Bougie through Suction Catheter
Question# 908
My question is about the new advisory against using a Bougie through suction catheter.
I agree with you that it should absolutely not be a routine practice. Inserting a Bougie through the suction catheter should be an almost last ditch effort before FONA, but that last solution isn't an option here. Which makes it the last resort.
For massive hemoptysis (Blood coming from the lungs/trachea), what is the alternative? No, letting people awfully drown on their own blood while hoping that the IGEL will do the trick isn't really going to help. Is your concern is the risk of hypoxia? If we are able to use the catheter to decontaminate and obtain a grade 1 view, I don't see the risk for the cords. The blade can remain in for the entire procedure which isn't worst that any attempt on grade 2b or 3 pass with Bougie alone.
Infection? For Emesis I agree but it shouldn't be done, that's a different technique. For massive hemoptysis that fluid is in the lungs anyways.
Back up plan?
I agree with you that it should absolutely not be a routine practice. Inserting a Bougie through the suction catheter should be an almost last ditch effort before FONA, but that last solution isn't an option here. Which makes it the last resort.
For massive hemoptysis (Blood coming from the lungs/trachea), what is the alternative? No, letting people awfully drown on their own blood while hoping that the IGEL will do the trick isn't really going to help. Is your concern is the risk of hypoxia? If we are able to use the catheter to decontaminate and obtain a grade 1 view, I don't see the risk for the cords. The blade can remain in for the entire procedure which isn't worst that any attempt on grade 2b or 3 pass with Bougie alone.
Infection? For Emesis I agree but it shouldn't be done, that's a different technique. For massive hemoptysis that fluid is in the lungs anyways.
Back up plan?
Answer:
We appreciate your comments surrounding this very difficult situation in airway management. You are correct that Front of Neck Access (FONA) nor iGel are viable options for paramedics currently when faced with a heavily soiled airway. This is one of the reasons the RPPEO brought in the Suction Assisted Laryngoscopy and Airway Decontamination (SALAD) technique to provide an additional tool with additional training to assist in these situations.
Hypoxia is always a risk for patients with heavily soiled airways, no matter where the contaminants are coming from. Obtaining a secure and functioning airway is paramount and intubating these patients is the correct clinical decision in most cases.
Ideally, the suction catheter would be used to decontaminate the airway continuously, as with the SALAD technique, the bougie placed and then the endotracheal tube. The suction catheter is a rigid piece of plastic that was not designed to be placed through the vocal cords due to the risk of vocal cord paralysis or other trauma.
While infection is a risk with many of the interventions we do, including intubation, that is not the biggest risk we see with the use of a bougie through the suction catheter. As mentioned in the Medical Advisory,
We hope that these clarifications help further your practice. We appreciate your interest and dedication to patient care and safety.
Hypoxia is always a risk for patients with heavily soiled airways, no matter where the contaminants are coming from. Obtaining a secure and functioning airway is paramount and intubating these patients is the correct clinical decision in most cases.
Ideally, the suction catheter would be used to decontaminate the airway continuously, as with the SALAD technique, the bougie placed and then the endotracheal tube. The suction catheter is a rigid piece of plastic that was not designed to be placed through the vocal cords due to the risk of vocal cord paralysis or other trauma.
While infection is a risk with many of the interventions we do, including intubation, that is not the biggest risk we see with the use of a bougie through the suction catheter. As mentioned in the Medical Advisory,
- Bougie use through the suction catheter is not an accepted use of the equipment as per the manufacturer
- There is currently a lack of evidence surrounding this technique therefore it is not considered validated nor endorsed by the manufacturer
- There is an increased risk of trauma, vocal cord damage, or paralysis
- Additional steps added to the intubation process that could add to additional hypoxia and hypotension in the patient
We hope that these clarifications help further your practice. We appreciate your interest and dedication to patient care and safety.