ADVANCED AIRWAY MANAGEMENT IN THE INTENSIVE CARE UNIT:FUNDAMENTALS OF INTUBATION AND DIFFICULT AIRWAY MANAGEMENT

ADVANCED AIRWAY MANAGEMENT IN THE INTENSIVE CARE UNIT: FUNDAMENTALS OF INTUBATION AND DIFFICULT AIRWAY MANAGEMENT Bassel Ericsoussi, MD Pulmonary and Critical Care Fellow University of Illinois at Chicago

ADVANCED AIRWAY MANAGEMENT IN THE INTENSIVE CARE UNIT

Positive-pressure Ventilation With a Face Mask and a Bag-valve Device

Orotracheal Intubation

ETT Position Assessment with Ultrasound

The Application of Endotracheal Tube Introducer (The Bougie)

LMA and the Difficult airway

Cricothyroidectomy

Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow

RAPID SEQUENCE INDUCTION (RSI)

The 7 P’s of Rapid Sequence Induction (RSI) in Critically Ill Patients

Preparation

Plan

Preoxygenation

Pretreatment and position

Paralysis after Induction

Protection

Placement with proof

PREPARATION

Place the pt on monitor

IV line for drug administration (sedatives, paralytics, and vasopressors)

BVM with 10L O2, PEEP valve, CO2 detector, laryngoscope (MAC/Miller blades), nasal and oral airways

ET tube with stylet, 10 cc syringe for balloon check up, ETT holder

DIRECT LARYNGOSCOPES

MACINTOSH

More effective at visualizing the glottis in a pt with large amounts of obscuring soft tissue in the upper airway

The end of the blade sit in the vallecula

MILLER

More effective in a small and narrow mouth, or if the epiglottis is long

The end of the blade sit on the tip of the epiglottis

PREOXYGENATION

BVM with 10-15L O2, 8-12 small tidal volumes

Large volumes may increase the risk of vomiting and aspiration due to gastric insufflation.

Cricoid pressure may minimize gastric overdistention and aspiration (controversial)

If O2 sat is slow to rise

PEEP valve of 10 cm H2O

Nasal or oral airways

Increases O2 reserves

Allows O2 sat > 90% during the apnea of the rapid sequence intubation (RSI)

INDUCTION AGENTS (SEDATIVES)

ETOMIDATE

The drug of choice

0.3 mg/kg

A single dose may inhibit adrenal steroidogenesis up to 72 hrs

Relatively contraindicated in sepsis: empiric coverage with stress dose steroid for 72 hrs after administration

No significant hypotension or cardiac depression

PROPOFOL

1-2 mg/kg

Significant hypotension, bradycardia

Not safe in cardiac dysfunction

MIDAZOLAM (VERCED)

Slow onset

Less sedative

Significant hypotension

PARALYTICS

Never paralyze unless you are certain you can ventilate

SUCCINYLCHOLINE

The drug of choice

Depolarizing neuromuscular blocking agent

1 mg/kg

Half life 5 min

Avoid

Renal failure due to hyperkalemia (K>5.5)

Neuromuscular disorders

Burns

Immobility

h/o Malignant hypertermia

ROCURONIUM

Non-depolarizing neuromuscular blocking agent

1 mg/kg

Half life 40 min

RAPID SEQUENCE INDUCTION

Rapid administration of sedatives and paralytics followed by immediate tracheal intubation

BVM ventilation should be avoided in between drug administration and the first attempt at direct laryngoscope if there is no evidence of hypoxemia

Hypotension is common during induction or after intubation

Treat with IVF NS bolus, or vasopressors

POSITION

Remove the head board and lower the bed side rails.

Raise bed (pt’s head at the level of the intubator’s xyphoid process)

Pt’s head in sniffing position: place towel roll underneath pt’s shoulder

To maintain an open airway

POSITIVE-PRESSURE VENTILATION WITH A FACE MASK AND A BAG-VALVE DEVICE

lifesaving maneuver

Indications

Respiratory failure (still breathing spontaneously)

Complete apnea

Any situation in which spontaneous breathing is failing or has ceased (cardiopulmonary arrest)

N Engl J Med 2007;357:e4. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow

CONTRAINDICATIONS

Severe facial trauma and eye injuries

Foreign material (may lead to aspiration pneumonitis). remove any dental prostheses or other foreign bodies that might be swallowed or aspirated

In these circumstances endotracheal intubation may be necessary

Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow POSITIVE-PRESSURE VENTILATION WITH A FACE MASK AND A BAG-VALVE DEVICE

