A 44-year-old man with a medical history of food allergy to peanuts is brought to the emergency department for an allergic reaction. The patient developed the acute onset of dyspnea and wheezing shortly after ingesting a cookie. His symptoms progressed to difficulty swallowing and swelling of the face and tongue. On arrival, temperature is 36.9 C (98.4 F), pulse is 115/min, blood pressure is 85/74 mm Hg, and respirations are 28/min. Oxygen saturation is 93% on a nonrebreather face mask. He is anxious and pale with swollen lips, swollen tongue, and inspiratory stridor. On lung auscultation, bilateral wheezing is present. Intramuscular epinephrine, intravenous fluids, and racemic epinephrine via nebulizer are administered without improvement. The patient's distress is increasing, and he is becoming more agitated. The decision to intubate using awake fiberoptic nasotracheal intubation is made. Severe swelling of the upper airway is seen on laryngoscopy, and 3 attempts to pass the endotracheal tube are unsuccessful. The patient's blood pressure is 70/40 mm Hg, pulse is 75/min, and respirations are 40/min. Oxygen saturation is 72% on a nonrebreather face mask. What is the best next step in management of this patient?

Question

A 44-year-old man with a medical history of food allergy to peanuts is brought to the emergency department for an allergic reaction.  The patient developed the acute onset of dyspnea and wheezing shortly after ingesting a cookie.  His symptoms progressed to difficulty swallowing and swelling of the face and tongue.  On arrival, temperature is 36.9 C (98.4 F), pulse is 115/min, blood pressure is 85/74 mm Hg, and respirations are 28/min.  Oxygen saturation is 93% on a nonrebreather face mask.  He is anxious and pale with swollen lips, swollen tongue, and inspiratory stridor.  On lung auscultation, bilateral wheezing is present.  Intramuscular epinephrine, intravenous fluids, and racemic epinephrine via nebulizer are administered without improvement.  The patient's distress is increasing, and he is becoming more agitated.  The decision to intubate using awake fiberoptic nasotracheal intubation is made. Severe swelling of the upper airway is seen on laryngoscopy, and 3 attempts to pass the endotracheal tube are unsuccessful.  The patient's blood pressure is 70/40 mm Hg, pulse is 75/min, and respirations are 40/min.  Oxygen saturation is 72% on a nonrebreather face mask.  What is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c06f_de4d_8f63_1f577ce2e1b3_MD0005_00 Several attempts to secure a definitive airway via awake intubation have failed, and this patient now has severe hypoxia (eg, oxygen saturation of 72% on a nonrebreather mask) and signs concerning for impending cardiac arrest (eg, severe hypotension, falling heart rate). Especially given this patient's rapidly progressive airway edema (which further airway instrumentation will only increase), additional intubation attempts are unlikely to succeed and will only increase the risk of deterioration (Choice A). Instead, cricothyrotomy should be performed immediately to bypass the upper airway obstruction and restore ventilation and oxygenation. The procedure involves incising the cricothyroid membrane and inserting an endotracheal or tracheostomy tube, which can be used for mechanical ventilation. cricothyroid membrane Management of the failed airway (ie, airway that cannot be intubated on initial attempts) is determined by the ability to oxygenate the patient using mask ventilation. In patients (such as this one) who cannot be adequately oxygenated ("can't intubate, can't oxygenate") due to upper airway obstruction, a surgical airway (ie, cricothyrotomy) should be performed. In contrast, patients who can be oxygenated via bag valve mask ventilation ("can't intubate, can oxygenate") may tolerate further intubation attempts. Adjunctive airway techniques (eg, video laryngoscopy) may increase the chance of success. (Choice C) Noninvasive positive pressure ventilation (eg, continuous positive airway pressure) can reduce atelectasis and ventilation/perfusion mismatch in certain patients with respiratory distress (eg, cardiogenic pulmonary edema). However, it will not bypass upper airway obstruction and is contraindicated when severe respiratory distress necessitates emergency intubation. (Choice D) A supraglottic device (eg, laryngeal mask airway) inserted into the pharynx may help provide ventilation in certain patients where intubation fails (eg, vocal cords cannot be visualized on laryngoscopy). However, it would likely be difficult to insert in this patient with a swollen tongue and stridor (ie, upper airway edema) and would not reliably bypass the upper airway obstruction, as cricothyrotomy would. (Choice E) Tracheostomy can bypass upper airway obstruction but is not typically performed in emergency situations because cricothyrotomy is faster and technically less difficult and has lower risk of hemorrhage than tracheostomy. In addition, cricothyrotomy can be converted to a tracheostomy if a surgical airway is still needed after the patient has stabilized. Educational objective: Cricothyroidotomy should be performed in hypoxic, unstable patients who cannot be oxygenated or ventilated due to an upper airway obstruction. References: The difficult airway with recommendation for management-Part 1-difficult tracheal intubation in an unconscious/induced patient. (http://www.ncbi.nlm.nih.gov/pubmed/24132407)

A 44-Year-Old Man with a Medical History of Food Allergy