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FAILED INTUBATION
Don’t panic. Have a plan.
Expected difficult intubation
Before every intubation, but especially if you expect difficulties,
have ready (or know the location of ) emergency tools, such
as:
| :: |
Intubating
stylet |
| :: |
Long
bougie |
| :: |
Laryngeal
mask airway (LMA). |
The
LMA can often be passed to maintain the airway when intubation
is impossible. If the stomach is full, as is often the case
in emergencies, you will have to balance the risk of regurgitation
with the LMA in place against the same risk during further
attempts at intubation, or complete failure to intubate.
Unexpected difficult intubation
If you cannot see the larynx clearly enough to get the tube in, possible remedies include:
| :: |
Reposition
the head – try a pillow under the head |
| :: |
Pass
an intubating bougie or use a stylet to make the tube
more curved |
| :: |
Hold
the laryngoscope to give upward traction |
| :: |
Reposition
the blade if the tongue is blocking the view |
| :: |
Change
the blade:
| • |
If
it is too big, you look down the oesophagus |
| • |
If
it is too small, you cannot lift the epiglottis |
|
| :: |
Give
further relaxant or deeper halothane anaesthesia to abolish
reflexes. |
Only if you can remedy one or more of the above problems should you try again,
but remember to:
| :: |
Call
for help |
| :: |
Stay
calm |
| :: |
Re-oxygenate
(mask and airway) and watch the oximeter |
| :: |
Maintain
cricoid pressure, if needed |
| :: |
Consider
the need for more atropine. |
If
intubation still fails, stop any further attempts at intubation. Remember
that it is an abuse of the patient to have several people
lining up to try their skills at this “interesting” case.
There are then the following two possible courses of action.
| :: |
If
the operation must now go ahead under general anaesthesia,
for example, in haemorrhage, ruptured uterus, long standing
intestinal obstruction:
| • |
Try
inserting an LMA |
| • |
If
LMA insertion is not possible, try an oral airway
and inhalation anaesthesia with a face mask |
| • |
If
neither of the above are possible, give ketamine
with oxygen by face mask |
| • |
Maintain
cricoid pressure if there is a regurgitation risk. |
|
| :: |
If
the operation can be postponed:
| • |
Allow
the patient to wake up, while maintaining oxygenation
and
ventilation as best you can |
| • |
Use
regional or spinal anaesthesia or abandon the procedure
and refer
the patient. |
|
Do not make your ability to
intubate more important than the patient’s life.
Endotracheal tube in the oesophagus
Apply the ten tests of correct tube placement on page 13–2. If in doubt, remove
the tube and follow the steps above.
No ventilation of the lungs
If you thought intubation was successful, but you cannot ventilate the lungs, think
of the following:
| :: |
Oesophageal
tube |
| :: |
Tube
is blocked |
| :: |
Patient
circuit wrongly connected or configured |
| :: |
Obstruction
in the trachea |
| :: |
Tube
is against the wall of the trachea or tube cuff has herniated:
let down the cuff. |
Only if you have tested and eliminated the above, consider:
| :: |
Severe
bronchospasm |
| :: |
Wrong
drug administration: e.g. neostigmine |
| :: |
Aspiration
of gastric contents |
| :: |
Tension
pneumothorax |
| :: |
Pulmonary
oedema |
| :: |
Infection,
such as bronchitis or pneumonia. |
Vomiting
and regurgitation
Seeing stomach contents in the unprotected airway of an unconscious patient
is probably the worst thing that can happen in the practice of anaesthesia.
Do not let this happen to you.
Aspiration of stomach contents into the lungs is often a terminal event
for the patient. However, regurgitation is both predictable and avoidable. This
is the moment when you must act with the greatest speed. Options are:
| :: |
Tilt
the bed head down, continue cricoid pressure (or put
it on) and suck away the vomitus with the biggest, most
powerful rigid sucker you can find |
| :: |
Turn
the patient on to the side and suck. |
The choice will depend on which can be done fastest, according to the
workings of the table, the available manpower and size of the patient.
In either case, intubation is recommended as soon as possible to
protect the airway and also to suck down the trachea, both for diagnostic
and therapeutic reasons.
Give steroids, antibiotics and bronchodilators if aspiration is suspected.
The pulse oximeter may show desaturation and the lungs may become stiff
to inflate.
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