October 2021 Critical Care Case of the Month: Unexpected Post-Operative Shock

Sharanyah Srinivasan MBBS

Sooraj Kumar MBBS

Benjamin Jarrett MD

Janet Campion MD

University of Arizona College of Medicine, Department of Internal Medicine and Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Tucson, AZ USA

History of Present Illness 

A 55-year-old man with a past medical history significant for endocarditis secondary to intravenous drug use, osteomyelitis of the right lower extremity was admitted for ankle debridement. Pre-operative assessment revealed no acute illness complaints and no significant findings on physical examination except for the ongoing right lower extremity wound. He did well during the approximate one-hour “incision and drainage of the right lower extremity wound”, but became severely hypotensive just after the removal of the tourniquet placed on his right lower extremity. Soon thereafter he experienced pulseless electrical activity (PEA) cardiac arrest and was intubated with return of spontaneous circulation being achieved rapidly after the addition of vasopressors. He remained intubated and on pressors when transferred to the intensive care unit for further management.

PMH, PSH, SH, and FH

• S/P Right lower extremity incision and drainage for suspected osteomyelitis as above
• Distant history of endocarditis related to IVDA
• Not taking any prescription medications
• Current smoker, occasional alcohol use
• Former IVDA
• No pertinent family history including heart disease

Physical Exam

• Vitals: 100/60, 86, 16, afebrile, 100% on ACVC 420, 15, 5, 100% FiO2
• Sedated well appearing male, intubated on fentanyl and norepinephrine
• Pupils reactive, nonicteric, no oral lesions or elevated JVP
• CTA, normal chest rise, not overbreathing the ventilator
• Heart: Regular, normal rate, no murmur or rubs
• Abdomen: Soft, nondistended, bowel sounds present
• No left lower extremity edema, right calf dressed with wound vac draining serosanguious fluid, feet warm with palpable pedal pulses
• No cranial nerve abnormality, normal muscle bulk and tone

Clinically, the patient is presenting with post-operative shock with PEA cardiac arrest and has now been resuscitated with 2 liters emergent infusion and norepinephrine at 70 mcg/minute.

What type of shock is most likely with this clinical presentation?

1. Cardiogenic shock
2. Hemorrhagic shock
3. Hypovolemic shock
4. Obstructive shock
5. Septic / distributive shock

Cite as: Srinivasan S, Kumar S, Jarrett B, Campion J. October 2021 Critical Care Case of the Month: Unexpected Post-Operative Shock. Southwest J Pulm Crit Care. 2021;23(4):93-7. doi: https://doi.org/10.13175/swjpcc041-21 PDF 

Impact of In Situ Education on Management of Cardiac Arrest after Cardiac Surgery

Bhargavi Gali, M.D.¹

Grace M. Arteaga, M.D.²

Glen Au, R.N., C.C.R.N.³

Vitaly Herasevich, M.D., Ph.D.¹

¹Division of Anesthesia-Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine

²Division of Pediatric Critical Care Medicine, Department of Pediatric and Adolescent Medicine

³Department of Nursing

Mayo Clinic

Rochester, Minnesota USA

Abstract

Background:  Advanced life support interventions have been modified for patients who have recently undergone sternotomy for cardiac surgery and have new suture lines. We aimed to determine whether the use of in-situ simulation increased adherence to the cardiac surgery unit-advanced life support algorithm (CSU-ALS) for patients with cardiac arrest after cardiac surgery (CAACS).

Methods:  This was a retrospective chart review of cardiac arrest management of patients who sustained CAACS before and after implementation of in-situ simulation scenarios utilizing CSU-ACLS in place of traditional advanced cardiac life support.  We utilized classroom education of CSU-ACLS followed by in-situ high-fidelity simulated scenarios of patients with CAACS..  Interprofessional learners (n = 210) participated in 18 in-situ simulations of CAACS.  Two groups of patients with CAACS were retrospectively compared before and after in situ training (preimplementation, n=22 vs postimplementation, n=38).  Outcomes included adherence to CSU-ALS for resuscitation, delay in initiation of chest compressions, use of defibrillation and pacing before external cardiac massage, and time to initial medication.

