Critical Care Airway

Management
 Outline
• how does critical care a/w management differ?

• identification of high-risk airways

• preparation for intubation/extubation including

alternate strategies

• backup strategies

• we will not be discussing devices and techniques

 ICU intubation outcome
• complications frequent and serious—up to 40%
• > 3 attempts —11%

•
esophageal intubation—8%

• aspiration—4%

• death subsequent to intubation effort

Schwartz et al. Anesthesiol 1995; 82: 367

 National Audit Project
Cook TM et al. BJA 2011

• Major complications resulting from airway management from 309

NHS hospitals over 1 yr (2008-09)

• death, brain injury, emergency surgical airway and unplanned ICU admission

• 184 events (36 from ICU/ 15 ED)

‣ 14 tracheostomy-related

‣ 7 failed intubations

‣ 3 esophageal intubations

• accounted for only 20% of intubations but nearly 50% of deaths

• 60% of events led to death or brain damage

 ICU Airway Management

Jaber S. et al CCM 2006; 34(9): 2355

• 253 consecutive ICU intubations

• > 1 serious complication in 28%

Jaber S. et al. CCM 2006
30%

25%

20%

15%

10%

5%

0%
 Impact of “intubation bundle”
Jaber et al. Inten Care Med 2010; 36: 248

• 3 MICUs (France)

• 2 consecutive 6 month trials (Control-121 pt v.

Intervention-123 pt); groups were similar

• 10-bundle management protocol

• primary end points: life-threatening

complications within 60 min of intubation
 Impact of “intubation bundle”
Jaber et al. Inten Care Med 2010; 36: 248
1. 2 operators present 6. cricoid pressure

2. fluid loading 7. capnography

3. long-term sedation 8. norepinephrine if

DBP<35
4. pre-oxygenation with
NIPPV 9. long-term sedation

5. RSI with etomidate or 10. protective ventilation

ketamine + SCh (Vt/ PEEP)
 Jaber et al. Int Care Med 2010

30% 15%
Control (n= 121)
Control (n= 121)

* * Intervention (n= 123)

Intervention (n= 123)
25%
NS
*
20% 10%

15%

NS NS
10% 5%
NS

5% NS
NS

0% 0%
Severe hypoxemia Severe collapse Cardiac arrest Difficult Esophageal Aspiration Cardiac Agitation Dental Injury
Intubation intubation arrythmia
or death

life-threatening complications reduced from 34% to 21%

 What’s different about ICU
Airway Management?
• physiologically marginal

• less tolerant of medications and PPV

• agitated and “unreasonable”

• non-fasted and delayed gastric emptying

• incomplete information

• insufficient time for preparation (resources)

Adnet F. et al. Anesthesiol 1997; 87, 1290-7

Text
IDS>5 mod-major difficulty
• 6.3% in OR
• 16.1% pre-hosp
Intubations outside OR
2 or fewer #2 attempts Relative risk for
Complication attempts (90%) (10%)* #2 attempts 95% CI for risk ratio
Hypoxemia 10.5% 70% 9X 4.20 – 15.92
1.9% 14X 7.36 – 24.34
Severe hypoxemia 28%
4.8% 6X 3.71 – 8.72
Esophageal intubation 51.4%
1.9% 7X 2.82 – 10.14
Regurgitation 0.8% 22%
4X 1.89 – 7.18
Aspiration 1.6% 13% 4X
Bradycardia 0.7% 18.5% 1.71 – 6.74
7X
Cardiac arrest 11% 2.39 – 9.87

Mort TC Anesth Analg 2004; 99: 607

 Cook TM et al. BJA 2011; 106: 632

• in UK serious adverse outcomes related to airway

management more common (x58) and more serious in ICU

• 61% events resulted in brain damage or death

• failure to use (or interpret) capnography was a contributing

factor in 74% of cases resulting in brain damage or death

• inadequate preparation

• delayed recognition of events and

• failed rescue
So what can we do?
 Prepare
• Provide better training (workshops/simulations)

