A 53-year-old man comes to the emergency department in moderate respiratory distress.
On examination, blood pressure is 90/58 mm Hg, pulse is 100/min, and SaO₂ is 82%-85% on FiO₂ 100% via nonrebreather mask. Lung examination reveals crackles and reduced breath sounds in the left base.
The patient undergoes rapid-sequence intubation due to respiratory distress. The endotracheal tube is 26 cm at the lip. The colorimetric end-tidal CO₂ device displays a color change, and normal waveform is noted on capnography. Chest auscultation reveals reduced breath sounds in the entire left lung field. Several minutes after intubation, SaO₂ remains 82%-85% and blood pressure is 94/56 mm Hg.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_96a3_b033_853d_51ce9527ec4e_MD0002_00 This patient has hypoxemia that has failed to improve with intubation. However, before intubation, breath sounds were reduced only in the left base (possibly due to pneumonia); after intubation, he has reduced breath sounds in the entire left lung. This is consistent with endotracheal (ET) tube placement in the right main bronchus. An ET tube should be inserted to an average depth of 20-21 cm in women and 22-23 cm in men (as opposed to the 26 cm noted in this patient). Following intubation, the chest should be inspected for symmetric rise, and both lungs should be auscultated to ascertain bilateral breath sounds; inequality can indicate endobronchial placement. Up to 10% of intubations are endobronchial, the majority involving the right mainstem bronchus due to its more vertical orientation. This leads to eventual collapse of the left lung. A normal end-tidal CO₂ measurement (eg, calorimetry, normal wave form) indicates tracheal intubation but does not allow for the differentiation between appropriate (endotracheal) and inappropriate (endobronchial or supraglottic) intubation. right mainstem bronchus The ET tube should be retracted 3 cm, and the patient should be inspected for signs of proper oxygenation. A chest x-ray or ultrasound should then be performed to confirm proper positioning of the ET tube and guide repositioning if necessary. (Choice A) Needle decompression of the chest is indicated for tension pneumothorax (TP). In addition to unilaterally decreased breath sounds, signs of TP include lung hyperexpansion with tympany on percussion, tracheal deviation, and acute cardiovascular collapse. Although this patient is mildly hypotensive, his blood pressure remains stable pre- and postintubation, making an acute TP unlikely. (Choice B) In patients with endobronchial intubation, high positive end-expiratory pressure (PEEP) will increase the risk of barotrauma. Early repositioning of the tube should improve this patient's hypoxia without the need for high PEEP. (Choice C) Bronchodilators are indicated for airway obstruction from smooth muscle contraction (eg, chronic obstructive pulmonary disease, asthma). This patient has no wheezing to suggest bronchoconstriction. (Choice E) Reintubation is required in cases of esophageal intubation. This patient's end-tidal CO₂ measurements with normal wave form and appropriate color change on capnography indicate that the ET tube is within the trachea; therefore, he will likely require ET tube repositioning only. As the esophagus can have small amounts of CO₂ present, patients with esophageal intubations may have a transient CO₂ waveform detected; however, this typically clears within 5 exhalations. Educational objective: Right endobronchial intubation is a frequent complication of endotracheal (ET) tube placement. If endobronchial intubation is suspected based on physical examination (asymmetric breath sounds and chest rise) and failure of oxygenation, the ET tube should be retracted and then a chest x-ray or ultrasound should be performed to confirm proper placement. __________ References: Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial. (http://www.ncbi.nlm.nih.gov/pubmed/21062875) Chest radiography after endotracheal tube placement: is it necessary or not? (http://www.ncbi.nlm.nih.gov/pubmed/23810228)

A 53-Year-Old Man Comes to the Emergency Department in Moderate