Results:  Chest compressions were used less often in the postimplementation vs the preimplementation period (11/22 [29%] vs 13/38 [59%], P = 0.02).  Time to initial medication administration, use of defibrillation and pacing, return to the operating room, and survival were similar between periods.  

Conclusion:  In this pilot, adherence to a key component of the CSU-ALS algorithm—delaying initiation of chest compressions—improved after classroom combined with in-situ simulation education.

Abbreviations

• ACLS, advanced cardiac life support
• CAACS, cardiac arrest after cardiac surgery
• CPR, cardiopulmonary resuscitation
• CSICU, cardiac surgical intensive care unit
• CSU-ALS, cardiac surgical unit–advanced life support EACTS, European Association for Cardio-Thoracic Surgery
• IQR, interquartile range
• STS, Society of Thoracic Surgeons

Introduction 

Immediate and appropriate resuscitation of patients with cardiac arrest has been called “the formula for survival” (1). Patient-specific and cause-specific resuscitation algorithms have been developed to optimize management and outcome measures (2). Advanced cardiac life support (ACLS) interventions are modified for special causes, environments, and patient populations. Patients who have recently undergone sternotomy for cardiac surgery and have new suture lines is one of these groups.

Because of their unique circumstances and physiologic conditions, patients who have recently undergone cardiac surgery benefit from modified cardiac-arrest management protocols. A recent consensus guideline by The Society of Thoracic Surgeons (STS) recommends use of a postcardiac surgery–specific resuscitation protocol prepared by the European Association for Cardio-Thoracic Surgery (EACTS), hereafter called the STS/EACTS protocol (3). In contrast to ACLS guidelines(4), the STS/EACTS protocol is based on recent sternotomy and increased risks of cardiac tamponade and cardiac ventricular rupture. The STS/EACTS protocol recommends sequential attempts at defibrillation before administration of chest compressions, administration of low-dose epinephrine, use of pacing to manage severe bradycardia or asystole, and immediate consideration of resternotomy (Table 1).

Because poststernotomy patients have new suture lines, they are at risk for comorbid conditions (e.g., cardiac tamponade, ventricular rupture) if external chest compressions are used (4). The cardiac surgical unit–advanced life support (CSU-ALS) protocol emphasizes use of defibrillation and delayed use of chest compressions (Table 1). In-situ simulation-based education has been shown to be an effective method for training in high-risk, low-frequency resuscitation situations (5). During in-situ simulation-based education, health care providers receive training in their clinical work environment.

A systematic review and meta-analysis of 182 studies reported that simulation-based training was highly effective in improving knowledge and process skill (6).

The STS/EACTS protocol was introduced to the CSICU in April 2014.  The CSICU team members, who all had background training in ACLS, received classroom-based education on the application of the cardiac surgery unit–advanced life support (CSU-ALS) algorithm. In-situ simulation-based training with resuscitation scenarios offered the team members the experimental application of the STS/EACTS resuscitation protocol-CSU-ALS protocol.  We hypothesized that adherence to the CSU-ALS protocol for the treatment of patients with CAACS would improve after a pilot implementing in-situ simulations with our CSICU team members.

Methods

After obtaining approval from the Mayo Clinic Institutional Review Board, we performed a single-center, retrospective review of the electronic health records of patients with CAACS. Only the records of patients that had consented to have their data utilized for research were included. The CONSORT 2010 Checklist was utilized in preparation of this manuscript. We identified patients who were treated before (October 2013 through March 2014; preimplementation period) or after simulation training (October 2015 through March 2016; postimplementation period). technicians; in total, 210 participants, took part in 18 simulations.  All participants, except the pharmacists, respiratory therapists, and phlebotomists, had participated in CSU-ALS classroom education.  No repeat participants were included in these sessions.  A combined 35% of our CSICU staff participated.

