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A grossly intoxicated and obese 52-year-old woman slips while leaving a restaurant, striking her head on a concrete step. She loses consciousness and while lying on her back vomits and aspirates. She is transported by ambulance to the emergency department (ED). By the time she reaches the ED, she is awake and complaining of difficulty in breathing. She is 5 ft (152 cm) tall and weighs 220 lb (100 kg). She has a heart rate (HR) of 122 beats per minute (bpm) (sinus rhythm on the cardiac monitor), respiratory rate (RR) of 28 breaths per minute (and labored), oxygen saturation (SpO2) 90% (on a non-rebreather), and a blood pressure 154/88 mm Hg. Computed tomography (CT) of her head is negative and she has no other injuries. The patient is admitted to the intensive care unit (ICU) for management of her aspiration pneumonitis. Following admission to the ICU, she becomes more distressed and her oxygen saturation falls into the low 80s despite optimal medical management and attempts at noninvasive ventilation. The decision is made to intubate the trachea of the patient. Airway evaluation reveals a thyromental distance of 4 cm; she has both upper and lower dentures. The initial attempt to intubate her trachea awake is unsuccessful and is complicated by further vomiting and aspiration. A second attempt employing a rapid-sequence intubation (RSI) technique, including Sellick maneuver is successful. During the intubation, particulate matter in the pharynx is noted. The laryngeal view with external laryngeal manipulation is a Cormack/Lehane Grade 2. Tracheal placement is confirmed with end-tidal carbon dioxide (ETCO2) detection. Bronchial lavage with a flexible bronchoscope (FB) is performed immediately after intubation.


The patient subsequently develops severe adult respiratory distress syndrome (ARDS) requiring deep sedation, with FiO2 1.0 and pressure-controlled ventilation, adjusted by using ARDSNet parameters1-4 to the following: pressure level (PC) 20 cm H2O, positive end-expiratory pressure (PEEP) 16 cm H2O, FiO2 1.0, tidal volume (TV) 500 to 550 mL, and RR 24 breaths per minute. She receives aggressive supportive care. On ICU day 5, corticosteroids are started and the patient subsequently improves. Her sedation is decreased and by day 7 she is switched to a PC of 18 cm H2O, RR 24 to 30 breaths per minute, and TV 385 to 760 mL.


On day 11, the patient develops a new fever, an increased WBC, hypotension requiring inotropic support, and falling oxygen saturation requiring an increase in FiO2 to 0.50. Bronchoscopy and CT scanning confirms a ventilator-associated pneumonia. On return from CT scan she self-extubates and within 30 minutes requires reintubation. This is accomplished by direct laryngoscopy following the application of topical airway anesthesia, and administration of 1 mg of midazolam, 50 μg of fentanyl. To facilitate tracheal intubation, a styletted orotracheal tube (OTT) and BURP (backwards, upwards, and right-side-orientated pressure on the larynx) are used. Broad-spectrum antibiotics are started. She undergoes a bedside percutaneous ...

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