSI could have been used as an option in this case.
In brief, DSI is medication-assisted preoxygenation. If a patient is so agitated that they cannot be preoxygenated, then a sedative medication (ideally one that preserves respiratory drive) can be used to facilitate preoxygenation prior to proceeding with neuromuscular blockade and laryngoscopy.
In cases of severe hypoxemia, respiratory acidosis, hypotension where rapid sequence intubation could compromise already dicey hemodynamics, an alternate procedure (sometimes called “ketamine sequence intubation”) can be considered. In this procedure, ketamine is used for sedation then laryngoscopy is performed without neuromuscular blockade so as to maintain respiratory drive. This would look a lot like the video above because the vocal cords will still be moving.
Additional reading:
3) Tube delivery is the challenging portion of video laryngoscopy - practice (in the lab) makes it smoother when the time comes.
4) Slow is smooth, smooth is fast.
note that the trachea and mediastinum are pulled towards the side with atelectasis from mucus plugging. This is the opposite of tension pneumothorax where the mediastinum is pushed away from the side of the pneumothorax. Assuming you recognized that this was a problem caused by mucus plugging before you intubated the patient, did you figure you needed to intubate the patient to do deep suctioning? who did the suctioning and how was it done? What med did you use for sedation for intubation?