Nasal intubation and no ventilatory assistance????

[MSDeltaFlt]

What size was the tube? Small tubes and/or tight nasal passages = increased work of breathing which sets a pt up for failure or quick decompensation. Even a good sized tube has resistance that must be overcome and thus that is why we have all sorts of tube compensation modes on ICU ventilators.

Any amount of secretions can further block the tube either partially or completely and pt can quickly decompensate without one knowing in the back of a noisy truck and the pt covered by clothing or sheet. Dramatic SpO2 change may be late and after pH has fallen with the rise of PaCO2 especially if the patient is in a hyperoxygenated environment like a NRBM.

Was there an ETCO2 monitor in place? A pulse ox will tell nothing about the patients ability to clear CO2. Was the nare adequately prepped prior to intubation? Blood from the nasal intubation may also hampered effective gas exchange.

If the patient was obtunded they may already have had impaired gas exchange. The respiratory effort once the airway was open may have been an attempt to decrease a possibly high PaCO2 level that had already accumulated and increase their pH out of the danger zone.

Respiratory effort can be deceiving especially with impaired mental status.

It is rare that we intubate anybody for alcohol unless they are apneic or a child with a toxic level.

In the hospital, it is very rare to see a nasal intubation due to the high risk of infection and damage. If a patient is being weaned from a ventilator or post op, they may be on a T-Piece but the tube size is very adequate and ABGs give baseline while ETCO2 is monitored. Even that is rare due to safety issues and newer ventilatory modes on ICU ventilators to mimic a T-Piece which monitor the airway resistance with the appropriate alarms in place.

Many, many years ago in the hospital, we used to leave the tubes in comfort care patients when we discontinued life support until it was ruled cruel and uncomfortable care by our medical ethics committee.

Medic30,

Vent and I see eye to eye on a lot things. This is no different. I can understand why they nasally intubated. When you don't have RSI/DAI capabilities, you have to go nasal in order to better secure the airway sometimes. However, "Airway" and "Breathing" are not the same. In the same way "Oxygenation" (measured by SpO2%), "Respiration" (respiratory rate), and "Ventilation" (measured by EtCO2) are three completely different entities.

You can be breathing normally and oxygenating like a champ, but if you're not ventilating worth a damn, you're still gonna die. You've seen this happen. We've all seen this happen. If the CO2 gets too high, the pH will drop too low. Nothing will work in an acidic medium; up to and including pulses.

Did any adverse conditions actually happen? Probably not. But here's the thing. Luck counts, but don't count on luck.

Bag 'em. If they're still breathing, bag with them, but still bag 'em.

[Spock]

I have to agree with VentMedic on this one especially the part about intoxicated patients rarely needing intubation. Blind nasal intubation is a lost art.

Live long and prosper.

Spock

[UMSTUDENT]

This is simply a group of medics who don't understand the principals of respiratory physiology. I mean seriously guys...

We breath by allowing positive atmospheric pressure to enter expanded lungs, which have an overall negative pressure. Sucking through an ET tube without mechanical assistance is essentially like sucking through a straw without the assistance of numerous accessory muscles.

SIMV settings on ventilators work by coordinating assisted ventilation with those of spontaneous breathing. It also allows a physician or respiratory therapist to prescribe a certain amount of pressure support during spontaneous breathing to assist with the problems created by breathing through a tube.

Again, we need to actually educate paramedics. Ugh!

[VentMedic]

SIMV settings on ventilators work by coordinating assisted ventilation with those of spontaneous breathing.

SIMV? You are way too young to remember that old mode even though some of the machines still have it and I actually had one MD moonlighter last year think he was going to order it in the ED. It sets the patient up for asynchrony with the different flow delivery. However, pressure support and tube compensation are utilized with the sensitivity being set for the patient's effort and comfort. I see flight/CCT teams also try to use SIMV when their deceiving little transport machines have no PSV capability. Or, even when it does, they can't understand why the patient is still bucking the vent with each different breath type. Pure assist, by either volume or pressure settings or both, is more popular now with various modes to achieve the correct delivery.

In this scenario it is hard to tell if the Paramedics had a poor understanding of the respiratory system or just lazy or both. Either way, I hope they do not get the privilege of adding RSI anytime soon.

[EMS49393]

What size was the tube? Small tubes and/or tight nasal passages = increased work of breathing which sets a pt up for failure or quick decompensation. Even a good sized tube has resistance that must be overcome and thus that is why we have all sorts of tube compensation modes on ICU ventilators.

Any amount of secretions can further block the tube either partially or completely and pt can quickly decompensate without one knowing in the back of a noisy truck and the pt covered by clothing or sheet. Dramatic SpO2 change may be late and after pH has fallen with the rise of PaCO2 especially if the patient is in a hyperoxygenated environment like a NRBM.

Was there an ETCO2 monitor in place? A pulse ox will tell nothing about the patients ability to clear CO2. Was the nare adequately prepped prior to intubation? Blood from the nasal intubation may also hampered effective gas exchange.

If the patient was obtunded they may already have had impaired gas exchange. The respiratory effort once the airway was open may have been an attempt to decrease a possibly high PaCO2 level that had already accumulated and increase their pH out of the danger zone.

