Some time ago, in this galaxy, our
good friend Jorge Cabrera was faced with managing respiratory failure in a 55’ish year old man with BMI of 92 (ht 6 feet, wt 675 lbs (307kg). This patient was initially admitted with an upper gastrointestinal bleed with congestive heart failure and a history of obstructive sleep apnea. He had required mechanical ventilation but was weaned off recently. His recent intubation involved 2 attempts by anesthesia with the first attempt being failed Mac 3 direct laryngoscopy and the second attempt being a successful glidescope intubation.
The patient was now in hypercapnic hypoxic respiratory failure despite all treatment including NIPPV. His arterial blood gas was not improving despite CPAP or BiPAP (EPAP of 12).
pH 7.1 PaCO2 90’s PaO2 60’s SaO2<90’s
The approach was as follows:
Etomidate 40mg (lean body weight) IV
Rocuronium 100mg IV
Re-oxygenation/pre-oxygenation: NIPPV FiO2 1.0 with Nasal Cannula at 15L/mins brought the SpO2 to maximum of 95%
HOB elevated at 45 degrees
Positioning not optimal due to bariatric bed and pt’s weight sinking him into air mattress.
Plan A: RSI then DL w/ MAC #4 and styletted size 8 ETT
Back-ups: Bougie, Glidescope, LMA unique, size 6 ETT and #11 blade
Here is what happened (patient consent given for #FOAMed publication):
What would your approach be? Would you do anything different? Comments or suggestions welcome! Next week we will present the Monday Morning quarterback discussion on this from Jorge and other airwayNauts.
Dec 12, 2o15 Y. Chow and J. Cabrera
airwayNautics 
Pingback: Definitive airway on BMI 92 hypoxic hypercapnic respiratory failure | Prehospital and Retrieval Medicine - THE PHARM dedicated to the memory of Dr John Hinds
Great work. You indeed actually make it look very easy. Since you asked if I would do anything different had I been in your place… Since there is a documented failed D/L earlier but a successful glidescope intubation, I would have probably gone for glidescope intubation as my first approach.
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Yes, a good idea to start with what worked last time (especially, if details, video, or direct consult is available). However, that may have been the limit of resources at that institution, and they got lucky. It’s likely with the needed lip-pull that the patient’s mouth is small or soft-tissues are heavily redundant.
The greatest danger with this patient is mass and flaccidity with paralysis. Manual laryngoscopy will be very fatiguing with head elevation not optimized due to air mattress. Consider:
*helper to elevate head & neck, prn.
*helper facing patient to assist with two-handed jaw thrust behind mandibular rami, or if need be overhead jaw hook towards the sky. These greatly lessen work of laryngoscopy and more widely open airway while tautening the soft-tissues.
Was the patient sedated during NIPPV, a la DSI? With Ketamine or Scopolamine to obliterate consciousness without paralysis, natural tone would persist. Conduit intubation would be ideal to maintain oxygenation & ventilation. I.e., Fastrach Intubating LMA, or other second-generation SGA designed for intubation. These are low-cost widely distributed equipment, and would maintain space between the tissues to the glottis without effort and some shielding of the peri-glottic area from contamination.
A better solution would be to use an endoscopic mask, a bronchoscopy swivel, from the beginning of NIPPV, and an optical stylet or A-scope, or chip nasopharyngoscope within the ETT to guide and drive where you go with the tube. An intubating OPA such as Ovassapian or Williams could help make space, in addition to those helpers. If no optical device, the Frova Intubating Catheter can be used to “sniff” CO2 via its hollow core if patient is still breathing or is ventilated. This could be a nice seamless transition without loss of tone that might be catastrophic.
Remember, too, that a nasal tube more easily gets behind and underneath the tongue and has a good natural axis to the glottis. Use Oxymetazoline to constrict the nasal tissues, generous lubrication, and a sensitive hand. Recall that morbidly obese patients often have narrowed nasal passages due to weight and have chronic congestion; rebound nasal congestion is also an effect of CPAP therapy. Jaw thrust may help if the pharynx is lax.
The #11 blade is small; a #10 may do faster work, and it may be necessary to undermine subcutaneous fat. Whatever your favorite tool, (finger, bougie, tracheal hook, or twisted scalpel handle) be sure to have something to keep that hole open! An endotracheal tube will give you more length than a tracheostomy cannula.
Such patients are often crumping in the ED at night, after struggling at home all day. If you have resources to send the patient to the OR with anesthesiology and ENT, you can be doing him the best favor and chance for safe success while also seriously disimpacting your ED.
An article that may be useful:
Doyle, D. J., Zura, A., Ramachandran, M., Lin, J., Cywinski, J. B., Parker, B., … & Lorenz, R. R. (2007). Airway management in a 980-lb patient: use of the Aintree intubation catheter. Journal of clinical anesthesia, 19(5), 367-369. PMID: 17869989. DOI: 10.1016/j.jclinane.2006.08.015
My own opinions; please preplan and assure validity to your own practice.
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