Included patients were those admitted to the CSICU after sternotomy for cardiac surgery, specifically patients who had undergone sternotomy and a cardiac surgical procedure (including those who underwent initiation of central extracorporeal membrane oxygenation). Patients from the above group who had cardiac arrest within the first 14 days after sternotomy for cardiac surgery were included. We excluded inpatients who were in the CSICU 14 days after their original sternotomy at time of cardiac arrest.

The educational in-situ simulations portrayed adult patients with cardiac arrest immediately after cardiac surgery. The details of the simulation have been previously published (7). Briefly, the learning objectives were established according to the CSU-ALS protocol. Before the simulation, a facilitator familiar with the CSU-ALS protocol reviewed it with the participants and discussed the differences compared to ACLS. Cardiopulmonary resuscitation (CPR) was defined as basic life support with use of the ACLS algorithm, airway management, greater epinephrine doses, and chest compressions initiated immediately after rhythm check; ACLS included all algorithms used in resuscitation, as recommended by the American Heart Association (4). In contrast to ACLS, CSU-ALS emphasizes the need to initially defibrillate rather than to perform chest compressions.  A patient room inside the CSICU was used as the scenario set-up. A high-fidelity mannequin was endotracheally intubated and mechanically ventilated. The simulation timeline involved 10 to 15 minutes for the case development and followed by a reflective debriefing period of 10 to 15 minutes.

The participating interprofessional team included critical care nurses, critical care fellows, cardiac surgical fellows, critical care physicians, pharmacists, nurse practitioners, respiratory therapists, and phlebotomy participants were included in these sessions. A combined 35% of our CSICU staff participated.

We collected data on patient demographic characteristics, surgical procedures and dates, specific cardiac arrest characteristics (initial cardiac rhythm and presumed cause), and resuscitation characteristics (return to the operating room for resternotomy [yes or no], intubation [yes or no], and survival of event [yes or no]).

The primary outcome measure in our scenarios was the use of defibrillation with successive “stacked” shocks prior to the standard ACLS, which recommends immediate initiation of chest compressions (7). Secondary outcome measures included time to initiation of chest compressions, time to use of ventricular defibrillation and pacing, and time to initial medication administration.

Statistical Analysis

Results are reported with descriptive statistics. All continuous variables are summarized as median (interquartile range [IQR]) or mean (SD) as appropriate, and we used the Wilcoxon rank sum test to compare the means and medians of continuous variables. Categorical data are summarized as number (percentage), and we used the Fisher’s exact test to compare categorical variables. Two-tailed hypothesis testing was used, and P < 0.05 was considered significant. Analysis was performed with JMP Pro 14.1.0 (SAS Institute Inc; Cary, North Carolina) and Microsoft Excel 2010 version 14 (Microsoft Corp; Redmond, Washington).

Results

Sixty patients met the inclusion criteria. We identified 22 patients in the preimplementation period (10 women, 45%) and 38 patients in the postimplementation period (12 women, 32%). In the preimplementation group, 6/22 patients (27%) received extracorporeal membrane oxygenation, compared with 8/38 patients (21%) in the postimplementation group.  Initial presentation and etiology of the arrests in the pre- and postimplementation period are presented in Table 2.

The use of chest compressions was 59% (preimplementation: 13/22 patients) vs 29% (the postimplementation phase 12/38 patients) (P = 0.02) and standard CPR (22/22 patients [100%] vs 27/38 patients [71%], P < 0.001) respectively (Table 2).  Median (IQR) time from onset of cardiac arrest to initiation of chest compressions was 1 minute (1-1.5 minutes) in the preimplementation period and 1.5 minutes (1-5 minutes) in the postimplementation period; these findings were statistically similar (P = 0.11) (Figure 1).

Median time to initial medication administration was similar between periods (P = 0.11).  However, in the preimplementation period, one patient was administered medication 47 minutes after cardiac arrest.  This result was an outlier (Figure 2). 

