better late than never…

The case.

An obese 86 year old female is bought to ED by private car with a 5-6 day history of progressive dyspnoea and fevers. She is promptly rushed into the resus bay in extremis with cyanosis & poor respiratory effort. She is hypoxic (SaO2 72%), febrile, tachycardic to 124/min & has a systolic BP of 98mmHg.

As you provide inspiratory assistance with a bag-valve mask & 100% O2, your team connects monitoring & gets IV access. This is her venous blood gas & CXR…

       

[DDET What’s your next move ?!]

• Do you intubate her right here & now ?
• What are your other options ??
• What can you do to make your life a little easier ???

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[DDET The story continues…]

The IPPV improved things. Her SaO2 rose to the mid-90’s and her level of consciousness improved to the point that she maintained her airway & posture in bed…

There are multiple issues here;

1. Type 2 Respiratory Failure
2. Sepsis
3. Advanced age – how aggressive should we be ??

Whilst we commence fluid resuscitation, IV antibiotics & early goal-directed therapy, we decide to trial non-invasive ventilation as a temporizing measure. This allows time to optimise her haemodynamics & discuss her management with the family…

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[DDET The decision to intubate ?!]

Our decision to intubate this lady seemed straight forward due to the following reasons…

• Type 2 Respiratory Failure with significant oxygen requirement…
  • ?Pneumonia ??ARDS (it was flu-season…)
• Her pathology [?pneumonia ??ARDS] is not easily reversible & will take time to resolve.
• Whilst 86 years old, she is independent & has good quality of life. Again her pathology is presumed to be reversible.
• NIV isn’t working.
  • An arterial line is placed. Here is a followup gas….

 

For an excellent discussion on the decision-making process surrounding intubation, see Andy Neil’s post “Decision to intubate”…

Essentially, we make a conscious decision to commit to a delayed sequence intubation ….

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[DDET How are you going to get this done ?!]

So….. This is what we did;

• Continued BiPAP;
  • 18/10 cmH2O & 100% FiO2.
  • Her SaO2 increases to 99%…
• Preparation;
  • 2x large bore IVs & arterial line (for assessment and management of blood-pressure during induction)
  • Drugs prepared (induction, paralysis, ongoing-sedation, vasopressors).
  • Airway equipment – including video laryngoscope, bougie, LMAs at bedside & open.
• Patient position;
  • We prop the patient bolt upright in bed & setup a ramp behind her.
  • The ramp is then tested to ensure when she is laid down we have an ‘ear to sternal notch’ alignment.
• Team discussion;
  • A quick briefing on our airway plan, sequence of events and confirm role designation…

The patient is induced sitting bolt upright with NIV still in place. We use 100mg Ketamine (~1mg/kg) & 100mg suxamethonium. As she fasiculates, we lower her onto the ready-made ramp & my airway assistant takes off the BiPAP mask, replacing it with nasal prongs which are cranked to 15L/min.

The actual intubation runs smoothly. A grade 2 laryngoscopy with tube placed over a bougie (my ‘go-to’ first preference for all intubations). Her SaO2 remains above 96% throughout and her BP doesn’t budge. We start her on a lung protective 6mL/kg tidal volume and titrate up her RR to target a falling ETCO2 whilst keeping an eye on her volume-loops to avoid breath-stacking…

This is her 10 minutes post-intubation…

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[DDET The follow-up…]

• Our patient remains in the ED for only 2 hours before heading off to ICU.
• We add in oseltamivir for ?influenza.
• Her serology returns strongly positive for Mycoplasma !
• She remains intubated for 48 hours and is weaned from the ventilator easily on Day 3.
• She is discharged back to her home after a 12 day admission.

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[DDET Reflection…]

I’ve been meaning to share this case for sometime now.

It was actually a patient that I saw on one of my first night shifts in a new department.

For my mate Alex & I, it served as a brilliant display of the powerful influence that online learning, podcasts and FOAM can have on our everyday practice. Neither of us had had formal teaching on such a scenario, but the application of various lessons (EGDT, DSI, apnoeic oxygenation) served us well on the night & truly made a difference to this patients outcome !!

Thanks for reading,
Chris.

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