George Kovacs left a great comment on the hemoptysis post:
Great discussion. Unfortunately with these cases getting the tube is THE major problem before we consider any bronchoscopic intervention. Here are my pearls based on experience and cadaveric simulations:
- Call for help: Patients with massive pulmonary hemorrhage die. Respect hemoptysis especially related to tumors or scenarios where there is an erosion into a vessel. They're ok until they're not and then its often too late,
- Send someone to the chart/x-ray to get info as to which side the pathology is on
- Raising the bed will help allow you to lift the epiglottis out of the pool of blood and see it more easily.
- Do the Ducanto thing… SALAD
- Hope that the disease is on the left. If you know this use a bougie and 1/4 turn to the right once (if) you feel clicks and place gently until holdup then go ahead with a BFT. As per the study quoted in this piece we have been able to consistently cannulate the bronchus of choice using a bougie in cadavers.
- If you are not sure of the side they are bleeding from then we would suggest a poor man's isolation technique using a 7.0 ETT and intubating the RM bronchus either with or without a bougie. The left side can then be accessed with a bougie again by a 1/4 turn to the left once in the trachea and advancing until gentle hold up at ~30 cm and placing a second 7.0 ETT. Yes I know that a bronch won't like these tubes but otherwise there is no opportunity for subsequent therapy as the patient drowns. It's an awful death. You can block the offending side with a foley.
- If bleeding is too much and SALAD etc approach fails… these patients die. One device that will be returning to the market developed here in Halifax is the lightwand and its the only device out there that will consistently be successful in a soiled airway…. IF YOU HAVE IT AND IF YOU HAVE EXPERIENCE WITH IT which most don't. It has saved my ass numerous times.
- If you can't see from above then FONA is indicated use a small ETT 5.0 and push it too hilt will usually go to RM bronchus. You will either be able to oxygenate or divert blood so now you can put a second tube in if necessary from above. Used a 5.0 ETT because takes up less real estate for second tube to pass from above.
- When your consultant comes down and complains about the size of tubes that are in place resist telling them to fuck off.
Now on to the Wee…
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Scott Weingart
An ED Intensivist from NY.
Build it…and they will come.
I’m going to build the “PumlCrit SALAD” modifications for us to simulate this on an airway mannequin for Oren (he has a course we’ll run it at Sept. 11th at Cedars-Sinai(. Video, photos, and laughter to follow.),
We will try the 4.0 microlaryngeal tube with a 7.5 or even 8,0 in the mannequin, then bronch away. Hopefully I’ll get the largest Ambu Ascope endoscope for this demonstration (hopefully it’s suction and working channel can be up to the job).
15 fr bougie and 10 fr bougie needed (they can both fit down an existing ETT together side by side, allowing removal of the that tracheal tube, placement of the microlaryngeal tube in the “good” lung’s mainstem bronchus, then the bigger tube in the trachea to allow for bronchoscopy.
Need more Shoo-Goo and vinyl tubing now….
I’ll open source these mods when I work them out and glue has dried.
From the #SALADLeagueOf Nations, I bid you good day!
sweeeeet!!
In the podcast you mention that double lumen tubes are crap. Why? They work great for lung isolation. Disclosure – I’m an anesthesiologist. BTW, just found the podcast recently. I love it and I’m learning a ton!
Great MacGyver..manuevers.
Need to rehearse them in the simulation lab.
Harder to get double lumen endotracheal tubes in my resuscitation bay.
These are acute immediate life-threatening unusual situations. Please escort Dr. MacGyver to the exit door. If DLTs, costing approximately $85 CAD each, are hard to come by in your ED, ask for the anesthesiologist to bring down one for you, or order a couple. Have the best most experienced person insert it. 37L fits most. IMHO, there is no place for ‘this may work’ strategies in the drowning patient.
Can you give some more info on the return of the lightwand? Who will be producing it and when?
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I work in a rural setting without any specialist on site, no bronchoscope, and transport to high level care is about 1 hour drive. Do you think that after lung isolation with double tube technique (whether cric + supraglottic, or both supraglottic), a whole lung lavage with iced water could be tried via the appropriate ETT ? Pubmed shows descriptions in the cases of pulmonary alveolar proteinosis where 40-50L are flushed. So feels like doing a 1L flush in ER would be feasible.
doesn’t strike me as a great idea. prob better off neb some txa through the tube to the bleeding side