Shane V. Cherry, MD
Resident Physician
Jackson Memorial Hospital
University of Miami Miller School of Medicine
Department of Anesthesiology, Perioperative Medicine, and Pain Management
Miami, Florida
Christian Diez, MD, MBA
Assistant Professor of Clinical Anesthesiology
University of Miami Miller School of Medicine
Department of Anesthesiology, Perioperative Medicine, and Pain Management
Miami, Florida
The authors did not report any relevant financial disclosures.
The medical literature has an abundance of research and clinical guidelines in regard to the oral care of intubated critically ill patients. These guidelines emphasize the importance of practices, such as chlorhexidine mouthwash and subglottic suctioning, as a means to decrease the incidence of ventilator-associated pneumonia.1 However, little attention has been given to the importance of oral care in nonintubated critically ill patients and the role that might play in preventing complications associated with securing the airway emergently.
Case Description
A 53-year-old man was transferred from the Dominican Republic to the ICU in Ryder Trauma Center at Jackson Memorial Hospital for further management of multiple orthopedic injuries. He sustained the injuries as a restrained driver in a motor vehicle collision 1 week earlier.
His medical history was significant for morbid obesity (body mass index, 54 kg/m2), obstructive sleep apnea not on continuous positive airway pressure, and non–insulin-dependent diabetes. Of particular interest, the patient had surgery for a broken leg approximately 5 years earlier. That surgery was complicated by difficult intubation, difficulty weaning from mechanical ventilation, and subsequent vocal cord problems necessitating rehabilitation. However, during his stabilizing treatment in the Dominican Republic, which included placement of an external fixation system on his right lower extremity, he was successfully intubated and subsequently extubated before his transfer to our facility. According to the patient’s family, this was again a difficult intubation and weaning process.
Upon arrival to the trauma center, his vital signs were stable; he was maintaining his oxygen saturation on room air; and had a Glasgow Coma Scale score of 15. Although his movement was limited by pain, sensation and motor function were intact throughout all 4 extremities. However, the patient had a short, thick neck, and the cervical collar he was wearing limited his range of motion. Upon exam, he had a Mallampati class II airway and intact dentition. Cardiac and pulmonary exams were unremarkable. Upon further radiographic workup, it was discovered that the patient had a nondisplaced C6 vertebral body fracture, multiple lumbar spine fractures, and fractures of the bilateral lower extremities and right upper extremity.
After admission, the anesthesiology department was consulted for airway management as part of an elective tracheostomy. Due to the expectation for multiple orthopedic procedures and the patient’s history of difficult intubation and subsequent vocal cord problems, the patient strongly requested an elective tracheostomy in order to avoid the risks associated with repeated intubations and prolonged oral intubation. After extensive discussion between the patient, surgical team, and anesthesiology department, this was deemed a reasonable request and preparations were made for an awake fiber-optic intubation (FOI) in the operating room (OR) prior to open tracheostomy. The patient’s airway was topicalized upon arrival to the OR. An Ovassapian airway was inserted and resistance was felt. A recognizable view could not be obtained with attempted advancement of the fiber-optic scope.
A Yankauer was inserted to attempt deep suctioning, and a hard mass was detected deep in the patient’s hypopharynx. We were unable to remove this mass until the attending anesthesiologist reached in to assist with his fingers. He removed a large, inspissated mass of mucus/saliva (Figure) measuring 3 inches long and 1.25 inches wide. The airway was successfully secured via awake FOI after removal of the mass, and the asleep tracheostomy proceeded without any further complications.
Oral Hygiene Protocol
This case illustrates the importance of adequate oral hygiene in nonintubated critically ill patients. The medical literature has an abundance of information on oral care and guidelines for intubated patients.1-3 However, to the best of our knowledge, the same does not exist for nonintubated critically ill patients. Some of the same practices can be adopted for this patient population—which can have injuries and illnesses that place patients at high risk for poor oral hygiene and copious, inspissated secretions—and could play a crucial role in preventing complications associated with securing the airway emergently.
All anesthesiologists may encounter this situation at some point when called for airway management in the ICU. Some of the factors responsible include repeated NPO (nothing by mouth) status as a patient is scheduled for surgery but then the surgery is canceled due to the ICU’s dynamic nature, significant pain resulting in splinting, poor respiratory effort, and an inability to properly expel airway secretions. Without adequate bedside care, there is a potential risk for disastrous complications should the airway need to be secured emergently, particularly under nonoptimal conditions such as those frequently encountered in an ICU.
In this case, the index patient had been hospitalized for over a week prior to his attempted intubation in the OR. We believe the mass found in this patient’s hypopharynx could have been prevented with adequate oral care (eg, routine suctioning of secretions and periodic hydration of the oral cavity with mouth swabs). Our patient fortunately avoided compromise because of the nonemergent nature of the airway and method of intubation. However, under different circumstances, it is easy to envision a scenario where this mass could have been inadvertently advanced further into the airway with either a laryngoscope blade or a supraglottic airway, resulting in a “cannot intubate, cannot ventilate” scenario.
Conclusion
We believe all ICUs should have a unit-driven oral hygiene protocol for nonintubated critically ill patients. At a minimum, it would include periodic oral hydration with mouth swabs, avoidance of unnecessary NPO, and periodic suctioning. All suction equipment should meet the recommendations of the Anesthesia Patient Safety Foundation: Anesthesia suction equipment should have the ability to clear a minimum of 2.5 to 4 L/min of water, which corresponds to a pressure at the tip of the Yankauer of –100 to –200 mm Hg.4 Following these simple steps would make airway intervention safer in this high-risk patient population.
References
- Berry AM, Davidson PM, Nicholson L, et al. Consensus based clinical guideline for oral hygiene in the critically ill.Intensive Crit Care Nurs. 2011;27(4):180-185.
- Feider LL, Mitchell P, Bridges E. Oral care practices for orally intubated critically ill adults.Am J Crit Care. 2010;19(2):175-183.
- Saddki N, Mohamed Sani FE, Tin-Oo MM. Oral care for intubated patients: a survey of intensive care unit nurses.Nurs Crit Care. 2014 Oct 28. [Epub ahead of print]
- Paulsen AW. Are there guidelines for anesthesia suction?APSF Newsletter. 2015;29(3):58-60.
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