UBP 6.5 (Long Form): ENT – Submandibular Abscess Flashcards
Secondary Subject -- Down Syndrome/Airway Management/Atlanto-Occipital Dislocation/Preoperative Respiratory Distress/Full Stomach/Difficult Intravenous Access/Subglottic Stenosis/Bronchospasm/ Pulmonary Aspiration/Ventilator Management
Intra-operative Management:
What is your plan for intubation?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
Given the patient’s respiratory distress and the potential difficulty of laryngoscopic intubation in this patient with a submandibular abscess, minimal mouth opening, large protruding tongue, excessive oral secretions, and characteristic airway abnormalities of Down syndrome,
my preference would be to perform an awake intubation or tracheostomy with local anesthesia.
My goals are to safely secure the airway while maintaining spontaneous ventilation, avoiding hypoxia, and avoiding aspiration.
To this end, I would attempt to explain my concerns to the patient and her mother, reassuring them that I would provide minimal sedation and adequate airway analgesia prior to either procedure.
However, considering her level of cooperation preoperatively, I think it unlikely that she would tolerate either of these procedures awake.
Therefore, I would –
- get emergency airway equipment in the room,
- have a surgeon available to obtain an emergency airway,
- prep and drape the patient for possible tracheostomy,
- have someone apply cricoid pressure with a sterile glove,
- administer a sedative dose of ketamine,
- place the patient in slight trendelenburg position,
- suction the mouth,
- perform a slow controlled inhalational induction,
- maintain spontaneous respirations, and
- perform a careful fiberoptic intubation.
While this approach carries increased risk of aspiration, it would:
- avoid inducing apnea, which could quickly lead to hypoxia;
- avoid excessive neck flexion, which could lead to atlanto-occipital dislocation; and
- allow for immediate surgical intervention, if required.
Intra-operative Management:
During fiberoptic intubation, you are unable to advance the ETT more than one centimeter beyond the vocal cords. What do you think? What will you do?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
This subglottic obstruction may be secondary to –
compression from the abscess or from the subglottic stenosis often associated with Down syndrome.
In either case, I would first attempt to pass a smaller endotracheal tube and,
if this failed, I would suggest that the surgeon infiltrate the skin with local anesthetic and perform a tracheostomy.
During the procedure, I would be prepared to treat aspiration, laryngospasm, bronchospasm, or apnea should they occur.
Intra-operative Management:
After successful tracheostomy, you give a dose of Vecuronium and begin positive pressure ventilation. Her blood pressure falls to 74/30 mmHg. What do you think might be the cause of this acute hypotension?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
Given the timing, this hypotension is most likely secondary to –
- depth of anesthesia or
- decreased venous return resulting from increased intrathoracic pressure with positive pressure ventilation.
Other potential causes would include –
- histamine-induced vasodilation,
- sepsis,
- anaphylaxis,
- surgical bleeding,
- tension pneumothorax,
- cardiac failure, or
- arrhythmia.
Intra-operative Management:
What would you do?
(After successful tracheostomy, you give vecuronium and begin positive pressure ventilation. Pt’s BP falls – acute hypotension)
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
I would inform the surgeon, place the patient in trendelenburg position, hand ventilate, decrease my inhalational agent, give a fluid bolus, check my EKG, inspect the surgical field, auscultate the chest, inspect the skin for signs of allergic reaction, and treat with vasopressors as necessary.
Intra-operative Management:
Is sepsis the likely cause of this hypotensive episode?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
Given her fever and the fact that she has a known infection that has been developing over several days, it is possible that sepsis played some role in her acute hypotension.
However, considering the timing and acute nature of the episode, it is more likely that hypovolemia in conjunction with decreased venous return from positive pressure ventilation and/or anesthetic-induced cardiovascular depression is the primary etiology.
Intra-operative Management:
As the case progresses, the saturation suddenly falls to 80%. What would you do?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
I would –
- hand ventilate with 100% oxygen,
- auscultate the chest,
- listen for air leak around the tracheostomy site,
- check the tidal volume and airway presures,
- check the capnography and SpO2 waveforms,
- check the EKG, and
- ensure adequate perfusion.
Depending on what I found, I would – add air to the tracheostomy cuff, administer bronchodilators, adjust the ventilator settings, deepen the anesthetic, or increase blood pressure.
Intra-operative Management:
You hear bilateral wheezing and notice decreased lung compliance with hand ventilation. What do you think is going on?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
The most likely cause of diffuse wheezing and hypoxia is –
bronchospasm, which could be due to – light anesthesia, blood or purulent material in the tracheobronchial tree, reactive airway disease, or aspiration.
However, these physical findings could also be the result of – pulmonary embolism, CHF, or anaphylaxis.
If I believed this to be bronchospasm, I would –
hand ventilate with 100% oxygen, deepen my anesthetic, and administer bronchodilators.
If the bronchospasm were severe with worsening hypoxemia, I would consider – a small dose (5-10 mcg) of IV epinephrine.
Intra-operative Management:
Is it possible for this patient to aspirate with a tracheostomy in place?
What are the symptoms of aspiration?
When do they present?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
It is possible to aspirate with either an endotracheal tube or tracheostomy tube in place.
Aspiration produces a chemical pneumonitis characterized initially by – hypoxemia, bronchospasm, and atelectasis.