Similar percentages of patients received defibrillation to manage ventricular fibrillation or tachycardia (14/22 patients [64%] in the preimplementation period vs 20/38 patients [53%] in the postimplementation period, P = 0.40), returned to the operating room for resternotomy (2/22 patients [9%] vs 3/38 patients [8%], P = 0.80), and survived the event (19/22 patients [86%] vs 32/33 patients [84%], P = 0.80) (Table 3).

Discussion

The findings in this pilot study revealed an increase in adherence to CUS-ALS principles in CAACS when online courses are followed by in-situ simulation-based education.  Our preliminary data show a decrease in the use of standard CPR and chest compressions to manage CAACS.  These results suggest that in situ simulation–based training may potentially increase adherence to alternative resuscitation protocols for special patient populations and circumstances.

Mundell et al. (6) described how team training, including practice of interactions during resuscitation with provision of feedback, positively affected trainee satisfaction, knowledge, time to action, and process skill outcomes.  In addition, a recent systematic review and meta-analysis of observational studies reported a positive association between participation in ACLS courses and patient outcomes, including return of spontaneous circulation (8).

The current study provides preliminary evidence that in situ simulation-based training improves clinical performance.  Participation in simulation-based training allowed our CSICU team members to apply classroom-based knowledge in an experiential-learning environment, thereby improving their clinical performance of CSU-ALS protocol when they managed high-risk events.

We were able to educate our team members about a key component of the CSU-ALS protocol-namely, delay initiation of chest compressions and standard CPR. Our study did not find significant differences between groups for time to medication administration, use of defibrillation, return to the operating room, or survival.  Because this study was retrospective, we were unable to determine whether our CSICU team members who participated in simulation-based training subsequently resuscitated patients after the CSU-ALS protocol was implemented at our institution.  This could have affected our ability to assess the effects of in situ simulation–based training on clinical management.

Limitations

Our study has limitations is its retrospective design and involvement of 35% of staff with the in-situ simulations.  Documentation of cardiac arrest has improved at our institution, but one patient in the preimplementation period had a long-documented time from cardiac arrest to initial medication administration (47 minutes); this result was an outlier and was most likely a charting error.  

Another limitation was our inability to exactly determine which CSICU team members who treated patients in the postimplementation period had participated in in situ simulation-based training. based on de-identified data collection, one-third of our CSICU staff participated in this educational experience. 

Due to our limited number of arrests, alterations in outcomes based on in situ simulation would not likely be noted.  In situ simulation–based training improves cardiac arrest management and provides health care personnel a safe environment to practice interventions, which subsequently improves patient safety.[6, 12-14]  Further prospective studies of  the use of in situ simulation–based training may help determine the true effectiveness of this tool in educational and clinical practices that use specific resuscitation algorithms and highlight the relationship to patient outcomes and patient safety.

Conclusions

Analysis of the effects of in situ simulation-based training in the clinical setting showed a significant beneficial decrease in the use of chest compressions for the management of CAACS in patients who recently had undergone sternotomy.  Increased adherence to the CSU-ALS protocol could improve the outcome measures of patients with CAACS and decrease the deleterious effects of chest compressions after recent sternotomy with the expectation of decreased complications and ultimately, improved clinical outcomes.  As this was a small pilot study, further investigation with use of in-situ simulation in special circumstances would help determine its utility as an educational tool for high risk low frequency events.

