The Physiologic Difficult Airway with Dr. Proshad Efune
Oct 2, 2023
auto_awesome
Dr. Proshad Efune, a dual-trained intensivist in pediatric ICU and pediatric anesthesiology, discusses the physiologic difficult airway. Topics include high-risk scenarios for cardiovascular collapse during intubation and approaches to minimize risk. They also explore challenges in intubating young children with bronchiolitis, rapid sequence induction in pediatric patients, and the challenges of mask ventilation and ECMO readiness.
Extensive preoxygenation and premedication using albuterol are recommended to optimize intubation in infants with bronchiolitis.
Fluid loading and increased infusion rate of vasoactive agents are crucial to prevent cardiovascular collapse in patients with septic shock during intubation.
Deep dives
Physiologic Difficult Airway
Intubating infants with bronchiolitis presents several challenges, including the risk of bronchospasm, hypoxemia, and upper airway obstruction. To optimize intubation in these cases, extensive preoxygenation is recommended, along with premedication using albuterol to reduce airway reactivity. Propofol is the preferred induction agent due to its bronchodilating properties. Paralysis is usually necessary, and rocurophonium is commonly used. Attention should be given to avoid mask ventilating these infants, as it may exacerbate airway resistance. If bronchospasm occurs after intubation, administration of albuterol via the endotracheal tube may help, but if ventilation is ineffective, more propofol can be given.
Septic Shock Intubation
Intubation in patients with septic shock can lead to cardiovascular collapse and intracranial hypertension, requiring careful optimization. Fluid loading, including additional fluid prior to intubation, is crucial to prevent cardiovascular instability. The infusion rate of vasoactive agents should be increased beforehand to anticipate worsening hypotension. Use of an H2 blocker prior to intubation can reduce the risk of aspiration. Ketamine is the preferred induction agent, as it can prevent and treat bronchospasm. Preparing for potential ecmo (extracorporeal membrane oxygenation) readiness by contacting the surgeon and having code meds readily available is essential.
Asthma Exacerbation Intubation
Intubating a patient with a severe asthma exacerbation poses a high risk due to the potential for cardiovascular collapse and exacerbation of bronchospasm. Mental status is a crucial factor in determining when to intubate, with somnolence or unresponsiveness indicating a heightened risk of respiratory arrest. Optimizing the patient's condition with volume loading and low-dose epinephrine infusion is recommended. Preoxygenation and the use of ketamine or a ketamine-propofol cocktail for induction can mitigate risks. Intubation should be delayed unless the patient arrests or the pericardial tap is needed urgently.
Pericardial Tamponade Intubation
Intubating a patient with pericardial tamponade carries a high risk of cardiovascular collapse due to fluid shifts caused by induction drugs and positive pressure ventilation. Attempting intubation is discouraged unless the patient is in cardiac or respiratory arrest. In an emergent setting, ketamine can be used, and the airway should be continuously monitored. If time allows, optimizing the patient's condition through controlled volume loading, vasoactive infusions, and maintaining spontaneous ventilation is crucial. Using anesthetic gas sparingly is an option if necessary. Intubation should be attempted only in extenuating circumstances.
Proshad Efune, MD is an Assistant Professor at UT Southwestern. She completed both her pediatric critical care and pediatric anesthesia fellowships here at UT, and she now practices in both the operating room and the pediatric ICU here at Children’s Medical Center in Dallas. She is interested in pre-operative management of critically ill children.
Learning Objectives After listening to this episode, learners should be able to:
Identify clinical scenarios at high risk for cardiovascular collapse surrounding endotracheal intubation.
Discuss a clinical approach to minimize the risk of peri-intubation cardiovascular collapse in the following high-risk scenarios:
How to support PedsCrit: Please complete our Listener Feedback Survey Please rate and review on Spotify and Apple Podcasts! Donations are appreciated @PedsCrit on Venmo , you can also support us by becoming a patron on Patreon. 100% of funds go to supporting the show.
Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.comfor detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updates.
Get the Snipd podcast app
Unlock the knowledge in podcasts with the podcast player of the future.
AI-powered podcast player
Listen to all your favourite podcasts with AI-powered features
Discover highlights
Listen to the best highlights from the podcasts you love and dive into the full episode
Save any moment
Hear something you like? Tap your headphones to save it with AI-generated key takeaways
Share & Export
Send highlights to Twitter, WhatsApp or export them to Notion, Readwise & more
AI-powered podcast player
Listen to all your favourite podcasts with AI-powered features
Discover highlights
Listen to the best highlights from the podcasts you love and dive into the full episode