better late than never…

The case.

An obese 86 year old female is bought to ED by private car with a 5-6 day history of progressive dyspnoea and fevers. She is promptly rushed into the resus bay in extremis with cyanosis & poor respiratory effort. She is hypoxic (SaO2 72%), febrile, tachycardic to 124/min & has a systolic BP of 98mmHg.

As you provide inspiratory assistance with a bag-valve mask & 100% O2, your team connects monitoring & gets IV access. This is her venous blood gas & CXR…


[DDET What’s your next move ?!]

  • Do you intubate her right here & now ?
  • What are your other options ??
  • What can you do to make your life a little easier ???


[DDET The story continues…]

The IPPV improved things. Her SaO2 rose to the mid-90’s and her level of consciousness improved to the point that she maintained her airway & posture in bed…

There are multiple issues here;

    1. Type 2 Respiratory Failure
    2. Sepsis
    3. Advanced age – how aggressive should we be ??

Whilst we commence fluid resuscitation, IV antibiotics & early goal-directed therapy, we decide to trial non-invasive ventilation as a temporizing measure. This allows time to optimise her haemodynamics & discuss her management with the family…


[DDET The decision to intubate ?!]

Our decision to intubate this lady seemed straight forward due to the following reasons…

    • Type 2 Respiratory Failure with significant oxygen requirement…
        • ?Pneumonia ??ARDS (it was flu-season…)
    • Her pathology [?pneumonia ??ARDS] is not easily reversible & will take time to resolve.
    • Whilst 86 years old, she is independent & has good quality of life. Again her pathology is presumed to be reversible.
    • NIV isn’t working.
        • An arterial line is placed. Here is a followup gas….



For an excellent discussion on the decision-making process surrounding intubation, see Andy Neil’s post “Decision to intubate”

Essentially, we make a conscious decision to commit to a delayed sequence intubation ….


[DDET How are you going to get this done ?!]

So….. This is what we did;

    • Continued BiPAP;
        • 18/10 cmH2O & 100% FiO2.
        • Her SaO2 increases to 99%…
    • Preparation;
        • 2x large bore IVs & arterial line (for assessment and management of blood-pressure during induction)
        • Drugs prepared (induction, paralysis, ongoing-sedation, vasopressors).
        • Airway equipment – including video laryngoscope, bougie, LMAs at bedside & open.
    • Patient position;
        • We prop the patient bolt upright in bed & setup a ramp behind her.
        • The ramp is then tested to ensure when she is laid down we have an ‘ear to sternal notch’ alignment.
    • Team discussion;
        • A quick briefing on our airway plan, sequence of events and confirm role designation…

The patient is induced sitting bolt upright with NIV still in place. We use 100mg Ketamine (~1mg/kg) & 100mg suxamethonium. As she fasiculates, we lower her onto the ready-made ramp & my airway assistant takes off the BiPAP mask, replacing it with nasal prongs which are cranked to 15L/min.

The actual intubation runs smoothly. A grade 2 laryngoscopy with tube placed over a bougie (my ‘go-to’ first preference for all intubations). Her SaO2 remains above 96% throughout and her BP doesn’t budge. We start her on a lung protective 6mL/kg tidal volume and titrate up her RR to target a falling ETCO2 whilst keeping an eye on her volume-loops to avoid breath-stacking…

This is her 10 minutes post-intubation…

DSI-CXR02 (post ETT)


[DDET The follow-up…]

      • Our patient remains in the ED for only 2 hours before heading off to ICU.
      • We add in oseltamivir for ?influenza.
      • Her serology returns strongly positive for Mycoplasma !
      • She remains intubated for 48 hours and is weaned from the ventilator easily on Day 3.
      • She is discharged back to her home after a 12 day admission.


[DDET Reflection…]

I’ve been meaning to share this case for sometime now.

It was actually a patient that I saw on one of my first night shifts in a new department.

For my mate Alex & I, it served as a brilliant display of the powerful influence that online learning, podcasts and FOAM can have on our everyday practice. Neither of us had had formal teaching on such a scenario, but the application of various lessons (EGDT, DSI, apnoeic oxygenation) served us well on the night & truly made a difference to this patients outcome !!

Thanks for reading,



    • says

      Hi Minh,

      The BiPAP did not require sedation for tolerance, so I guess it may not be a true ‘DSI’. I believe her CO2-narcosis was doing all the sedation we required for the job…

      I still think the decision to delay the RSI gave us time to prepare her (& ourselves) for the difficult task ahead, particularly the PEEP and 100% O2 optimising her pre-oxygenation. The IV fluid surely gave us a slight ‘buffer’ in preserving her haemodynamic profile.

      Most importantly the delay allowed us to discuss matters with the family to ensure we were doing the right thing by this elderly patient ! (Just because we can, doesn’t necessarily mean we should).


  1. says


    Another great post. NIPPV as bridge to ETI working to a tee. Battle at my ED is always “can we BIPAP a pneumonia?” which is frustrating. This case is anecdotal evidence of its great utility!


  2. rfdsdoc says

    sorry Chris if I came across negtively. not my intention. good teaching case to share, thankyou. it was coincidental as the day you posted I had a question from a resident about how to learn DSI, ketamine, NODESAT…all these novel concepts..well maybe ketamine not so novel :-)
    It made me reflect on a deeper issue that Scott and others raised a while ago and has been a silent undercurrent to the FOAMEd movement.

    How does one learn somethings that your peers and supervisors are clearly not supporting, not aware of nor interested in learning? How do you find the balance between positive educational debate/discussion versus appearing as a lone wolf and arrogant know it all?
    And how do you do this when you are a junior trainee? How do you strike the balance between evidence, eminence and patient safety?
    Your case points to these issues which is why I felt compelled to comment on firstly the definition of DSI since it is by all accounts still a controversial technique and secondly the nature of learning and professional development in the new world of FOAMEd, asynchronous learning and narrowing of the information/knowledge gap.

    Would you be interested in podcating this on PHARM? Scott, you too?

    • says

      Hey Minh,

      Sorry for the delayed reply.

      Firstly, no offense taken 😛

      Secondly; You certainly raise some great questions & I’d love the opportunity to discuss these with you further !!


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