Airway management – it’s a team sport, not a technical skill

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Adam gives practical pearls about managing the unexpected difficult airway. He uses a good example, emphasises the importance of effective teamwork and draws from the Vortex approach and the DAS guidelines. Watch out for more from Adam via the Safe Airway Society.

Gesundheit & Medizin

Airway Mx of the
Critically Ill…
A team sport, not a
technical skill
Dr Adam Rehak

Airway Mx of the
Critically Ill…
A team sport, not a
technical skill
Dr Adam Rehak FANZCA

Rationale/Background
• Delayed/failed intubations
• CICO events where FMV/SGA
omitted or poorly
optimised
• Excessive no. intubation
attempts
• Poor recognition/
agreement when to
“transition” to CICO
Rescue

Objectives
Barriers
Goals
Utilise existing tools/models

Case Study
• 69y/o BIBA with severe SOB
• Suspected cardiogenic
pulmonary oedema
• PHx IHD/AMI/Poor LVEF
• BMI 35
• SpO2 92% on non-rebreather
• Confused and combative,
removing mask
• Refusing NIV/CPAP/BiPAP
• Plan to intubate

Airway Plan
Delayed sequence induction
(ketamine)  RSI with CP
• Plan A
• CMac #4 blade
• CMac D blade
• 3rd attempt only If anaesthestic
help arrives
• Plan B
• iGel
• Plan C
• FMV w OPA/NPA & two-hands
• Plan D
• CICO Rescue scalpel technique

Case Study
Delayed Sequence Induction
• 150mg Ketamine given IV
• SpO2 falls to 85%. Apnoeic
What now?

Case Study
Airway Rescue
• FMV attempted but big leak due
to beard
• Unable to get iGel into mouth
• 100mg Sux given
• SpO2 76% when fasciculations end
• Grade IV larynx with standard #4
Macintosh blade laryngoscope
• Grade IV larynx with cMac #4
blade
• Grade IIIb larynx with CMac D
blade (CP removed, BURP
attempted)
• SpO2 68%
Is this CICO?

Case Study
Return to FMV
• FMV with OPA and two hands
produces some chest movement
• Poor capnograhy trace
• SpO2 steady at 84%
What now?

Case Study
Anaesthetic Registrar Arrives
• A.R. - “What have you tried?”
• FACEM – “We’ve tried
everything…can barely
ventilate with FMV and LMA
didn’t work. Couldn’t intubate
with cMac. Do you want to have
a look?”
What now?

Case Study
Anaesthetic Registrar
• Attempts intubation with Mac #4
blade – Grade IV view
• SpO2 70%
• cMac #4 blade – Grade IV view
• Returns to FMV – impossible
• SpO2 58%
• cMac D-blade – Grade IIIb view,
blind insertion = No ETCO2
• SpO2 unrecordable
• Returns to FMV – impossible…”I
think this is CICO”
Is it?
Who? How?

Case Study
CICO Rescue
• FACEM – “Do you want to do
it?”
• A.R. – “Ok. Give me a 14G
cannula”
• 2 mins - Cannula inserted
• A.R. – “Have you got a Rapid-
O2?....What about an ENK?”
• (Silence)....
• 3 mins - FACEM performs
scalpel-bougie
• 5 mins – O2 delivered, SpO2
90%

The Unanticipated Difficult Airway
Management Goals
• Try all three lifelines
• Optimise all three
lifelines
• Do it quickly (minimum no.
of attempts)
• Don’t repeat anything
• Recognise and exploit
opportunities of the GZ
• Know when to declare CICO
• Be ready to perform CICO
Rescue

• Try all three lifelines
• Optimise all three
lifelines
• Do it quickly (minimum no.
of attempts)
• Don’t repeat anything
• Recognise and exploit
opportunities of the GZ
• Know when to declare CICO
• Be ready to perform CICO
Rescue
The Unanticipated Difficult Airway
Management Goals

Why?
The Unanticipated Difficult Airway
Management Goals

Dual-process theory
• Default to type 1 decision-making
• Biases & errors
• Compounded by distractors and
technical tasks
Fundamental airway errors – Why?

Role clarity?
Fundamental airway errors – Why?

Solutions?
Safe Airway Society
• Multi/interdisciplinary
• Focus on universal
principles, not
discipline-specific
• Watch this space

Summary
• High rates of morbidity including avoidable
complications
• Complex patients/situations require robust
teamwork practices
• Coordination
• Shared mental models
• Rehearsal and practice
• Much still to learn in this area

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