All Emergencies - Basic life support principles:

1. Maintain an airway
2. Assess breathing
3. Monitor circulation

Differential diagnosis:

1. Bronchial asthma
2. Bronchospasm due to airway manipulation with inadequate anesthesia
3. Pulmonary edema
4. Aspiration
5. Allergic response to medication or latex
6. Pneumothorax
7. Obstructed ETT - kinking, secretions, cuff
8. Endobronchial intubation

Aspiration:

Any patient that has decreased protective airway reflexes can aspirate. During moderate sedation the goal is to sedate the patient just enough to achieve the desired goals of relaxation and patient cooperation without depressing the protective reflexes. It is easy to overshoot.

Treatment of aspiration:

1. Turn patient on side to and suction the upper airway to remove foreign material
2. If the patient does not appear to be in any respiratory distress and the arterial saturation remains above 90%, administer supplemental oxygen by mask and observe closely.
3. If the patient does appear to have respiratory distress or desaturates, intubate and ventilate with 100% oxygen. Use positive pressure ventilation with positive end-expiratory pressure as needed.
4. Suction down the endotracheal tube. Consider bronchoscopy to remove particulate material.
5. Administer bronchodilators as needed.
6. Do not administer prophylactic antibiotics. Treat bacterial infections as they develop.
7. Benefit of steroid treatment is unclear.

The best management of aspiration is to avoid it by following the NPO guidelines. In this simulation the patient is simply choking on secretions. Stop the procedure, suction to clear the airway promptly, administer supplemental oxygen and listen to the breath sounds. Then resume the procedure since all is well.