THE ROLE OF VIDEO LARYNGOSCOPY IN FUTURE
ADVANCED AIRWAY MANAGEMENT
>> BY TERENCE VALENZUELA, MD, MPH; JARROD MOSIER, MD; & JOHN SAKLES, MD
Dispatch sends you to the home of a 79-year-old male with chronic obstruc- tive pulmonary disease (COPD) who
is complaining of “shortness of breath.” He sits
upright, leaning forward and supporting his weight
with both arms. His head seems to be attached
directly to his shoulders. He appears drowsy, and
replies to your questions about medical history with
single-word answers only. His wife relates that he
has grown increasingly short of breath during the
past three days. After he refused to see his doctor, his
wife called 9-1-1.
You palpate a pulse of 98 beats per minute
(bpm) and measure his blood pressure at 180/90.
His respiratory rate is 30. Breath sounds are
diminished and wheezy bilaterally, but there’s little
chest movement with each breath. The pulse oximeter reveals an oxygen saturation (SpO2) level of 93%
and an end-tidal carbon dioxide (EtCO2) level of 35.
He grows more somnolent. Narcan doesn’t improve
his level of arousal.
This patient is on the verge of acute respiratory
failure. Level of arousal (wakefulness) is a sensitive and reliable indicator of brain function. The
patient is drowsy and growing more so because of
the buildup of CO2 from a lack of effective ventilation. An easily reversible cause (opiate effect) for his
lethargy isn’t present. The pulse oximeter indicates
borderline hypercapneic respiratory failure. It can
often be misleading, as in this case, with the EtCO2
number indicating adequate ventilation; however, it
likely represents an increase of expired partial pressure of carbon dioxide (PCO2) with ineffective ventilation. Noninvasive positive pressure ventilation,
such as continuous positive airway pressure (CPAP),
may be considered to decrease the work of breathing
in hypercapneic respiratory failure. But this patient
is unlikely to be cooperative because of his somnolence, and his respiratory drive is failing rapidly. The
likeliest clinical course is continued deterioration.
You and your partner attempt to augment the
patient’s ventilation with a bag-valve mask (BVM).
You maintain a tight seal with two hands on
the mask while your partner squeezes the bag.
The patient becomes apneic. His SpO2 drops to