• Anticipate and prepare for failure

• Have backup plans

• Be prepared to deploy backup plans quickly

Anticipate
Prepare for failure
 EMERGENCY INDUCTION CHECKLIST

Prepare for
Prepare Patient Prepare Equipment Prepare Team
difficulty

‰Is preoxygenation ‰
W hat monitoring is ‰Who is ...? ‰If the airway is difficult,
optimal? applied? could we wake the patient
‰
Team leader up?
‰
ECG ‰
First Intubator
‰
Blood pressure ‰
Second Intubator
‰Is the patient’s position ‰
Sats probe ‰
Cricoid Pressure ‰If the intubation is difficult,
optimal? ‰
Capnography ‰
Intubator’s Assistant how will you maintain
‰
Drugs oxygenation? (Plans
‰
MILS (if indicated)
A,B,C,D)

‰Can the patient’s condition ‰

W hat equipment is ‰How do we contact further ‰Where is the relevant
be optimised any further checked and available? help if required? equipment, including
before intubation? alternative airway?
‰
Self-inflating bag
‰
Suction
‰
2 ET tubes
‰How will anaesthesia be ‰
2 laryngoscopes ‰Are any specific
maintained after ‰
Bougie complications anticipated?
induction?

Call for
‰Do you help
have all the early!
required, including
drugs

vasopressors?

This Checklist is not intended to be a comprehensive guide to preparation for induction RTIC Severn

Cook et al: Current Opinion in Anaesthesiology 2012; 25:461

 Predictors of difficult DL
CAFG II Law et al. CJA 2013

• Limited mouth opening • decreased

Submandibular compliance
• limited mandibular • decreased sternomental
protrusion distance

• narrow dental arch • limited head and neck

extension
• decreased thyromental • increased neck
distance circumference
 Predictors of difficult GVL
CAFG II Law et al. CJA 2013

• Cormack-Lehane III or IV with DL

• Abnormal neck anatomy (radiation, prior

surgery, neck pathology)

• limited mandibular protrusion

• decreased sternothyroid distance

 Predictors of difficult FM ventilation
CAFG II Law et al. CJA 2013

• higher BMI
• Mallampati III or IV
• older age
• beard
• male
• lack of teeth
• limited mandibular
protrusion • snoring or OSA

• decreased • neck irradiation

thyromental distance
 Predictors of difficult SGA use
CAFG II Law et al. CJA 2013

• reduced mouth • male

opening
• increase BMI
• supra/subglottic
pathology • poor dentition

• fixed cervical spine • alteration of table or

• applied CP during procedure

 Prepare patient
• Preoxygenation
• Mort TM: preoxygenation for 4 or 8 minutes of marginal
benefit in preventing desaturation (CCM 2005)

• Boussignac or NIV: oral/nasal airway, FiO2

• Weingart SD: “Delayed Sequence Intubation”—

Some patient at high risk of desaturation during apnea and
laryngoscopy despite pre oxygenation (JEM 2011)
‣ high-flow O2 with nasal prongs during apnea/laryngoscopy
 Positioning
• anatomical alignment of axes

• sniffing position thought to be

helpful

• with obese patients, head up

position helpful re ventilation

• tragus aligned with sternal

angle

• Troop pillow
 Induction
• awake vs. “induced”

• ketamine, benzodiazepine, etomidate,

dexmedetomidine, remifentanil, propofol, “ketofol”

• NMB or spontaneous ventilation

• post-procedural sedation

• resuscitation drugs immediately available

 EMERGENCY INDUCTION CHECKLIST

Prepare for
Prepare Patient Prepare Equipment Prepare Team
difficulty

‰Is preoxygenation ‰
W hat monitoring is ‰Who is ...? ‰If the airway is difficult,
optimal? applied? could we wake the patient
‰
Team leader up?
‰
ECG ‰
First Intubator
‰
Blood pressure ‰
Second Intubator
‰Is the patient’s position ‰
Sats probe ‰
Cricoid Pressure ‰If the intubation is difficult,
optimal? ‰
Capnography ‰
Intubator’s Assistant how will you maintain
‰
Drugs oxygenation? (Plans
‰
MILS (if indicated)
A,B,C,D)

‰Can the patient’s condition ‰

W hat equipment is ‰How do we contact further ‰Where is the relevant
be optimised any further checked and available? help if required? equipment, including
before intubation? alternative airway?
‰
Self-inflating bag
‰
Suction
‰
2 ET tubes
‰How will anaesthesia be ‰
2 laryngoscopes ‰Are any specific
maintained after ‰
Bougie complications anticipated?
induction?

