The Science Journal of the American Association for Respiratory Care

2010 OPEN FORUM Abstracts

A CASE STUDY: EFFECTIVE VENTILATION DURING RAPID RESPONSE WITH THE PATIENT IN THE SEATED POSITION.

Marnni E. Hutchins, Daniel Davis; Respiratory Care, UCSD Medical Center, San Diego, CA

Introduction: This case study describes a non-traditional “seated” resuscitation position, with potential advantages including: decreased work of breathing, lower airway pressures, and diminished risk of aspiration. In addition, the importance of anemia as a predictor of rapid desaturation during invasive airway management is illustrated. Finally, the risk of vocal cord edema with aspiration is discussed. Case Summary: A 26-year-old male with acute liver failure secondary to Hodgkin’s lymphoma, was placed in the supine position for an abdominal CT scan. The patient began to passively aspirate gastric contents, leading to severe respiratory distress and hypoxemia, with SpO2 .60. The code team was activated, and the first responding RCP placed the patient in the seated position, and began bag-mask ventilation with 100% oxygen. The second RCP moved to the front of the patient and positioned both hands on the mask using the two thumbs up technique. The patient was effectively ventilated in the seated position. The patients’ SpO2 increased to 100%. For airway protection, the physician proceeded with rapid sequence intubation with an 8.0 ETT without success. The patient desaturated rapidly into the low 80’s within 45 seconds of the first attempt. A second attempt at intubation with a 7.0 ETT was successfully performed using a gum-elastic bougie. The failed first attempt was possibly due to stomach acid induced vocal cord edema. It was later noted that the patient had hemoglobin of 5.7, indicating that anemia status predicts oxygen reserve. The patient was transported to the ICU, and placed on mechanical ventilation. Discussion: Patients with decreased level of consciousness may be at increased risk for aspiration, when placed in the supine position. In such cases, resuscitation efforts in the spontaneously breathing patient in respiratory distress should be performed in the “seated” position to decrease the risk of aspiration and minimize work of breathing while offloading of the chest and abdomen. In addition, rapid desaturation may occur in the presence of anemia. Finally, patient who have aspirated may require a smaller ETT or require the use of adjuncts, such as the bougie, due to vocal cord edema. Sponsored Research - None