Critical illness airway management
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An overview of considerations, the mindset and the approach to the critical airway
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Critical illness airway management
- 1. Airway management in critical illness ARUN RADHAKRISHNAN
- 2. Case 50/M with bad CAP SpO2 70% on 4 L NP RR 40, HR 120, BP 100/70, Temperature 39o C Agitated, not accepting mask How are you going to intubate this guy?
- 3. Why is intubation required? 8 P’s Airway protection Maintain airway patency To provide higher PEEP High FiO2 requirements (Purified O2) Pulmonary toileting Reduce WOB (Power-up breathing) Anticipated need for unusual positioning (e.g., prone ventilation) Facilitate procedures/investigations
- 4. What are the goals of airway management?
- 5. Goals of airway management Achieving ‘First-pass’ success Keeping the patient safe ◦ Preventing Hypoxaemia ◦ Preventing Hypotension
- 6. Introduction Why is airway management very different in ICU as compared to the OT? ◦ Suboptimal conditions ◦ Limited physiologic reserve ◦ Practitioners with variable levels of experience ◦ Time
- 7. Situations where the airway may be difficult? Head and neck trauma Known airway &/or C spine pathology Morbid obesity or pregnancy Burns affecting airway Do you know of any scoring systems?
- 8. The ‘Physiologically Difficult’ airway Hypoxaemia Hypotension Severe metabolic acidosis RV failure
- 9. Definitions Impossible Mask Ventilation: Absence of ETCO2, no chest wall movement during positive pressure ventilation despite airway adjuvants and additional personnel Difficult Intubation: Multiple attempts required, in the presence or absence of tracheal pathology Difficult Laryngoscopy: Not possible to visualize any portion of the vocal cords after multiple attempts at conventional laryngoscopy ( Cormack-Lehane grade 3 or 4 view)
- 10. Where can things go wrong? At all stages! Airway assessment Patient selection and preparation Human and team factors Selection of technique and equipment Haemodynamic management Post-intubation management Hence the term ‘Airway Management’ as opposed to ‘Intubation’!
- 11. Airway management Airway Management Patient‘s Airway assessment Operator experience and resources available Haemodynamic and respiratory stability Patient preparation and optimization Post-intubation care Team management
- 12. Pitfalls Failure to plan Positioning and preparation Pre-oxygenation Haemodynamic management Equipment Surgical airway Post-intubation management
- 13. How do we approach the critical airway? Preparation, more preparation, communication, planning for all eventualities Strategies to avoid intubation in the first place ?!
- 15. Don’t forget… Feel and mark the Cricothyroid membrane Considering the need for FONA is crucial in all patients!
- 16. What can be optimised?
- 17. Achieving safety-Preparation Optimize Patient physiology ◦ Positioning ◦ Oxygenation ◦ Haemodynamics Monitoring Resources-identify and allocate Prepare the team- communication
- 18. Achieving safety Secure IV Access Drugs for emergencies – ◦ Atropine, Adrenaline, Metaraminol ◦ Norad, metaraminol infusions Routine medications ◦ Dosing considerations Fluid bolus
- 20. Achieving safety- Equipment Remember the acronym MALES/MEALS M Mask A Airway L Laryngoscope E ETT S Suction
- 21. Equipment considerations Laryngoscopes of various sizes and types ◦ Video laryngoscopes increasingly used Stylets and bougies Airway exchange catheters ETTs of 1 size larger and smaller than anticipated Rescue equipment ◦ SGA ◦ FOB ◦ Cricothyroidotomy set
- 22. Safety CHECKLIST DIFFICULT AIRWAY TROLLEY
- 23. The team… TEAM MANAGEMENT Communicate plan A/B/C clearly Advantages? Ensure backup resources available
- 24. Induction techniques Rapid sequence (RSI) Graded Sedation Intubation (GSI) Delayed sequence (DSI) Awake intubation
- 25. RSI Rapid push of IV agents (Anaesthetic and paralytic) simultaneously to facilitate rapid securing of the airway Increases potential for surprises – difficulty with intubation Preparation is key Do you ventilate the patient?
- 27. What are the problems with RSI?
- 28. Delayed Sequence induction Procedural sedation, the procedure being…preoxygenation Position, preoxygenate Ketamine 1-2 mg/kg IV slow, use more if required Nasal cannulae O2 @ 15 Lpm Preoxygenate with BVM + PEEP Valve or NRB, at least 3 min Administer NMB Intubate
- 29. Graded Sedation Intubation (GSI) Both GSI and DSI aim to prioritize oxygenation and patient safety over rapid intubation GSI doesn’t involve paralysis whereas DSI does Induction/anaesthetic agents used may differ
- 30. Awake intubation Best left to the anaesthetist ?!!! Patient selection Indications & advantages?