‰Do you have all the drugs

required, including
vasopressors?

This Checklist is not intended to be a comprehensive guide to preparation for induction RTIC Severn

Cook TM et al. Curr Opin Anesthesiol 2012; 25:461

 Prepare equipment
• Equipment must be familiar and immediately
available

• Difficult airway cart reduces delays and fixation

errors

• monitors: EKG, BP, SpO2, capnography

• meds: sedatives/hypnotics, NMB, resuscitation

• SLOPESSS
 EMERGENCY INDUCTION CHECKLIST

Prepare for
Prepare Patient Prepare Equipment Prepare Team
difficulty

‰Is preoxygenation ‰
W hat monitoring is ‰Who is ...? ‰If the airway is difficult,
optimal? applied? could we wake the patient
‰
Team leader up?
‰
ECG ‰
First Intubator
‰
Blood pressure ‰
Second Intubator
‰Is the patient’s position ‰
Sats probe ‰
Cricoid Pressure ‰If the intubation is difficult,
optimal? ‰
Capnography ‰
Intubator’s Assistant how will you maintain
‰
Drugs oxygenation? (Plans
‰
MILS (if indicated)
A,B,C,D)

‰Can the patient’s condition ‰

W hat equipment is ‰How do we contact further ‰Where is the relevant
be optimised any further checked and available? help if required? Don’t wait until it’s including
equipment, too
before intubation? alternative airway?
‰
Self-inflating bag late.
‰
Suction
‰
2 ET tubes
‰How will anaesthesia be ‰
2 laryngoscopes ‰Are any specific
maintained after ‰
Bougie complications anticipated?
induction?

‰Do you have all the drugs

required, including
vasopressors?

This Checklist is not intended to be a comprehensive guide to preparation for induction RTIC Severn

Cook TM et al. Curr Opin Anesthesiol 2012; 25:461

 Rapid sequence intubation
• pre-determined dose of hypnotic followed immediately
by NMB (consider DSI)

• Cricoid pressure

• Cricoid cartilage frequently misidentified

• CP may impair laryngeal view—if this happens reduce

pressure

• CP may obstruct airway and prevent insertion of SGA

• benefit uncertain
Succinylcholine

Benumof JL Anesthesiol 1997; 87

 EMERGENCY INDUCTION CHECKLIST

Prepare for
Prepare Patient Prepare Equipment Prepare Team
difficulty

‰Is preoxygenation ‰
W hat monitoring is ‰Who is ...? ‰If the airway is difficult,
optimal? applied? could we wake the patient
‰
Team leader up?
‰
ECG ‰
First Intubator
‰
Blood pressure ‰
Second Intubator
‰Is the patient’s position ‰
Sats probe ‰
Cricoid Pressure ‰If the intubation is difficult,
optimal? ‰
Capnography ‰
Intubator’s Assistant how will you maintain
‰
Drugs oxygenation? (Plans
‰
MILS (if indicated)
A,B,C,D)

‰Can the patient’s condition ‰

W hat equipment is ‰How do we contact further ‰Where is the relevant
be optimised any further checked and available? help if required? equipment, including
before intubation? alternative airway?
‰
Self-inflating bag
‰
Suction
‰
2 ET tubes
‰How will anaesthesia be ‰
2 laryngoscopes ‰Are any specific
maintained after ‰
Bougie complications anticipated?
induction?

‰Do you have all the drugs

required, including
vasopressors?

This Checklist is not intended to be a comprehensive guide to preparation for induction RTIC Severn

Cook TM et al. Curr Opin Anesthesiol 2012; 25:461

 4. Develop primary and alternative strategies:
AWAKE INTUBATION INTUBATION AFTER
INDUCTION OF GENERAL ANESTHESIA
Airway approached by (b)*
Invasive Airway Access
Noninvasive intubation Initial intubation Initial intubation
attempts successful* Attempts UNSUCCESSFUL

FROM THIS POINT ONWARDS

Succeed* FAIL CONSIDER:
1. Calling for help.
2. Returning to
Cancel C onsider feasibility Invasive spontaneous ventilation.
(b)*
Case of other options(a) airway access 3. Awakening the patient.