EQUIPMENT

Face mask

Bag-valve device (nonrebreathing, unidirectional valve)

Supplemental oxygen is flowing through the bag-valve device

Suction should be readily available

Positive-Pressure Ventilation with a Face Mask and a Bag-Valve Device. N Engl J Med 2007;357:e4. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow POSITIVE-PRESSURE VENTILATION WITH A FACE MASK AND A BAG-VALVE DEVICE

ONE-HAND TECHNIQUE

Thumb and index finger on the body of the mask while your other fingers pull the jaw forward and extend the head (jaw-thrust with head extension)

Minimize the pressure applied to the submandibular soft tissues (pressure may obstruct the airway by pushing the tongue against the palate)

Assess adequate ventilation: rising and falling of the chest and breath sounds

Gastric insufflation : excessive pressure is delivered to the airway

Epigastric sounds and abdominal distension

Increased intraabdominal pressure

Predisposing patients to vomiting or regurgitation.

USING OROPHARYNGEAL AND NASOPHARYNGEAL AIRWAYS

If difficult or impossible to provide ventilation

Cough and gag reflexes are absent

Select the appropriate-sized device (The tip should reach the angle of the mandible)

Insert the airway upside down and then rotate it 180 degrees as it is being advanced posteriorly

Nasopharyngeal airways are useful when the patient’s mouth cannot be opened

COMPLICATIONS

Corneal abrasions and eye injury

Injuries to the nose and lips

OROTRACHEAL INTUBATION

INDICATIONS

General anesthesia

Multisystem disease or injuries

Cardiac or respiratory arrest

Protect the airway from aspiration

Inadequate oxygenation or ventilation

Existing or anticipated airway obstruction.

N Engl J Med 2007;356:e15. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow

CONTRAINDICATIONS

Partial transection of the trachea (the procedure can cause complete tracheal transection and loss of the airway)

Unstable cervical spine injury is not a contraindication

In-line stabilization of the cervical spine

Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION

EQUIPMENT

Gloves and protective face shield

Suction system

Bag-valve mask attached to an oxygen source

Laryngoscope blades

Curved (Macintosh blade)

Straight (Miller blade)

Endotracheal tube with stylet (sized according to the internal diameter of the tube)

Adults: cuffed.

Size 7, 7.5, 8 mm

Tube depth: align the 22-cm marking on the tube with the front teeth

Children: uncuffed.

Tube size (in mm) [age in years + 4] ÷ 4 or matching the external diameter of the tube to the width of the patient’s little fingernail

Tube depth (in cm ) [(child’s age in years)/2]+12

10-ml syringe (inflate the balloon on the distal end to create a seal between the tube and the tracheal lumen)

Prevent leakage of air and aspiration of gastric contents.

Carbon dioxide detector

Endotracheal-tube holder

Stethoscope

10 years old Tube size: 10+4 /4= 3.5 mm Tube depth: 10/2+12= 17 cm Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION

PREPARATION

Inflate the cuff of the endotracheal tube to check for leaks

Make sure the tip of the stylet does not extend beyond the end of the tube

The stylet can be used to reshape the endotracheal tube to facilitate intubation

Obtain intravenous access, and place the patient on a monitor

PREPARATION (cont.)

“ sniffing” position: by placing a folded towel under the patient’s neck (optimal visualization of the vocal cords)

Preoxygenate with through a bag-valve mask for at least 3 minutes before intubation

Minimize the need for positive-pressure ventilation during intubation, thus reducing the risk of aspiration of gastric contents

Sellick maneuver (cricoid pressure) firm pressure to the cricoid cartilage.

Compresses the esophagus between the cricoid cartilage and the cervical vertebrae (preventing regurgitation of gastric contents). Controversial

Pressure may improve visualization of the glottis

SEDATION AND PARALYSIS

Improve visualization of the vocal cords, and prevent the patient from vomiting and aspirating gastric contents

Indicated in difficult intubation

Limited neck mobility

Small mandible,

Limited ability to open the mouth

Anatomical distortion

Edema or obstruction of the airway

LARYNGOSCOPE BLADE PLACEMENT

Insert the blade to the right of the patient’s tongue. Gradually move the blade to the center of the mouth, pushing the tongue to the left.

