Tales from the ICU: Best Practices in Airway Management

image of ICU scene

Respiratory therapists are known for their expertise in airway management, and nowhere are those skills more valued than in the ICU.

Two AARC members share recent stories illustrating just how important it is to keep best practices top of mind when managing the airway in patients who are critically ill.

Blunt chest trauma

Photo of Keith Lamb
A challenging air-leak led to a unique solution for Keith Lamb and his colleagues.

Keith Lamb, RRT-ACCS, FAARC, FCCM recalls a time when he treated a patient who suffered a blunt chest trauma due to a motor vehicle collision.

The accident left the teenaged boy with a disruption of a segmental bronchus that caused massive hemorrhage and a significant air-leak syndrome.

“After an emergent thoracotomy to control the bleeding, the injured segment was removed and an anastomosis eventually slowed the bleeding,” said Lamb, who serves as the ECMO director at INOVA Fairfax Medical Campus in Falls Church, VA.

But a consistent air-leak out of the anastomosis remained, making mechanical ventilation a challenge because gas exchange was inadequate and positive pressure ventilation made the air-leak more significant.

To each lung its own

In order to mitigate these issues and provide a more definitive way of protecting the patient, Lamb and his colleagues decided to place a double-lumen endobronchial tube and provide ventilation to each lung independently.

“Once the double lumen endobronchial tube was placed, the side with the chest tube and air-leak was placed on high frequency oscillatory ventilation and the other lung was ventilated with conventional ventilation with a low stress and strain protective lung ventilation strategy,” says Lamb.

The patient was eventually tracheostomized without complication and went on to survive his injuries, with discharge to rehabilitation occurring on day 34 of his hospital stay.

Red flags were raised

Photo of Karsten Roberts
For Karsten Roberts, an experience with one patient helped reinforce best practices when another patient presented with a similar problem.

A few months ago, Karsten Roberts, MS, RRT-ACCS, was taking care of a patient with acute lymphoblastic leukemia who suffered from complications that led to the development of chronic respiratory insufficiency.

She had a tracheostomy placed and Roberts and the rest of the team were finding it a challenge to wean her from mechanical ventilation.

“At some point during her hospitalization she had a mucus plug that caused pulseless electrical activity, PEA arrest,” said Roberts, an RT at the Hospital of the University of Pennsylvania in Philadelphia. “She was initially resuscitated, but unfortunately died later.”

The case stayed on his mind, and when he entered the room of another patient with a history of bilateral lung transplant and subsequent tracheostomy some weeks later and saw that the heated humidification system had been off for an undetermined amount of time, red flags were raised.

Fast action saves the day

“She was receiving Q6 hour nebulizers and had undergone several bronchoscopies during her two months in the ICU,” Roberts said. “About five minutes after I started her daily trach collar trial she developed a mucus plug and became bradycardic, hypoxemic, and nearly coded.”

He immediately placed her on 100% oxygen concentration, put her back on the ventilator, and suctioned a moderate amount of secretions from her airway.

“My experience with the patient a few months ago helped me to identify risk factors with the patient last week,” Roberts said . “Patients with tracheotomies require humidification and suctioning of the airway to avoid emergent, even life threatening, situations.”

The patient recovered to baseline and was able to complete her trach collar trial later that same day.

The benefits are clear

These two stories — and many others out there like them — show how important it is for RTs to stay apprised of best practices and use them to help inform the experience they bring to the bedside of their patients.

“If respiratory therapists continuously seek best practices, there are clear benefits for patient safety and improved outcomes,” Roberts said.