FACE MASK VENTILATION ADEQUATE FACE MASK VENTILATION NOT ADEQUATE

CONSIDER/ATTEMPT SGA

SGA ADEQUATE* SGA NOT ADEQUATE

OR NOT FEASIBLE
NONEMERGENCY PATHWAY EMERGENCY PATHWAY
Ventilation adequate, intubation unsuccessful Ventilation not adequate, intubation unsuccessful
IF BOTH
Alternative approaches FACE MASK Call for help
to intubation(c) AND SGA
VENTILATION (e)
Emergency noninvasive airway ventilation
BECOME
INADEQUATE
Successful FAIL after
Intubation* multiple attempts Successful ventilation* FAIL

Emergency
Invasive Consider feasibility Awaken invasive airway
(b)* (d) (b)*
airway access of other options(a) patient access

*Confirm ventilation, tracheal intubation, or SGA placement with exhaled CO . 2

DIFFICULT AIRWAY ALGORITHM

Anesthesiol 2013; 118: 251
Canadian Airway Focus Group II: CJA 2013; 60, 1089
 The Vortex Airway Management Checklist
Prepare Interventions Prevent Hypoxia Promote Teamwork

Intravenous Access Safe Apnoea Time Additional Staff:

! !PreOx: !
Adequate 100% O2 Connected/Flowing Supervision
Running Optimise FRC Help: Senior/Anaesthetics/ENT
PreOx Complete !!
!
ApOx: !!
O2 Connected/Flowing
Drugs:
!! Agent Dose Labelled ! !
ReOx:
Intubation: BVM/Ventilator
Roles: Capable Briefed
Induction
Paralysis
Ventilator Settings
Consider PEEP
!
Team Coordinator
Vortex
Adjuncts Airway Operator
Emergency Airway Assistant
! Vortex Approach Cricoid
! Position Manual In-Line Stabilisation
Post Intubation: Suction Drugs
Anaesthesia
Analgesia
! Monitors/Time
Face Mask: Emergency Surgical Airway
Paralysis Adjuncts !
FM: size/type !
! !
Supraglottic Airway: !
SGA: size/type !
Monitoring: Confirm Optimise ! Plan: Discussed
! Endotracheal Tube: !
ETCO2 Adjuncts Anticipated Difficulties: FMV/ETT/SGA/ESA
SaO2 Laryngoscope: size/type (incl VL), functioning Vortex Sequence
BP ETT: size/type Vortex Optimisations
ECG Syringe/Cuff Test Green Zone Options
Alarms Tape/Ties Questions/Concerns?
!
Emergency Surgical Airway:
ESA Kit

49
© Copyright Nicholas Chrimes & Peter Fritz 2014
 Difficult airway cart
• rigid direct laryngoscope

• videolaryngoscope

• tracheal tubes and guides (stylets, introducers)

• SGA

• flexible bronchoscope

• emergency invasive airway

• capnograph
 Extubation
• extubation is always elective

• required reintubation of an elective surgical= 0.1-0.2%

• reintubation of an ICU patient is 10-30%

• impaired oxygenation, ventilation, neurological status,

pulmonary toilet or obstruction

• reintubation of some patients may be difficult or life-

threatening
 Communication
• patients with airway difficulties may be transferred to ICU
from ER or OR

• essential that the problems encountered be thoroughly

discussed with receiving physician

• airway responsibility is a team effort and may require

involvement of anesthesia/surgical teams

• if problem may recur, patient, surgeon, FD and an

accessible registry should be notified

• consideration of MedicAlert Airway Registry (24/7)

 Summary
• airway complications in ED, ICU are more common and more serious

• identification of high-risk airways not perfect

• preparation of patient, equipment, team and dificulty

• never fail to plan for failure (Plan B, C, D)

• avoid repeating ineffective techniques

• extubation strategies
• communication
• Limited resources doesn’t mean limited strategy and planning
TERIMA KASIH
AEC = Airway Exchange Catheter
DA = Difficult Airway
SGA = Supra Glotic Airway
DIS = Difficult Intubation Scale
GVL =Guidance Video Laryngoscope
VL + Video Laryngoscope
DL = Direct Laryngoscope
CP = Cricoid Pressure
DSI = Daily Sedation Interuption