Respiratory effort can be deceiving especially with impaired mental status.

It is rare that we intubate anybody for alcohol unless they are apneic or a child with a toxic level.

In the hospital, it is very rare to see a nasal intubation due to the high risk of infection and damage. If a patient is being weaned from a ventilator or post op, they may be on a T-Piece but the tube size is very adequate and ABGs give baseline while ETCO2 is monitored. Even that is rare due to safety issues and newer ventilatory modes on ICU ventilators to mimic a T-Piece which monitor the airway resistance with the appropriate alarms in place.

Many, many years ago in the hospital, we used to leave the tubes in comfort care patients when we discontinued life support until it was ruled cruel and uncomfortable care by our medical ethics committee.

Vent, if I were a dude, I'd wanna marry you. 8) I can't even add to this, it nicely sums up every idea I had when I read the original post.

Sadly, this sounds like something someone would do at the service I still moonlight for. I'd think if they needed a patent airway bad enough that they required intubation, then they would require supportive ventilation. If they were an alcoholic, and not just a social party drunk, I'd be concerned with a blind intubation attempt, and probably would have tried a less invasive adjunct and some supportive BVM. Just let that tube travel the esophagus and bust a varicies, and it's curtains. Let's also remember that intubation, nasal or oral, introduces an easy route for infection in the lungs.

There is nothing wrong with BLS airway adjuncts, and they work well with patients that are teetering on the brink of needing a full intubation, especially if RSI isn't an option. Since your service doesn't have capnography capabilities, there is no real way to know how well the patient is ventilating. SPO2 readings are a vital sign, but a patient can maintain a good reading a lot longer than you might think. EtCO2 readings are nearly instant, which is one reason they are so useful in cardiac arrest situations.

It just sounds like a fishy story, period.

[UMSTUDENT]

SIMV? You are way too young to remember that old mode even though some of the machines still have it and I actually had one MD moonlighter last year think he was going to order it in the ED. It sets the patient up for asynchrony with the different flow delivery. However, pressure support and tube compensation are utilized with the sensitivity being set for the patient's effort and comfort. I see flight/CCT teams also try to use SIMV when their deceiving little transport machines have no PSV capability. Or, even when it does, they can't understand why the patient is still bucking the vent with each different breath type. Pure assist, by either volume or pressure settings or both, is more popular now with various modes to achieve the correct delivery.

In this scenario it is hard to tell if the Paramedics had a poor understanding of the respiratory system or just lazy or both. Either way, I hope they do not get the privilege of adding RSI anytime soon.

It appears we're talking semantics...kinda (they're obviously different things). I was always taught that on modern ventilators that SIMV and PSV are kind of in the same, with regular SIMV being replaced by ventilators capable of providing mandatory breaths with "pressure support" for spontaneous breathing. I was taught/told that newer processor technology had greatly improved the capability of SIMV to adequately predict where to place mandatory breaths while simultaneously providing adequate pressure support.

It makes sense that there would be a PSV only mode. I'll be the first to admit that I have limited experience with ventilators. My knowledge is limited to purely what I was taught and used while I was still in clinical training.

Thanks!

[VentMedic]

SIMV is a mode that provides mandatory breaths, usually volume, and can or can not be used with pressure supported breaths. PSV is a spontataneous breathing mode. SIMV flow delivery and wave pattern is very different from a demand flow PSV breath.

[paraloco]

I've seen this twice, both back in the 80's. One was a guy with a cerebral bleed. The doc inserted the et tube nasally, secured it, then just left it like that. the guy was breathing deeply and rapidly. The other was a head injury from an mva. Out in the sticks with no good lz. his teeth were clenched. We had no paralytics back then, just a jaw screw that I almost lost down his throat when he opened his mouth, then closed it again. I had to do something, so I nasally intubated him and put a nrb mask on over it. The little community hospital left it just like that, even when a flight crew came to get him. I heard the doc talking to the receiving hospital over the phone. He told them he did it, then turned to me and informed me that he just saved my @ss.

[Doczilla]

I'm in favor of doing this for a pediatric DKA patient who is kussmaul breathing but requires airway protection. You don't want to paralyze these patients or sedate them too much for ventilation. If on a ventilator, I put them on CPAP alone. You just can't keep up with the volume or rate of ventilation that they can do with the Kussmaul, and if you paralyze them, the acidosis will get much worse.

'zilla

[VentMedic]

I'm in favor of doing this for a pediatric DKA patient who is kussmaul breathing but requires airway protection. You don't want to paralyze these patients or sedate them too much for ventilation. If on a ventilator, I put them on CPAP alone. You just can't keep up with the volume or rate of ventilation that they can do with the Kussmaul, and if you paralyze them, the acidosis will get much worse.

'zilla

Maybe straight CPAP on a trach but with a nasally intubated child, no less than 5 cmH2O of PSV to overcome the resistance. No need to make the little one stuggle for each breath and increase the work of breathing. Modern ventilators were invented to alleviate suffering. Let's not give people the wrong idea they can try this with some ATV in the field on a child. The face mask to ETT stuff is bad enough without ETCO2 monitoring in an acute field situation.