FBAO Intubation

[under-dreaming]

I am currently assisting my department and medical director in revising our treatment protocols.

The protocol for an obstructed airway states that "If the airway still remains obstructed [after attempting to remove with Magill forceps], drive an ET tube into the right mainstem bronchus, withdraw, and attempt to ventilate."

The medical director was unhappy with the wording of this and requested that it be changed to something more like: "withdraw into normal position, and attempt to ventilate."

So I have been looking into books and AHA guidelines on this because I am wondering if it would be more appropriate to remove the tube and replace it with a new one just in case the FBAO ended up inside the ET tube. If it remained inside the tube and ventilations were attempted using the same tube, the FBAO will wind up inside the trachea again and continue to act as a FBAO.

I have checked four books here at the station (three EMT-I and one paramedic level). None of them reference this maneuver in the first place. None of these books that I have state in the airway obstruction section or the intubation section that one should drive the ET tube into the right mainstem bronchus in the first place. AHA does not get into it either as far as I have found. The only reference to this procedure is in what seems to be a somewhat unofficial blog of a paramedic here: My link.

I have heard this procedure referenced verbally a few times in the past, but I have never read anything about it. Do any ALS providers here have experience with this protocol? I would appreciate any and all advice. I really hit a wall on this one.

[Just Plain Ruff]

I have indeed had this experience. 29 year old male, choking. Arrived to find patient in Arrest. Attempted to intubate, total blockage. Tried magill's, couldn't get it grabbed. Finally pushed it down into the right mainstem.

Got an airway, ventillated and able to get a pulse back. Arrived at hospital, they worked him. Got him to the ICU. He was discharged with a moderate level of brain damage.

doc's were not happy that I shoved the foreign body which was a piece of well chewed steak into his right mainstem but you know what, they guy is alive, he knows his family, he had to relearn to talk and to do some basic things but in the end, no matter how upset the docs were in having to bronch the guy, He's alive and well living a semi productive life in the community.

Our protocol states if cannot pull with Magill's then moving it down to the right mainstem is an option.

I know the patient thanks us.

[under-dreaming]

I have indeed had this experience. 29 year old male, choking. Arrived to find patient in Arrest. Attempted to intubate, total blockage. Tried magill's, couldn't get it grabbed. Finally pushed it down into the right mainstem.

Got an airway, ventillated and able to get a pulse back. Arrived at hospital, they worked him. Got him to the ICU. He was discharged with a moderate level of brain damage.

Our protocol states if cannot pull with Magill's then moving it down to the right mainstem is an option.

I know the patient thanks us.

Would you happen to have the ability to send me that section of your protocols? I have pretty much been tasked with making this thing make sense, pending review of course. Thanks for sharing the experience.

[fiznat]

What a ballsy protocol. Push the obstruction farther down into the airway? That isn't part of any standard of care I've ever heard of. I'm not even sure that an orally-placed ET tube would even reach the carina, nevermind be capable of pushing a bolus into a bronchus...

Here in CT, the next step after cant intubate/cant ventilate is a surgical airway. Is that option available where you work?

Edited August 25, 2010 by fiznat

[under-dreaming]

What a ballsy protocol. Push the obstruction farther down into the airway? That isn't part of any standard of care I've ever heard of.

Here in CT, the next step after cant intubate/cant ventilate is a surgical airway. Is that option available where you work?

It is available. However, it is strictly a paramedic skill. In Alaska, we have three levels of EMT that are below paramedic (MICP). EMT-2s and 3s are able to intubate. Furthermore, this department has only one paramedic working part time (very part time), which is actually very common in this state, aside from the handful of larger cities. This particular procedure came from one of the other departments in the interior of Alaska.

I do find it strange that no textbooks make reference to this procedure

[mobey]

To answer your question, NO. Once the tube is placed, leave it there. IF the object got lodged in the tube you still have a murphy eye to ventilate through, but really..... is it gonna stick in the tube?? Unlikely. The chances of you removing a tube and not being able to re-intubate... much more likely.

I disagree that this is a ballsy procedure. It is a last ditch effort of trying to get a patent airway. People heve lobectomies all the time, and live normaly with only 50% lung capacity, why not try?

When the object is below the cricothyroid membrane, what other option do you have?

[Just Plain Ruff]

To answer your question, NO. Once the tube is placed, leave it there. IF the object got lodged in the tube you still have a murphy eye to ventilate through, but really..... is it gonna stick in the tube?? Unlikely. The chances of you removing a tube and not being able to re-intubate... much more likely.

I disagree that this is a ballsy procedure. It is a last ditch effort of trying to get a patent airway. People heve lobectomies all the time, and live normaly with only 50% lung capacity, why not try?

When the object is below the cricothyroid membrane, what other option do you have?

At the time that I did what I did we had not even considered implementing any type of surgical airway. Even needle cric's were not allowed.

I have only had two FBAO's and both ended up being arrests. The first was a marshmallow inhaled - we pushed our tube through the sticky goo and even though she had pneumonia from the marshmallow, she survived without any negative problems

The second was the Steak and I already told you what happened on him.

Would I do it again, yes if I did not have a surgical airway option.

[Kaisu]

I do have a surgical airway option, however, I would push the obstruction into the bronchi with the tube before I attempt a crike. This is under the general principal of doing the least risky procedures first and escalating if required. By the same token, there is not a lot of time to ponder these options. I would move through them as quickly as possible.

I would leave the tube unless ETCO2 is unacceptable. It is possible to plug the tube and the murphy eye does not generally provide adequate ventilation.

[Richard B the EMT]

This is, admittedly outside my level of training.

I have heard some paramedics state they might force down the foreign object in deep enough that air exchange can at least be accomplished in one lung, even if temporarily leaving the other blocked pending surgical intervention. I've no idea if this is even covered in NYC/NY State protocols.

[mobey]

and the murphy eye does not generally provide adequate ventilation.

Source?