Critical Care Medicine-Pulmonary Disorders>>>>>Respiratory Diagnostic Modalities and Monitoring
Question 14#

A 47-year-old male patient (BMI 55 kg/m2 ) with methicillin-resistant Staphylococcus aureus pneumonia suffers an aspiration event. His oxygen saturation on a nonrebreather face mask is 72%. His previous endotracheal intubation was described as “straightforward.”

What is the best initial approach for airway management? 

A. Awake fiberoptic intubation
B. Rapid-sequence induction followed by intubation via direct laryngoscopy
C. Noninvasive ventilation
D. Rapid-sequence induction followed by intubation via video laryngoscopy

Correct Answer is B

Comment:

Correct Answer: B

The patient is acutely hypoxic, and invasive mechanical ventilation seems to be the safest option. While noninvasive ventilation has a role in management of respiratory failure in the morbid obese population its use in acute hypoxic respiratory failure is limited. Given that the patient is already hypoxemic, an awake fiberoptic intubation would be not easily tolerated and likely result in further potentially dangerous hypoxemia. Morbid obese critically ill patients desaturate quickly during airway manipulation due to limited reserve. Rapid-sequence induction followed by intubation via direct laryngoscopy is the fastest way to secure the airway and hence the safest. In this patient, previous record of intubation without difficulty is further reassuring. However, fiberoptic intubation and video laryngoscopy are important backup options in this patient, if direct laryngoscopy fails.

Reference :

  1. Andersen LH, Rovsing L, Olsen KS. GlideScope videolaryngoscope versus Macintosh direct laryngoscope for intubation of morbidly obese patients: a randomized trial. Acta Anaesthesiol Scand. 2011;55:1090-1097.