Tag Archives: airway

visual aid: bougie handling tips

25 Sep

recent article by Dr. Levitan in ACEP Now, with some handy tips for gripping the bougie so it feeds with the Coude tip up.  Click through for the article, but if you have 30 seconds, check out the visual aids below:




References: ACEP Now article (w/ pictures).

tracheostomy complications

2 Sep

There are generally three categories of tracheostomy complications

Immediate after placement, early, and late.

  • Immediate and early happen within 48 hours of placement.
  • Late happens after


the most concerning late complication is tracheoinnominate fistula

  • this is severe with high mortality.
  • may be heralded by small amounts of bleeding in the days prior to a large hemorrhage.
  • Usually it takes about 5 days for a tracheostomy tract to mature.
  • Tracheoinnominate fistula usually occurs in the first three weeks after placement, peaking in the 1st to 2nd week.

Treatment for hemorrhage is pressure

Usually by first hyperinflating the trach tube cuff in attempt to tamponade the bleeding.

If this is unsuccessful, then next is placing a finger in the tracheostomy and applying direct digital pressure by pressing the artery against the manubrium.

Surgical consultation should be immediate.  And tamponade of the artery should be maintained to the operating room.


Other complications may be recurring tracheitis or bronchitis related to tracheostomy tube site infection.

Gauze soaked with 0.25% acetic acid can treat local wound infections.


Submitted by J. Stone.


References: Tintinalli’s Emergency Medicine Chapter 242 Compications of Airway Devices; picture

EtCO2 Monitoring for procedural sedation

21 Aug

Potential complications of procedural sedation include hypoventilation, aspiration, and respiratory failure capnowith hypoxic brain injury.

Capnography -> the non-invasive measurement of the partial pressure of carbon dioxide in exhaled breath.

Capnometer -> a device that displays what numeric value for end tidal carbon dioxide (ETCO2).


Hypoventilation always precedes hypoxia during procedural sedation, either due to airway obstruction or diminished respiratory drive.

ETCO2 monitoring provides an early warning signal to provide time to intervene before the onset of hypoxia.


The evidence:

132 subjects undergoing procedural sedation with Propofol (1 mg/kg then 0.5 mg/kg boluses using ideal body weight) were randomized to intervention (standard monitoring + capnography measuring ETCO2 via nasal cannula using the Capnostream 20™) or control (standard monitoring alone) groups.

All patients received 3L/minute oxygen and 0.5 μg/kg fentanyl or 0.05 mg/kg of morphine at least 30-minutes prior to the procedure.

The primary outcome was hypoxia, as defined by an oximetry reading of ≤ 93%. Respiratory depression was defined as ETCO2 ≥ 50 mm Hg, an absolute increase or decrease from baseline ETCO2 ≥ 10%, or loss of the waveform for > 15 seconds.

Capnography-defined respiratory depression was 100% sensitive and 64% specific in predicting hypoxia with the loss of a waveform being the most likely finding to precede hypoxia.

In patients with hypoxia, the median time from onset of respiratory depression to hypoxia was 60 seconds (range 5 to 240 seconds). 


A few things to consider:

-insufficient demographic variables were identified (history of obstructive sleep apnea, comorbidities, etc.)

-the Capnostream 20™ costs $4,950 per unit


Submitted by Kelly Estes.


Reference: Dietch K, Miner J, Chudnofsky CR, et al. Does end tidal CO2 monitoring during emergency department sedation and analgesia with Propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med 2010; 55: 258-264.

Picture: covidien.com

tongue buzzer for sleep apnea?

9 May

check out this recent post on PulmCCM:



hypoglossal nerve stimulator

small generator in the upper chest like a defibrillator or pacemaker

for moderate to severe sleep apnea who can’t tolerate CPAP


could cut apnea events and hypoxemia by almost 70% after one year

BUT WAIT… mean body mass index of enrolled patients was 28, and those with BMI > 32 were excluded (maybe not as applicable)?