Slowly advance the blade and locate the epiglottis (the tip of the blade between the base of the tongue and the epiglottis)

Keep left elbow against the chest to use shoulder rather than arm muscles, generating more force and limiting muscle fatigue

PROPER ORIENTATION OF THE LIFTING ACTION

Lift the laryngoscope upward and forward at a 45-degree angle to expose the vocal cords

Avoid bending your wrist or rocking the blade against the patient’s teeth

ENDOTRACHEAL TUBE INSERTION

The tube should not obstruct your view of the vocal cords

Pass the tube through the vocal cords until the balloon disappears into the trachea.

Remove the stylet, and advance the tube until the balloon is 3 to 4 cm beyond the vocal cords.

21-22 cm at the teeth in females

22-23 cm at the teeth in males

Inflate the endotracheal balloon (10 ml air) to prevent air leakage during ventilation.

If O2 sat falls by 5% or < 90%, the attempt should be aborted and the pt should receive BMV Direct laryngoscope (DL) causes laryngeal edema, repeated DL may cause failure to intubate and failure to ventilate Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION

TROUBLESHOOTING

Cannot see the vocal cords or epiglottis

The blade Inserted too far

The blade is not in the midline

Withdraw the blade gradually in the midline

BURP maneuver: apply firm backward, upward, and rightward pressure

Gently release the cricoid pressure (compression can sometimes compromise the view)

You should always achieve the best possible view of the vocal cords before attempting to insert the endotracheal tube Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION

CONFIRMATION

Carbon dioxide detector

In some patients carbon dioxide may not be present

In cardiac arrest, gas exchange may not occur.

In such cases, you may use fiberoptic endoscope to visualize the tracheal rings

Auscultation

If breath sounds are diminished on the left side after intubation, the right main bronchus has probably been intubated.

Gradually withdraw the endotracheal tube until bilateral breath sounds are auscultated

Chest radiography

The end of the endotracheal tube should lie in the mid-trachea, 3 to 7 cm above the carina

ETT length = patient's height (cm)/10 +5

Patient's height is 170 cm, ETT should be taped at 170/10 + 5 = 22 cm Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION

ETT POSITION ASSESSMENT WITH ULTRASOUND

Proximal ETT malposition:

Esophageal.

ETT too high (can measure distance from vocal cord to tip of tube; in most, tube should not be visible above sternal notch).

Distal ETT malposition:

Bilateral lung sliding indicates normal ETT position.

Unilateral pleural sliding may indicate mainstem intubation.

Combination of both may eliminate the need for chest x-ray (study underway).

Transverse view showing ETT Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow

Longitudinal view showing ETT Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow

ETT Position Tube position OK Confirm with auscultation, ETCO2 Translaryngeal Ultrasound Tip visible Intratracheal Remove and reintubate May be too high, measure distance below VC Pleural Ultrasound Bilateral sliding pleura Unilateral sliding pleura Mainstem intubation Pull tube back 1-2 cm Yes Yes No No Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow

SECURING THE TUBE

Endotracheal-tube holder

Endotracheal-tube tape

Sedation and hand restraints may be used to prevent the patient from inadvertently removing the tube

COMPLICATIONS

Esophageal intubation (hypoxemia, hypercapnia, and death)

Vomiting and aspiration of gastric contents

Pharyngeal stimulation

Bradycardia

Laryngo/bronchospasm

Apnea

Trauma to teeth, lips, and vocal cords

Exacerbation of cervical spine injuries

INITIAL AIRWAY ASSESSMENT

PAST MEDICAL HISTORY

Decreased cervical mobility: RA, ankylosing spondilitis, cervical fixation device

Anatomic abnormalities: major neck surgery, acromegaly, epiglittitis, tumors

h/o airway problem in surgery

MODIFIED MALLAMPATI CLASSIFICATION open mouth, stick out tongue without saying “aah” Soft palate Uvula Posterior pharynx Soft palate Uvula Portion of posterior pharynx Soft palate Soft palate obscured by base of tongue Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow

THYROMENTAL DISTANCE

From upper edge of thyroid cartilage to the chin

<6cm difficult intubation

<7cm a sign of an easy intubation

3-3-2 RULE

Jaw to neck >3 fingers

Jaw >3 fingers

Mouth opening > 2 fingers

INITIAL APPROACH / PREPARATION Initial Intubation Attempts Unsuccessful BVM Adequate Non-Emergency Pathway Can Ventilate, Can’t Intubate BVM Not Adequate Consider LMA LMA Adequate LMA Not Adequate or Not Feasible Emergency Pathway Can’t Ventilate Can’t Intubate Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow

