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MAXIM: Endotracheal intubation is not always the best initial intervention for respiratory failure.
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Some patients in respiratory distress may benefit from other interventions, short of intubation. Patients with flash pulmonary edema may have dramatic improvement with intravenous nitroglycerin, intravenous furosemide, and BiPAP (Bi-Level Positive Airway Pressure) ventilation (see Fig. 22.1). Patients with airway narrowing (edema, neoplasm, stricture, foreign body) can have significant decreased work of breathing by decreasing airway resistance to inspired gas using administration of helium-oxygen (HELIOX) mixture. HELIOX, usually as a 78%: 22% helium: oxygen mixture, is much less dense than either air or 100% oxygen by virtue of helium replacing nitrogen or oxygen, respectively. This lowers resistance to laminar flow by as much as 20% to 25% and the effects are immediate.
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Alternative ventilatory adjuncts include HELIOX, CPAP, BiPAP, and Vapotherm (see Fig. 22.2). These adjuncts may prevent the need for intubation in selected patients.
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MAXIM: The most important initial airway intervention may be to ask for help.
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Clinical scenarios where asking for help include:
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Laryngeal injury/tracheal disruption, for whom a nonendoscopic intubation attempt can result in tracheal disruption and fatally lost airway (see Fig. 22.3).
Recent neck surgery, with pending loss of airway from an expanding hematoma; definitive and life-saving intervention in this case is to open up the recent incision and evacuate the hematoma.
Suspected epiglottitis, where an immediate operative tracheostomy or cricothyroidotomy may be required if intubation fails due to epiglottic edema.
Severe angioedema with tongue, oropharynx swelling where endotracheal or nasotracheal intubation may be obstructed (see Fig. 22.4).
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