Question

*paramedics*

You are called to a 65 year old male, found unconscious in his bed. Nil trauma, nil medical history, NAD on head to toe.

The patient is

GCS 3

HR 100

BP 140/80

RR 4

SPO2 85% RA

BSL 6.0

Temp 36.5

You observe that he is short, approximately 130kgs, has a thick and long beard, has removed his dentures and is snoring.

Discuss difficulties associated with managing this patient’s airway to ensure adequate ventilation. Consider the specific patient information provided.

Discuss what procedures or airway adjunct/s you would use on this patient and justify why. Relate this to airway patency and protection.

 

Answer 1

The patient has a saturation of 85 % in room air and respiratory rate of 4 breaths per minute. This patient needs immediate intubation and mechanical ventilation.

He needs preoxygenation with 100 % oxygen followed by rapid sequence induction and intubation. His fasting period is unknown and hence RSI is preferred.

The factors that make airway management difficult are:

1. Obese. He is of short stature and has a weight of 130kgs. Due to accumulation of fat in neck as well as back and around the airway, mask holding- maintenance of seal as well as patency, positioning for intubation, process of intubation are all difficult. Mechanical ventilation in obese is also difficult due to decreased compliance. Weaning from mechanical ventilation is also difficult.

2.Beard- the presence of beard makes adequate preoxygenation hard due to difficulty of maintenance of seal while using face mask.

3. Snoring indicates deposition of fat around the airway structures and presence of obstructive sleep apnea. Intubation, mechanical ventilation and weaning will be difficult.

4. Edentulous patient- this makes mask holding and intubation difficult

This is a case of anticipated difficult airway.

• Patency of airway during preoxygenation should be ensured with oral or nasopharyngeal airway of appropriate size.
• Apnoeic oxygenation can be done using nasal cannula during intubation attempts
• Difficult airway cart with second generation LMA, cricothyroidotomy sets, fibre-optic bronchoscope, smaller endotracheal tubes should be kept ready.
• Tracheostomy standby
• Fibre-optic intubation after glossopharyngeal, superior laryngeal and transtracheal blocks or Spray as you go technique; intubation without muscle relaxants is preferred to maintain the patency of airway.
• Mechanical ventilation will be difficult due to decreased compliance.