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