References

1. Søreide E, Morrison L, Hillman K, Monsieurs K, Sunde K, Zideman D, Eisenberg M, Sterz F, Nadkarni VM, Soar J, Nolan JP; Utstein Formula for Survival Collaborators. The formula for survival in resuscitation. Resuscitation. 2013 Nov;84(11):1487-93. [CrossRef] [PubMed]
2. Truhlář A, Deakin CD, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation. 2015 Oct;95:148-201. [CrossRef] [PubMed]
3. Advanced Cardiovascular Life Support (ACLS) American Heart Association 2020 Guidelines for CPR and ECC Available at: https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines , Accessed July1, 2021.
4. Society of Thoracic Surgeons Task Force on Resuscitation After Cardiac Surgery. The Society of Thoracic Surgeons Expert Consensus for the Resuscitation of Patients Who Arrest After Cardiac Surgery. Ann Thorac Surg. 2017 Mar;103(3):1005-1020. [CrossRef] [PubMed]
5. Greif R, Lockey AS, Conaghan P, Lippert A, De Vries W, Monsieurs KG.  European Resuscitation Council Guidelines for Resuscitation 2015: Section 10. Education and implementation of resuscitation. Resuscitation. 2015;95:288-301. [CrossRef] [PubMed]
6. Mundell WC, Kennedy CC, Szostek JH, Cook DA. Simulation technology for resuscitation training: a systematic review and meta-analysis. Resuscitation. 2013 Sep;84(9):1174-83. [CrossRef] [PubMed]
7. Gali B, Au G, Rosenbush KA. Simulation Incorporating Cardiac Surgery Life Support Algorithm Into Cardiac Intensive Care Unit Practice. Simul Healthc. 2016 Dec;11(6):419-424. [CrossRef] [PubMed]
8. Lockey A, Lin Y, Cheng A. Impact of adult advanced cardiac life support course participation on patient outcomes-A systematic review and meta-analysis. Resuscitation. 2018 Aug;129:48-54. [CrossRef] [PubMed]
9. Fernández Lozano I, Urkía C, Lopez Mesa JB, Escudier JM, Manrique I, de Lucas García N, Pino Vázquez A, Sionis A, Loma Osorio P, Núñez M, López de Sá E. European Resuscitation Council Guidelines for Resuscitation 2015: Key Points. Rev Esp Cardiol (Engl Ed). 2016 Jun;69(6):588-94. [CrossRef] [PubMed]
10. Dunning J, Fabbri A, Kolh PH, Levine A, Lockowandt U, Mackay J, Pavie AJ, Strang T, Versteegh MI, Nashef SA; EACTS Clinical Guidelines Committee. Guideline for resuscitation in cardiac arrest after cardiac surgery. Eur J Cardiothorac Surg. 2009 Jul;36(1):3-28. [CrossRef] [PubMed]
11. Dunning J, Nandi J, Ariffin S, Jerstice J, Danitsch D, Levine A. The Cardiac Surgery Advanced Life Support Course (CALS): delivering significant improvements in emergency cardiothoracic care. Ann Thorac Surg. 2006 May;81(5):1767-72. [CrossRef] [PubMed]
12. Haffner L, Mahling M, Muench A, et al. Improved recognition of ineffective chest compressions after a brief Crew Resource Management (CRM) training: a prospective, randomised simulation study. BMC Emerg Med. 2017 Mar 3;17(1):7. [CrossRef] [PubMed]
13. Edwards FH, Ferraris VA, Kurlansky PA, et al. Failure to Rescue Rates After Coronary Artery Bypass Grafting: An Analysis From The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2016 Aug;102(2):458-64. [CrossRef] [PubMed]
14. Mahramus TL, Penoyer DA, Waterval EM, Sole ML, Bowe EM. Two Hours of Teamwork Training Improves Teamwork in Simulated Cardiopulmonary Arrest Events. Clin Nurse Spec. 2016 Sep-Oct;30(5):284-91. [CrossRef] [PubMed]

Acknowledgements

We would like to acknowledge Robin Williams for her work on editing and formatting the manuscript.

Cite as: Gali B, Arteaga GM, Au B, Herasevich V. Impact of In Situ Education on Management of Cardiac Arrest after Cardiac Surgery. Southwest J Pulm Crit Care. 2021;23(2):54-61. doi: https://doi.org/10.13175/swjpcc028-21 PDF 

Single-Use Telescopic Bougie: Case Series

Evan Denis Schmitz MD

La Jolla, CA USA

Abstract

AIROD^TM is a single-use telescopic bougie that is small enough to fit into a pocket. AIROD^TM is sterile and can be expanded in hast when needed, saving precious seconds, while attempting to intubate a patient. The non-malleable bougie is able to overcome the compressive force of the oropharyngeal tissue improving the view of the vocal cords and facilitating advancement of an endotracheal tube into the trachea along with a laryngoscope. This series reports four cases of successful first pass intubation with the AIROD^TM.