The earliest physiologic change following aspiration is – intrapulmonary shunting, resulting in hypoxia.
Other changes may include – pulmonary edema, pulmonary hypertension, and hypercapnia.
It should also be recognized that, although a patient may look well in the immediate period following aspiration, without rhonchi or wheezes on auscultation, respiratory distress may still yet develop.
It may take as long as 6 to 12 hours before the syndrome manifests itself.
Therefore, if aspiration were suspected, I would observe the patient closely for 24 to 48 hours.
Intra-operative Management:
If you believed the patient had aspirated, what would you do?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
I would immediately –
- place the patient in the trendelenburg position,
- add air to the tracheostomy cuff, and
- suction the trachea and oropharynx.
Post-operative management would include – keeping the patient intubated, following arterial blood gases, and obtaining serial chest x-rays.
Regulation of the inspired oxygen concentration, tidal volume, and PEEP, may be necessary to optimize ventilation and oxygenation.
Bronchoscopy, pulmonary lavage, and broad-spectrum antibiotics are only indicated in patients who have aspirated solid material resulting in significant airway compromise.
Intra-operative Management:
Would you administer steroids or antibiotics?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
I would NOT give steroids at this time since they have not been shown to help in the immediate post-aspiration period and are not currently recommended.
Likewise, the routine use of prophylactic antibiotics is NOT recommended because antibiotic treatment may alter the normal flora and promote colonization of resistant organisms.
However, antibiotics should be administered to patients with secondary bacterial pulmonary infection demonstrated by positive Gram stain and cultures.
Post-operative Management:
Does this patient need to go to the ICU or can she be monitored on the floor?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
This patient with a newly placed tracheostomy, suspected aspiration, and possible sepsis, would require a level of care and close monitoring that would only be possible in the ICU.
This patient will require intensive care while she is assessed for aspiration syndrome and sepsis, and while she is being weaned from the ventilator.
Post-operative Management:
During transport the SpO2 falls to 80%.
You quickly evaluate the situation and notice air leaking around the tracheostomy site.
You then realize that the tracheal tube has become dislodged from its original position.
The SpO2 is now 65%.
What will you do?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
I would send someone for a surgeon and difficult airway equipment, and
quickly attempt to replace the tracheostomy tube.
If this were unsuccessful, I would attempt to intubate her under direct laryngoscopy or try to place a small endotracheal tube or nasal trumpet through the tracheostomy site.
If these measures were also unsuccessful, I would plug the tracheostomy opening, attempt to mask ventilate, and quickly transport the patient back to the OR to surgically obtain an airway.
Post-operative Management:
You perform direct laryngoscopy and are able to pass a 4.0 ETT beyond the tracheostomy site. Her SpO2 icnreases to 94%. Will a 4.0 ETT allow sufficient ventilation of this patient?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
Although her oxygen saturation has improved, a 4.0 ETT would create significant airway resistance and not provide adequate access for long-term ventilation.
Additionally, the cuff on a 4.0 ETT may not be sufficient to provide a reliable seal within the trachea, making positive pressure ventilation difficult and increasing the risk for further aspiration.
Post-operative Management:
How would you establish a long-term airway in this patient?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
I would take this patient back to the operating room where the tracheostomy tube could be replaced by a surgeon under controlled conditions.
My plan would be to maintain the patient’s airway with the 4.0 ETT until the surgeon was ready to insert the tracheostomy tube.
I would then retract the ETT just cephalad of the tracheostomy site, until the tracheostomy tube was positioned and secure.
Post-operative Management:
After replacement of the tracheostomy, the patient still requires high airway pressures to maintain adequate tidal volumes.
What mode of ventilation would you choose for this patient?
- (An 18-year-old, 124 kg, female presents for incision and drainage of a large submandibular/sublingual abscess. The patient was uncooperative with IV placement and preoperative studies.*
- HPI: The patient has Down syndrome and is uncooperative. Her mother, who is her caretaker, states she has noticed significant drooling and difficulty swallowing over the last 2 days. She also reports that the patient had part of a bowl of soup one hour ago.*
- PMH: Her past medical history is significant for Down syndrome and frequent urinary tract infections. The mother says her daughter’s heart has been evaluated, and she was told everything was normal.*
- Meds: Macrobid, Multi-vitamin, oral birth control pills*
- Allergies: NKDA*
- PE: Vital Signs: BP = 140/90, P = 77, RR = 25, T = 103.5ºF, SaO2 = 91% on room air.*
- Airway exam: She has a large protruding tongue and a swollen submandibular space. She is drooling and making snoring sounds with each respiration. She is unable to open her mouth more than 2 cm and was uncooperative with further examination.*
- Cardiac: RRR*
- Lungs: During auscultation of the chest, decreased breath sounds are heard bilaterally.*
- Labs: WBC = 21, Hgb = 14 gm/dL, Urine HCG = negative*
- CT: The patient was uncooperative for CXR and CT)*
I would place the patient on pressure-controlled ventilation,
as this would limit peak inspiratory pressure by allowing low tidal volumes.
The goal of ventilatory management would be – to minimize volutrauma, barotrauma, and shearing forces caused by the frequent collapse and opening of alveolar units.
If oxygenation were inadequate, I would first titrate the Fio2 up to 60%, and then add PEEP to recruit additional alveoli with the goal of avoiding higher inspired oxygen concentrations that increase the risk of oxygen toxicity.
