Medical Image of the Month: An “Intubation Box” to Protect Healthcare Professionals

Figure 1. A: Intubation box. B: Intubation box in use.

The COVID-19 pandemic has emerged as growing global healthcare crisis. There is evidence of transmission of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARC-CoV-2) from aerosolized spread to personal protective equipment worn by healthcare professionals (1). In an attempt to mitigate hazards to healthcare professionals during the COVID-19 pandemic, particularly those at greater risk to exposure during endotracheal intubation, an Intubation Box has been designed by our Emergency Department (Figure 1A) (2). This is an inexpensive apparatus adjusted to include patients of large body habitus. We illustrate use of the box during endotracheal intubation using video laryngoscopy (Figure 1B). The box protects providers from aerosolized particulate and can be cleaned between each use with anti-viral reagents such as bleach-based or alcohol-based solutions. It is assembled in under one hour using acrylic with acrylic adhesive or equivalent plastic welding adhesive. Information on how to build this box in several easy steps, or how to order boxes, are provided for hospitals around the world at http://www.intubationbox.com.

Lavi Nissim MD¹ and Benjamin Reeser MD²

Departments of ¹Radiology and ²Emergency Medicine

Abrazo Central Campus

Phoenix, AZ USA

References

1. Ong SWX, Tan YK, Chia PY, Lee TH, Ng OT, Wong MSY, Marimuthu K. Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. JAMA. 2020 Mar 4. [Epub ahead of print] [CrossRef] [PubMed]
2. Cook TM. Personal protective equipment during the coronavirus disease (COVID) 2019 pandemic - a narrative review. Anaesthesia. 2020 Apr 4. [Epub ahead of print] [CrossRef] [PubMed]

Cite as: Nissim L, Reeser B. Medical image of the month: an “intubation box” to protect healthcare professionals. Southwest J Pulm Crit Care. 2020;20(5):173-4. doi: https://doi.org/10.13175/swjpcc030-20 PDF

Medical Image of the Week: Bilateral Vocal Cord Paralysis

Figure 1. Flow-volume curve demonstrating flattening of both the inspiratory and expiratory limbs consistent with extra-thoracic obstruction.

Figure 2. Video demonstrated the vocal cords essentially fixed in the adducted position during the inspiratory and expiratory cycle.

A 59-year-old morbidly obese woman with acute hypoxemic respiratory failure secondary to pulmonary emboli required emergency intubation. She was described by the anesthesiologist as having a difficult airway. The patient was liberated from the ventilator after two days. Following extubation she complained of hoarse voice and dyspnea. Physical exam revealed audible stridor. The upper airway was normal by CAT imaging. Flow-volume curve demonstrated marked flattening of both the inspiratory and expiratory limbs, consistent with a fixed extra-thoracic obstruction (Figure 1). Endoscopy revealed the vocal cords to be in the adducted position, with minimal movement throughout the respiratory cycle, consistent with bilateral vocal cord paralysis (Figure 2).

Traumatic intubation follows thyroid surgery as the most common cause of bilateral vocal cord paralysis (1). In a minority of patients spontaneous recovery may occur. Surgical treatment options include cordotomy or tracheostomy. Nocturnal BIPAP has been used in patients who decline surgery (2).

Charles J. Van Hook MD, Britt Warner PA-C, Angela Taylor MD,  and Jacquelynn Gould MD.

Longmont United Hospital

Longmont, CO USA

References

1. Brandwein M, Abramson AL, Shikowitz MJ. Bilateral vocal cord paralysis following endotracheal intubation. Arch Otolaryngol Head Neck Surg. 1986 Aug;112(8):877-82. [CrossRef] [PubMed]
2. Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope. 2007 Oct;117(10):1864-70.[CrossRef] [PubMed]

Cite as: Van Hook CJ, Warner B, Taylor A, Gould J. Medical image of the week: bilateral vocal cord paralysis. Southwest J Pulm Crit Care. 2017;15(2):82-3. doi: https://doi.org/10.13175/swjpcc099-17 PDF

Medical Image of the Week: Tracheal Perforation

Figure 1. Axial thoracic CT scan showing air in the mediastinum (red arrow).

Figure 2. Coronal thoracic CT scan showing air in the mediastinum (orange arrow).

Figure 3. Axial thoracic CT scan showing air in the mediastinum (yellow arrow).

Figure 4. Axial thoracic CT scan showing pneumopericardium (blue arrow).

A 45 year old Caucasian man with a history of HIV/AIDS was admitted for septic shock secondary to right lower lobe community acquired pneumonia. The patient’s respiratory status continued to decline requiring emergency intubation in a non-ICU setting. Four laryngoscope intubation attempts were made including an inadvertent esophageal intubation. Subsequent CT imaging revealed a tracheal defect (Figure 1, red arrow) with communication to the mediastinum and air around the trachea consistent with pneumomediastinum (Figure 2, orange arrow and figure 3, yellow arrow). Pneumopericardium (figure 4, blue arrow) was also evident post-intubation. The patient’s hemodynamic status remained stable. Two days following respiratory intubation subsequent chest imaging revealed resolution of the pneumomediastinum and pneumopericardium and patient continued to do well without hemodynamic compromise or presence of subcutaneous emphysema. Post-intubation tracheal perforation is a rare complication of traumatic intubation and may be managed with surgical intervention or conservative treatment (1).

Nour Parsa MD, Konstantin Mazursky DO, Sepehr Daheshpour MD, Naser Mahmoud MD

Department of Medicine

University of Arizona

Tucson, AZ

Reference

1. Fan CM, Ko PC, Tsai KC, Chiang WC, Chang YC, Chen WJ, Yuan A. Tracheal rupture complicating emergent endotracheal intubation. Am J Emerg Med. 2004;22(4):289-93. [CrossRef] [PubMed]

Reference as: Parsa N, Mazursky K, Daheshpour S, Mahmoud N. Medical image of the week: tracheal perforation. Southwest J Pulm Crit Care. 2014;9(6):335-6. doi: http://dx.doi.org/10.13175/swjpcc159-14 PDF