DP45: RESPIRATORY FAILURE IN A 26-YEAR-OLD FEMALE WITH STAGE 3 OBESITY: A CASE STUDY
Elena Silverstein1; Jason Burtch, DO2; Bryce Sebade, DO2; Pedro Garcia, MD2
1Nova Southeastern University College Of Osteopathic Medicine; 2Mount Sinai Medical Center
Introduction: In obese patients, airway management can be challenging; increased adipose tissue causes reduced neck mobility and narrows the upper airway. Additionally, increased soft tissue around the pharynx makes ventilation and intubation challenging or unachievable. Furthermore, these patients experience rapid oxygen desaturation during apnea because of their low functional residual capacity, making speed even more important when securing an airway. Preoxygenation and contingency planning—such as ensuring the availability of a surgeon capable of performing an emergent cricothyroidotomy—are crucial to mitigating adverse outcomes.
Case Report: We present the case of a 26-year-old female with class III obesity (BMI 102.06), hypertension, non-insulin-dependent diabetes mellitus, and hyperlipidemia, who arrived at the Emergency Department with shortness of breath and cough. At baseline, the patient used 1L of oxygen. She presented on 4L of nasal cannula oxygen with an oxygen saturation of 80%, which dropped to 60%, necessitating escalation to 10L.
Laboratory tests revealed an elevated D-dimer (2.26 mg/L), normal troponin (13.00 ng/L), a negative COVID-19 test, and a positive RSV PCR. Arterial blood gas (ABG) analysis showed respiratory acidosis (pH 7.26, PCO2 103 mmHg, PO2 60 mmHg, HCO3 46.2 mmol/L). A chest X-ray demonstrated bilateral perihilar opacities consistent with multifocal pneumonia. She was treated with DuoNeb, levofloxacin, and BiPAP (14/7), achieving an oxygen saturation of 100% before transferring to the intensive care unit (ICU).
In the ICU, oxygen saturations were between 70%–80%. She became nonverbal and arousable only to painful stimuli. A repeat ABG showed worsening respiratory acidosis with severe hypercapnia (pH 7.15, PCO2 >115 mmHg, PO2 65 mmHg, HCO3 43.2 mmol/L). Adjustments to BiPAP settings (20/12) temporarily restored oxygenation.
Unfortunately, the patient's oxygen saturation fell to 40%, and anesthesia was paged for intubation. A GlideScope was used, and a grade 3 view was obtained, which was obscured by significant bloody secretions, likely due to deep vein thrombosis prophylaxis with heparin. The scope was removed, and an oral airway was placed. Bag-mask ventilation was started, and oxygen saturation improved to 80%.
A laryngeal mask airway placement was attempted and failed, necessitating an emergency tracheotomy. The cardiothoracic surgery team was paged and placed a size #8 XLT endotracheal tube, confirmed via bronchoscopy. She was transferred to the operating room (OR) for bronchoscopy and bronchoalveolar lavage. Imaging suggested a right pneumothorax, requiring chest tube placement. Despite mechanical ventilation, hypoxia persisted. Unfortunately, she progressed to asystole, and ultimately, the time of death was called.
Conclusion: It is critical to be proactive in the airway management of severely obese patients with respiratory failure. This case highlights that, for complex airways, bedside intubation is suboptimal. Intubation should have been done in the OR, as transferring a patient after a failed emergency intubation is not feasible. The OR provides the anesthesia team with better resources and greater control over airway management. Additionally, performing a tracheotomy in the OR would have allowed for better preparation, precision, and overall management of this complex airway.