Introduction

There are approximately 50 million intubations performed a year with 1/3 of those occurring in the USA. A multicenter registry of ED intubations, reporting data from 2002-2012, found that approximately 12% of intubations resulted in adverse intubation-related events such as death (1). In order to reduce the likelihood of adverse events it is imperative that the first attempt at endotracheal intubation is successful (2). Despite increasing adoption of expensive video laryngoscopy first-attempt intubation success rates are only 85% (1). The BEAM trial reported a 96% success rate in first-attempt intubation of a difficult airway with a bougie vs only 82% with endotracheal tube + stylet (3).

AIROD^TM was designed to aid in the advancement of an endotracheal tube past the vocal cords with the use of a laryngoscope (Figure 1).

Figure 1. Single-Use Telescopic Bougie in the closed (A) and extended (B) position with an endotracheal tube loaded at the distal end.

AIROD^TM can also improve the view of the vocal cords during intubation by displacing oropharyngeal tissue. The following case series demonstrates the usefulness of the AIROD^TM: each of the 4 intubations were successful on the first attempt and facilitated by the single-use telescopic bougie without causing any trauma. All intubations were performed by the author.

Case 1

A 70-year-old woman with severe COPD not on home oxygen presented with an oxygen saturation of 70%. She was found to have multi-lobar pneumonia predominately in the right upper and middle lobes. Despite bilevel positive airway pressure (BiPAP) therapy her hypoxia worsened, and she required intubation. Inspection of her oropharynx prior to intubation revealed very prominent 1^st incisors as well as canines that were eroded at the roots left worse than right. Multiple black, necrotic molars were noted, right worse than left, with a putrid odor. Her oxygen saturation, despite being on 15L nasal cannula, hovered in the low 90s. In anticipation of a difficult airway the AIROD^TM was prepared by extended the rods and ensuring the rods were in the locked position. A Miller 4 blade was gently inserted past the teeth and into the oropharynx. A grade 2 view (larynx plus the posterior surface of epiglottis) was obtained. This was immediately followed by gentle insertion of the AIROD^TM which was advanced just distal to the vocal cords. An 8.0 endotracheal tube was advanced down the AIROD^TM by the respiratory therapist while the AIROD^TM was held in position. As the endotracheal tube was advanced into the oropharynx, hand position was changed from holding the AIROD^TM to holding the tip of the endotracheal tube while the respiratory therapist held the distal end of the AIROD^TM. The endotracheal tube was then advanced past the vocal cords and into the trachea while the respiratory therapist removed the AIROD^TM with ease. No complications occurred. No trauma occurred to the oropharynx, vocal cords or trachea. The patient was successful ventilated and oxygen saturations improved to high 90s.

Case 2

A61-year-old man with severe schizophrenia and acute delirium had a PaO2 of 61 mmHg despite BiPAP 14/6 on 90% fio2 with a minute ventilation of 18 L/min from multi-lobar pneumonia. A Miller 4 blade was gently inserted past the teeth and into the oropharynx. A grade 1 view (whole vocal cords seen; the epiglottis is not seen at all) was obtained. The AIROD^TM was gently advanced 2 cm past the vocal cords followed by an assistant advancing a 7.5 endotracheal tube down the AIROD^TM until grasped, then the endotracheal tube was slid into the trachea while the assistant held the distal end of the AIROD^TM. The AIROD^TM was then removed intact with no evidence of airway trauma.