- 32. Anything missing so far? Team management Skilled assistance Plan B/C/D Post- intubation management
- 33. Patient positioning Keep patient as upright as possible until intubation Continue NIV Best position to intubate: ◦ Classic ‘ Sniffing’ position ◦ Ear (EAM) in same plane as sternal notch (Ramp position)
- 34. Why is positioning important? Alignment of all axes Pt comfort Prevents de- recruitment of basal lung regions Degree of protection from hypoxaemia
- 35. Preoxygenation Why is this important? How do we do it? What are the processes involved?
- 36. Preoxygenation Vs. Denitrogenation Denitrogenation – replacement of nitrogen (in lungs) with oxygen Oxygenation- providing best possible conditions to withstand intubation process ◦ NIV- do not discontinue ◦ Supplemental Oxygenation- NPs/HFNPs ◦ Which one technique is superior (NIV Vs. O2 insufflation)?
- 37. Pre-oxygenation 3 minutes, or 8 VC breaths with tight-fitting mask at 100% O2 Difficult to achieve What sats do you aim for pre-intubation?
- 38. Peroxygenation…??? Peri-intubation oxygenation ◦ NPs at 15 Lpm ◦ CPAP (5-10 cm H2O) ◦ Apnoiec oxygenation ◦ Transnasal humidified rapid insufflation ventilator exchange (THRIVE) – HFNPs @ 70 Lpm ◦ Oxygenation during mask ventilation (BMV) ◦ NIV
- 39. What are we trying to do? Prolong the ‘Safe Apnoea’ time How does O2 insufflation help during apnoea?
- 40. Other methods – the triple 15 rule Nasal prongs with 15 Lpm flow NRB mask with 15 Lpm flow And, if SpO2 still less than 95%, NIV or BVM with PEEP of 15 cm H2O https://www.jems.com/articles/print/volume-43/issue-4/features/a-modern-approach-to-basic-airway-management.html?c=1
- 41. Haemodynamic preparation Secure IV access Preload – fluid bolus Vasopressors already commenced, and push pressors available Aim for a SBP of > 100 - 120 or MAP around 70-80 prior to induction
- 43. Optimization
- 44. Unable to intubate- what next??? Plans B,C and D Various algorithms Call out ‘Difficult Intubation’ Attempt Oxygenation ◦ BMV ◦ SGA Do not make more than 3 attempts-why?
- 45. Unable to intubate- what next??? Protect oxygenation BMV ventilation (if patient sedated and paralyzed) or allow spontaneous breathing Next steps depend on Ability to oxygenate Availability of skilled help
- 46. Unable to intubate- Supraglottic airway Logical next step- rescue oxygenation LMAs and other devices Can facilitate Fibreoptic intubation
- 48. Unable to intubate or oxygenate- what next??? Call out ‘Can’t Intubate Can’t Oxygenate’ (CICO) Prepare for Surgical airway Thinking about it beforehand is the first step ◦ https://youtu.be/RrIzIxoshMg
- 49. Achieving safety - Checklists Have you seen them being used?
- 50. Difficult Airway Society guidelines https://www.das.uk.com/guidelines/icu_guidelines2017
- 52. Post-intubation Do not walk away!!!! Confirm ETT placement Manage haemodynamics Plan for ventilation, sedation, analgesia etc. Potential issues post-intubation?
- 53. Recap Avoid common pitfalls Prepare for the difficult airway Positioning, Preoxygenation, Physiologic optimization, Planning Team approach
- 54. Coming back to the case… What do you do? Can we summarize what we have learnt today?
- 55. Difficult intubation scenarios… H&N trauma Airway burns Anaphylaxis Pregnancy Morbid obesity Cervical spine pathology Upper airway obstruction Paediatric Unplanned extubation
- 56. The end Failing to plan is planning to fail!
- 57. References (in no particular order) 1. Umobong and Mayo. Crit Care Clin 34 (2018) 313–324 2. De Jong et al. Critical Care 2014, 18:209 (http://ccforum.com/content/18/2/209) 3. Griesdale et al. Lung 2011, DOI 10.1007/s00408-011-9278-3 4. Higgs et al. British Journal of Anaesthesia, 120 (2): 323-352 (2018) 5. Difficult airway society guidelines. https://das.uk.com/guidelines/icu_guidelines2017 6. Vortexapproach.org 7. https://lifeinthefastlane.com/ccc/airway-assessment/ 8. Myatra SN et al. Indian J Anaesth 2016;60:885-98