Sooty Boogers Are Bad News

A while ago, I responded to a structure fire. We arrived to find a real, actual fire like you imagined when you were a kid, or see on TV shows about firefighters, but never really actually see in real life. My partner and I staged and watched the proceedings. After a few minutes, there seemed to be a flurry of activity. One of the firefighters helped walk a patient out of the house, pointed to the ambulance as though to direct her to my partner and me, then went back into the burning bungalow. When there is hot stuff that needs wet stuff, EMS can take a back seat. My partner and I went to the patient.

Like, house ON FIRE on fire... Source

Out patient was a 50-something year old lady who had been in the burning house. She was coughing and complaining of a sore throat and slight shortness of breath, but seemed to be okay otherwise and speaking in full sentences. She had soot on her face and sooty streams of black boogers running to either side of her nose. Her eyebrows were even singed. When I asked her to open her mouth, I saw that she had a soot-covered tongue, as well. 

My partner got the pram over to us and we loaded the patient up. This was a good medic that I had for a partner, so she knew where I was going – she restrained the patient’s wrists to the pram siderails with some Velcro restraints that we carry. I grabbed a prep kit and squirted a bunch of Neosynephrine into the patient’s nares, while telling the patient that we would help her breathing get better. The patient’s dyspnea was worsening and her voice was becoming noticeably more hoarse. I knew time was short.

I asked my partner to grab a set of vital signs and I lay an unrolled sheet behind the patient’s head. I find that any mess that I make is easy to wipe up with a sheet, then toss. Looking cool is EMS Rule #2, after all. I took a 7.0mm endotracheal tube out of its packet, aligned the notches on the adaptor cap with the end of the tube, and smashed the cap hard onto the tube. (From hard-won and embarrassing experience, I know that having the cap pop off is a pain in the ass.) I squirted a healthy glob of viscous lidocaine onto the end of the tube, and added some to the patient’s nares as well, for good measure. 

The patient was altered by this point, appearing much more dyspneic, somnolent, and more difficult to communicate with. Every time I see it, I am re-surprised at how fast a patient’s mentation can change and how quickly their respiratory status can decompensate after airway burns. I tried to keep talking to her while I was setting everything up, letting her know that everything would be okay and that I was going to take good care of her. My partner was grabbing other equipment like a BVM and an endotracheal end-tidal capnography detector. When everything was ready to go, I made sure the patient’s head was straight on three planes.

See, I knew it is important to start in an anatomically correct position. The patient needs to be straight in the nodding (chin up-and-down), shaking (chin side-to-side), and tilting (ears to shoulders) planes of motion. If the anatomy isn't straight, nothing will line up. It has to line up for me to slide a tube into lungs without being able to see what I am doing. Once her head was straight in comparison to her torso, I advanced the endotracheal tube into her nose. She was pretty much unconscious by this point. A few centimeters into her right nare, the tube needed more pressure to push through. I have attempted to intubate patients with crazy nasal and sinus anatomy and that feels completely different - like a bony wall. This was more like popping past structures, rather than breaking through them. Most people have what feels like little obstructions a few centimeters into their noses and you have to push past or around them. It doesn’t really crunch, but it does feel more like you have to mash the tube around the obstacles. 

And, unsurprisingly, it wakes patients right-the-hell up. That is why my partner tied this patient’s hands as the first step. Her eyes popped open and she gave a hoarse, gasping groan. I kept her head in position and advanced the tube a bit more, listening the whole time to air passing in and out of the endotracheal tube. I can tell where the tip of the tube is, in most cases, by how the airway anatomy feels and by the volume of air passing through the tube. I wanted to get the tip of the ETT right above the patient’s cords, where the air was loudest. 

Perfect. My tube was in position and I paused for the patient to take a deep breath. Her respiratory effort was too low for this to be easy. Sometimes it helps to gently tap the tube against the cords to generate a cough, so I tried that. Knock knock, open up. The patient coughed and I waited for the cough to end and the patient to take the deep breath. She took a huge gasping inhalation and I advanced the tube. The inhaled air seemed to pull the tip of the tube through the cords and into her lungs.

The sound of a successful nasal intubation is pretty clear, in many cases. I have heard it described as the “Who’s Your Daddy Cough.” When you hear it, you will know why it is called that: The patient’s glottis is no longer closed, holding air in the lungs. So air escapes with a gasping cough noise. Then the patient begins to breathe in and out through the tube. That is exactly what happened with this patient. If advancing the tube didn’t work pretty easily, it was probably because the curve of the endotracheal tube didn’t match up with her airway – her trachea could have been more anterior or whatever. When that happens, I adjust the patient’s head position to make the volume of air passing through the tube louder as it sits just above the vocal cords. I could move the head foreward, chin down, chin up, etc., in order to find a good position with the loudest volume of air being breathed through the tube. I didn’t need to do all of that in this case, though. She pretty much sucked the tube right into her lungs.

So at that point, I believed that I had successfully intubated that patient. My whole concern was where the tip of my tube was located. I had to make sure it was in the patient’s lungs and would stay there. I listened to breath sounds to confirm the  tube’s placement, but I also knew that auscultation was a crappy way to confirm the tube’s location. I had my partner listen, too, because she was a good medic and her opinion mattered to me. The best way (the only way that matters at all, really) to confirm tube placement was to use continuous waveform capnography. Continuous confirmation of the location of the end of the tube is critical. It is an ongoing struggle, to know if your tube is still good. It became almost all I could think about. This patient had a good waveform with an end-tidal carbon dioxide reading of 45 mmHg. I used umbilical tape to tie the tube into position and began to assist the patient’s ventilations. There was a little bit of a nosebleed, so I used the sheet I had placed behind her head to wipe her up a little.

A firefighter arrived to take over the BVM on the ride to the hospital, so I could start an IV and give the patient some Versed. A few milligrams of benzo-love after the tube is in place and confirmed goes a long way to making a patient like this more comfortable (plus the amnesiac effects of midazolam is a nice bonus, too). 

Airway burns are a serious thing. Even adult airways don’t have much of an interior diameter. It is pretty easy for swelling associated with the inhalation of hot gasses to swell an airway shut. I was lucky with this patient that she didn’t close down completely before I could get her intubated. If you see a patient with airway soot, especially in the mouth, with singed facial or nasal hair, get on the tube quick-like.

And so, those are the steps of a blind naso-tracheal intubation. Maybe this post is a swan song of the procedure, for historical interest only. You can look back on this post in the future and laugh at how barbaric EMS used to be. "Tell me about when you used intracardiac epi and nasally intubated patients, grandpa! Did you ever use MAST pants and drive around in a white hearse?" Nasal tubes are a procedure that are on the march toward extinction (probably for the best). In my experience, RSI stands for “Really Slow Intubation” and I can nasally intubate a patient much faster. But oral intubation after rapid sequence induction doesn't bash through and break nasal structures, causing airway concerns to be complicated by epistaxis. Blind nasal tubes are procedures in which success is heavily influenced by experience. You need between six and ten per year to get really good and maintain your competence. There just isn’t enough reason to get enough practice to get good at the skill, nowadays.