Case 3

A 54-year-old man with severe coronary artery disease on aspirin and Plavix with a history of a seizure disorder associated with alcohol withdrawal became unresponsive and a code blue was called. He was found to be apneic with oxygen saturation in the 50s. He was stimulated by the hospitalist and woke up. He was transferred to the ICU where he became completely unresponsive again and became apneic. He was immediately ventilated with a bag-valve mask and oxygenation improved to 100%. He then bolted up out of bed and became very combative. Propofol was given and he was laid supine and ventilated with a bag-valve mask. Inspection of his oropharynx revealed a very large tongue, some missing and multiple sharp teeth with mouth opening of only 2 fingerbreadths. There was blood and emesis in his oropharynx that was suctioned. A Miller 4 blade was inserted into the oropharynx but only a grade 4 view (the anterior tip of the epiglottis is seen and encroaching on the view of vocal cords obstructing <50% of view) could be obtained. The AIROD^TM was inserted into the oropharynx in the fully extended and locked position and the proximal tip was used to gently lift the epiglottis exposing the vocal cords and improving the view to a grade 2. AIROD^TM was advanced 2 cm past the vocal cords and an assistant advanced an 8.0 endotracheal tube down the AIROD^TM until it was grasped, and the endotracheal tube was advanced successfully past the vocal cords while the assistant held the distal end of the AIROD^TM. The AIROD^TM was removed intact without any oropharyngeal or vocal cord trauma.

Case 4

A 48-year-old obese who was an alcoholic and a smoker was critically ill with an admission albumin of 0.9 and lactic acid of 9 with multiorgan system failure from an intra-abdominal abscess with septic shock on 15 mcg/min of epinephrine and 25 mcg/min of Levophed. He was obtunded and in acute respiratory failure. The AIROD^TM was pre-loaded with an 8.0 endotracheal tube onto the distal end of the AIROD^TM prior to providing sedation with Etomidate and bag-valve mask ventilation in anticipation of a difficult airway: full beard, mouth opening 2 cm, large tongue, collapse of the walls of the oropharynx as well as false cords. Using a Miller 4 blade a grade 2 view was obtained and the AIROD^TM was advanced 1 cm past the vocal cords followed by the endotracheal tube while an assistant held the distal end. There was no significant desaturation or trauma to the vocal cords or oropharynx. Pre-loading the AIROD^TM with the endotracheal tube improved the speed and autonomy of the intubation.

Discussion

AIROD^TM is a single-use telescopic endotracheal intubation bougie. It is rigid, made of stainless steel and sterilized. It telescopes to two feet and has a specialized 20-degree angled tip. Once expanded it locks so it cannot be retracted. An endotracheal tube 7.0 or greater can be advanced over the telescoping bougie for smooth placement in the adult trachea.

AIROD^TM is non-malleable and can gently displace oropharyngeal tissue, it does not sag and pull like plastic bougies, the unique locking mechanism prevents collapse and the square handle improves dexterity as well as spatial awareness of the proximal tip.

AIROD^TM telescopes open allowing for storage in small spaces such as a pocket or a crash cart without damaging its integrity like so many bougies that are ruined when bent for storage. Because of its small size, it can be stored in a myriad of places and easily accessed by emergency personnel in the field, emergency department, intensive care unit and operating room.

AIROD^TM can be used with multiple different varieties of laryngoscopes. My preference is a Miller 4 laryngoscope because of the ability to lift the epiglottis and visualize the vocal cords especially in patients with a large tongue, limited mouth opening and decreased neck mobility. The AIROD^TM can be slid along the length of the laryngoscope blade if needed to overcome the force of oropharyngeal tissue. Once the AIROD^TM is advanced a few centimeters past the vocal cords the rigidity of the AIROD^TM allows advancement of the endotracheal tube with ease because it can withstand the forces applied by the oropharyngeal tissue without significant bending. I have also used a Macintosh laryngoscope with the AIROD^TM which allows for displacement of the tongue and oropharyngeal tissue but placement into the vallecula above the epiglottis can limit exposure to the vocal cords. The AIROD^TM can overcome the limitation of the Macintosh laryngoscope by directly lifting the epiglottis, exposing the vocal cords then the AIROD^TM can be gently slid along the posterior surface of the epiglottis past the vocal cords followed by advancement of an endotracheal tube for successful intubation. Because the AIROD^TM is made of steel, similar to the Gliderite stylet used with the Glidescope as well as laryngoscopes and rigid bronchoscopes, it is possible that if used incorrectly trauma to the oropharynx as well as the trachea may occur, and caution is advised.