Develop expertise with 1-2 of the following options

Different blade

LMA intubation

Gum elastic bougie

Video laryngoscope

Fiberoptic laryngoscope, bronchoscope

Non-Emergency Pathway Can Ventilate, Can’t Intubate Alternative Approaches to Intubation Successful Intubation Unsuccessful Intubation Invasive Airway Access Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow

LMA (1 st choice)

Esophageal-tracheal combitube

Tracheal jet ventilation

Rigid bronchoscopy

Emergency Pathway Can’t Ventilate Can’t Intubate Call for Help Emergency Non-Invasive Airway Ventilation Successful Unsuccessful Emergency Invasive Airway Access Invasive Airway Access Consider Feasibility of Other Options

Cricothyroidectomy

Tracheostomy

THE APPLICATION OF ENDOTRACHEAL TUBE INTRODUCER (THE BOUGIE)

Airway adjunct

Difficulty in endotracheal tube insertion after laryngoscope blade placement and proper orientation of the lifting action

Advance the bougie to the airways after visualizing the epiglottis or vocal cords (23 cm mark on the bougie to secure the bougie before advancing the ETT)

Then thread the endotracheal tube over the bougie (with counter-clock wise rotation of the ETT as advanced to decrease the chance of the tube to catches on the laryngeal soft tissue).

Always thread the endotracheal tube while the laryngoscope blade in place (otherwise the ETT and the bougie will be pushed posteriorly by the soft tissue and results on the tube catching on the arytenoid)

Finally remove the bougie

TROUBLESHOOTING

Cannot see the laryngeal inlet

Feel the tracheal rings while advancing the bougie

Feel some resistance as it encounters the carina or twist as it enters one of the main bronchi

Or curve the bougie 60 degree anteriorly and then advance it blindly

Unable to advance the ETT over the bougie

Pull back 2 cm then 90 degree counter-clock wise rotation and re-advance

Counter-clock wise rotation of the ETT as advanced to decrease the chance of the tube to catches on the laryngeal soft tissue

LARYNGEAL MASK AIRWAY (LMA)

Supraglottic airway device

Easy and short time to apply (minimal training)

1 st line choice in can’t ventilate, can’t intubate scenario

Not useful in glottic or subglottic obstruction

LMA Classic Low pressure mask (20 cm H2O) Airway tube Inflation Line LMA Proseal Larger mask (30 cm H2O) Drain tube Airway tube Inflation Line LMA Flaccid Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow

THE INTUBATING LMA (ILMA-FASTRACH)

Blind intubation

Should be considered in can ventilate (mask ventilation), can’t intubate(failed attempts with direct laryngoscopy)

can facilitate the passage of a size 8.0mm cuffed endotracheal tube (ETT).

Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow Advantages Disadvantages

Blind placement

High success rate with minimal training

Improves outcomes in emergency ventilation

Not useful for glottic, subglottic obstruction

Doesn’t protect aspiration

Limits to use of positive pressure

LMA INTUBATION TECHNIQUES

Pt’s head in the neutral position

Insert the lubricated LMA following the soft palate/posterior pharynx

The specially designed ETT is passed through the I-LMA to a depth predefined on the tube

An extender tube is placed to facilitate removal of the I-LMA.

The I-LMA cuff can be deflated and left in place once the ETT is in its place.

CRICOTHYROIDOTOMY (SELDINGER TEQUNICE)

OVERVIEW

Emergency procedure performed on patients with severe respiratory distress in whom attempts at orotracheal or nasotracheal intubation have failed

Making an incision in the cricothyroid membrane, and inserting a tracheostomy tube into the trachea to allow ventilation

Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow N Engl J Med 2008;358:e25.

WHO CAN PEROFORME THE PROCEDURE

Should be performed by physicians fully trained and skilled

Emergency physicians

Surgeons

Intensivists.

If you think about it, do it! Surgeon not required

High success rate for minimal skill

Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow CRICOTHYROIDOTOMY

INDICATIONS

The inability to establish an airway through orotracheal or nasotracheal intubation

Difficult patient anatomy

Excessive blood in the mouth or nose

Massive facial trauma

Airway obstruction

Angioedema

Trauma

Burns

Foreign body

FOR HOW LUNG CAN BE LEFT IN PLACE?

Performed under emergency conditions can be left in place for up to 72 hours

Subglottic stenosis

Damage to the thyroid and cricoid cartilages

Should be converted to a tracheostomy if airway access is needed for more than 72hrs (it should be performed in the controlled setting of the operating room)

Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow CRICOTHYROIDECTOMY

CONTRAINDICATIONS