Food for thought.  Interesting, though.  Not every device you see on the chest wall may be a defib/ICD, soon.


References: PulmCCM post; picture


Epiglottitis (quick hits)

24 Apr


-Also can be referred to as supraglottitis

Haemophilus influenza type b (cause approximately 25% of cases even now after vaccination), Staphylococcus and Streptococcus species are the most common causes



-Classic 3 D’s= Drooling, dysphagia, and distress

-Commonly describe worsening dysphagia, dysnpea,

-Fever, tachycardia, and cervical lymphadenopathy also presently common

-Insiratory stridor

-Patients often are sitting in the sniffing position to provide easier breathing



Xrays can be obtained which show “thumb sign”if you are really concerned about epiglottis and the patient is unstable, do any necessary imaging at the bedside

-Transnasal fiberoptic laryngoscopy is the imaging test of choice

-CT is not needed and should be avoided in any patient who develops worsening symptoms with laying down



-Supplemental humidified oxygen

-ENT consultation

-IV antibiotics (Ceftriaxone is first line drug)

-IV steroids

-ENT consultation


NOTE:  If intubation is needed, try performing awake fiberoptic intubation in the OR with tracheostomy equipment available if needed


Submitted by Joey Grover. 


References: Image: http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2011/nejm_2011.365.issue-5/nejmicm1009990/production/images/large/nejmicm1009990_f1.jpegTintinalli’s Emergency Medicine 7th Edition

Laryngeal Trauma

28 Mar


second most common cause of death from head and neck trauma

Mortality from injuries directly associated with the laryngeal trauma:  2%-15%


signs and symptoms of blunt laryngeal trauma,

  • neck or facial crepitus (from subcut emphysema)
  • Hamman’s sign – crunching sign over precordium from mediastinal air
  • dysphonia,
  • hemoptysis,
  • hematoma,
  • dysphagia,
  • cartilaginous step-offs
  • pneumothorax
  • stridor


initially stable-appearing airway may progress quickly to obstruction secondary to swelling 


stick with the ABC’s first: if signs of respiratory distress/compromise, go get an airway first.


beware of false passages


Awake fiberoptic intubation is preferred 


Laryngeal mask airways are contraindicated, as they can not only complete the airway obstruction but may also ventilate air through the mucosal defects in the larynx out into the neck.


If necessary, formal tracheotomy is preferable to cricothyrotomy, as the latter may further injure the laryngotracheal complex. 



  • if possible, endoscopic examination before radiographic examination (ideally nasopharyngoscope or bronch)
  • Examination is best performed with the patient in the upright position if possible
  • CT scan of the neck with contrast, with fine cuts of the larynx. 



  • AIRWAY if needed
  • most should be admitted for observation 24–48 h with serial exams
  • 8–10 mg of IV dexamethasone q8hr or methylprednisolone 250 mg IV q4hr  (for 24 hr)
  • IV antibiotics for mixed upper aerodigestive tract flora (for known mucosal tears or initial empiric tx)


Submitted by Heather Reed-Day.


References: Brett T. Comer, Thomas J. Gal Recognition and Management of the Spectrum of Acute Laryngeal Trauma; The Journal of Emergency MedicineVolume 43, Issue 5November 2012Pages e289-e293; picture.

surgical airway tips

21 Mar

nice video up on EMCrit by Dr. Levitan on the surgical airway, worth a watch.


Some quick takeaways from the video:

Hardest part is making the decision to cut; decide quickly/early

Laryngeal handshake (use whole hand rather than just 1 finger to feel your landmarks)

Sternal stabilization (rest your hand on the sternum, rather than hanging free in the air)

Cords to carina = 11cm (remember, its shorter than you’d normally push an ETT from above)


Not from the video, but good advice:

Stash a scalpel (know where one is at all times. if you need to tape one somewhere, that’s an option, too).

References: EMCrit post; picture