The cost of the AIRODTM is similar to the Glidescope’s disposable covers that are used with each intubation. Because of the loss of direct sight and acute angles involved in the process of advancing an introducer during intubation with the Glidescope I do not recommend using the AIRODTM with the Glidescope. The AIRODTM was designed only to be used with adults.

Conclusion

AIROD^TM is a sterile single-use telescopic bougie that is used along with a laryngoscope when performing endotracheal intubation. Because of its small size it is easily stored in a pocket, helicopter, ambulance, crash cart, operating room, emergency department, intubation box and in the intensive care unit. Its rigidity helps displace oropharyngeal tissue improving the view of the vocal cords and it facilitates advancement of an endotracheal tube. It can also be used in the closed position as a stylet making it an ideal instrument for first-attempt intubation along with a laryngoscope.

Conflict of Interest Disclosures

The author Evan Denis Schmitz, MD is the inventor of the AIROD^TM.

References

1. Brown CA 3rd, Bair AE, Pallin DJ, Walls RM; NEAR III Investigators. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med. 2015 Apr;65(4):363-70. [CrossRef] [PubMed]
2. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med. 2013 Jan;20(1):71-8. [CrossRef] [PubMed]
3. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, Cleghorn MR, McGill JW, Cole JB. Effect of use of a bougie vs endotracheal tube and stylet on first-attempt intubation success among patients with difficult airways undergoing emergency intubation: a randomized clinical trial. JAMA. 2018 Jun 5;319(21):2179-89. [CrossRef] [PubMed]

Cite as: Schmitz ED. Single-use telescopic bougie: case series. Southwest J Pulm Crit Care. 2020;20(2):64-8. doi: https://doi.org/10.13175/swjpcc005-20 PDF 

Editor's Note: On April 19, 2020 Dr. Schmitz has submitted a video showing a 6 second intubation using the AIROD and a mannequin which is below.

November 2012 Critical Care Case of the Month: I Just Can’t Do It Captain! I Can’t Get the Sats Up!

Bridgett Ronan, MD

Department of Pulmonary Medicine

Mayo Clinic Arizona

Scottsdale, AZ

History of Present Illness

A 61 year old man was seen in consultation after undergoing a laparoscopic repeat Nissen fundoplication with mesh reinforcement.  He developed worsening hypoxia postoperatively. He was initially extubated without difficulty to nasal cannula. However, he had progressive hypoxemia requiring a nonrebreathing mask, followed by BiPAP and eventually reintubation. Discussion with the surgeons revealed he had gastric contents present on intraoperative esophagogastroduodenoscopy (EGD). There was a small perforation of the fundus, with possible contamination of the peritoneum.

PMH, FH, SH

He has a long history of a paraesophageal hernia and reflux esophagitis and had previously undergone a Nissen fundoplication. There was also a history of atrial flutter and a 4.8 cm thoracic aortic aneurysm. A pre-operative echocardiogram was othewise normal. There was no remarkable family history. He was a non-drinker and non-smoker.

Physical Examination

Vital signs: Heart rate 79 beats/min, BP 95/67 mm Hg, Temperature 99.4°F, SpO2 78% on 100% FiO2.

His lungs were clear interiorly.

No murmurs or gallops were heard on cardiac auscultation.

His abdomen was post-surgical and distended but soft and nontender.

Which of the following is true regarding hypoxemia?

1. Most hypoxia is secondary to alveolar-capillary block
2. A normal pCO2 excludes hypoventilation as a cause of hypoxemia
3. Low inspired FiO2 is a common cause of hypoxia in the ICU because of attaching air to the oxygen line on the ventilator.
4. A normal chest x-ray excludes ventilation-perfusion mismatch as a cause of hypoxemia
5. The patient’s age of 61 excludes a congenital heart lesion

Reference as: Ronan B. November 2012 critical care case of the month: I just can’t do it captain! I can’t get the sats up! Southwest J Pulm Crit Care 2012;5:235-41. PDF