ADVANCED AIRWAY MANAGEMENT IN THE INTENSIVE CARE UNIT: FUNDAMENTALS OF INTUBATION AND DIFFICULT AIRWAY MANAGEMENT Bassel E...
ADVANCED AIRWAY MANAGEMENT IN THE INTENSIVE CARE UNIT <ul><li>Positive-pressure Ventilation With a Face Mask and a Bag-val...
RAPID SEQUENCE INDUCTION (RSI) <ul><li>The 7 P’s of Rapid Sequence Induction (RSI) in Critically Ill Patients </li></ul><u...
PREPARATION <ul><li>Place the pt on monitor </li></ul><ul><li>IV line for drug administration (sedatives, paralytics, and ...
DIRECT LARYNGOSCOPES <ul><li>MACINTOSH </li></ul><ul><li>More effective at visualizing the glottis in a pt with large amou...
PREOXYGENATION <ul><li>BVM with 10-15L O2, 8-12 small tidal volumes </li></ul><ul><ul><li>Large volumes may increase the r...
INDUCTION AGENTS (SEDATIVES) <ul><li>ETOMIDATE </li></ul><ul><ul><li>The drug of choice </li></ul></ul><ul><ul><li>0.3 mg/...
PARALYTICS <ul><li>Never paralyze unless you are certain you can ventilate </li></ul><ul><li>SUCCINYLCHOLINE </li></ul><ul...
RAPID SEQUENCE INDUCTION <ul><li>Rapid administration of sedatives and paralytics followed by immediate tracheal intubatio...
POSITION <ul><li>Remove the head board and lower the bed side rails.  </li></ul><ul><li>Raise bed (pt’s head at the level ...
POSITIVE-PRESSURE VENTILATION WITH A FACE MASK AND A BAG-VALVE DEVICE <ul><li>lifesaving maneuver  </li></ul><ul><li>Indic...
CONTRAINDICATIONS <ul><li>Severe facial trauma and eye injuries </li></ul><ul><li>Foreign material (may lead to aspiration...
EQUIPMENT <ul><li>Face mask </li></ul><ul><li>Bag-valve device (nonrebreathing, unidirectional valve) </li></ul><ul><li>Su...
ONE-HAND TECHNIQUE <ul><li>Thumb and index finger on the body of the mask while your other fingers pull the jaw forward an...
USING OROPHARYNGEAL AND NASOPHARYNGEAL AIRWAYS <ul><li>If difficult or impossible to provide ventilation </li></ul><ul><li...
COMPLICATIONS <ul><li>Corneal abrasions and eye injury </li></ul><ul><li>Injuries to the nose and lips </li></ul>Bassel Er...
OROTRACHEAL INTUBATION <ul><li>INDICATIONS </li></ul><ul><ul><li>General anesthesia </li></ul></ul><ul><ul><li>Multisystem...
CONTRAINDICATIONS <ul><li>Partial transection of the trachea (the procedure can cause complete tracheal transection and lo...
EQUIPMENT <ul><li>Gloves and protective face shield  </li></ul><ul><li>Suction system </li></ul><ul><li>Bag-valve mask att...
PREPARATION <ul><li>Inflate the cuff of the endotracheal tube to check for leaks </li></ul><ul><li>Make sure the tip of th...
PREPARATION (cont.) <ul><li>“ sniffing” position: by placing a folded towel under the patient’s neck (optimal visualizatio...
SEDATION AND PARALYSIS <ul><li>Improve visualization of the vocal cords, and prevent the patient from vomiting and aspirat...
LARYNGOSCOPE BLADE PLACEMENT <ul><li>Insert the blade to the right of the patient’s tongue. Gradually move the blade to th...
PROPER ORIENTATION OF THE LIFTING ACTION <ul><li>Lift the laryngoscope upward and forward at a 45-degree angle to expose t...
ENDOTRACHEAL TUBE INSERTION <ul><li>The tube should not obstruct your view of the vocal cords </li></ul><ul><li>Pass the t...
If O2 sat falls by 5% or < 90%, the attempt should be aborted and the pt should receive BMV Direct laryngoscope (DL) cause...
TROUBLESHOOTING <ul><li>Cannot see the vocal cords or epiglottis </li></ul><ul><ul><li>The blade Inserted too far  </li></...
You should always achieve the best possible view of the vocal cords before attempting to insert the endotracheal tube Bass...
CONFIRMATION <ul><li>Carbon dioxide detector </li></ul><ul><ul><li>In some patients carbon dioxide may not be present  </l...
Bassel Ericsoussi, MD.  Pulmonary and Critical Care Fellow
ETT POSITION ASSESSMENT WITH ULTRASOUND <ul><li>Proximal   ETT malposition: </li></ul><ul><ul><li>Esophageal. </li></ul></...
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 ...
SECURING THE TUBE <ul><li>Endotracheal-tube holder </li></ul><ul><li>Endotracheal-tube tape </li></ul><ul><li>Sedation and...
COMPLICATIONS <ul><li>Esophageal intubation (hypoxemia, hypercapnia, and death) </li></ul><ul><li>Vomiting and aspiration ...
INITIAL AIRWAY ASSESSMENT <ul><li>PAST MEDICAL HISTORY </li></ul><ul><ul><li>Decreased cervical mobility: RA, ankylosing s...
MODIFIED MALLAMPATI CLASSIFICATION open mouth, stick out tongue without saying “aah” Soft palate  Uvula Posterior pharynx ...
THYROMENTAL DISTANCE <ul><li>From upper edge of thyroid cartilage to the chin </li></ul><ul><li><6cm difficult intubation ...
3-3-2 RULE <ul><li>Jaw to neck >3 fingers </li></ul><ul><li>Jaw >3 fingers  </li></ul><ul><li>Mouth opening > 2 fingers </...
INITIAL APPROACH / PREPARATION Initial Intubation Attempts Unsuccessful BVM Adequate Non-Emergency Pathway Can Ventilate, ...
<ul><li>Develop expertise with 1-2 of the following options </li></ul><ul><li>Different blade </li></ul><ul><li>LMA intuba...
<ul><li>LMA (1 st  choice) </li></ul><ul><li>Esophageal-tracheal combitube </li></ul><ul><li>Tracheal jet ventilation </li...
THE APPLICATION OF ENDOTRACHEAL TUBE INTRODUCER (THE BOUGIE) <ul><li>Airway adjunct </li></ul><ul><li>Difficulty in endotr...
TROUBLESHOOTING <ul><li>Cannot see the laryngeal inlet </li></ul><ul><ul><li>Feel the tracheal rings while advancing the b...
Bassel Ericsoussi, MD.  Pulmonary and Critical Care Fellow
LMA Classic Low pressure mask (20 cm H2O) Airway tube Inflation Line LMA Proseal Larger mask (30 cm H2O) Drain tube Airway...
THE INTUBATING LMA  (ILMA-FASTRACH) <ul><li>Blind intubation  </li></ul><ul><li>Should be considered in can ventilate (mas...
LMA INTUBATION TECHNIQUES <ul><li>Pt’s  head in the neutral position </li></ul><ul><li>Insert the lubricated LMA following...
Bassel Ericsoussi, MD.  Pulmonary and Critical Care Fellow
CRICOTHYROIDOTOMY (SELDINGER TEQUNICE) <ul><li>OVERVIEW </li></ul><ul><ul><li>Emergency procedure performed on patients wi...
INDICATIONS <ul><li>The inability to establish an airway through orotracheal or nasotracheal intubation </li></ul><ul><ul>...
FOR HOW LUNG CAN BE LEFT IN PLACE? <ul><li>Performed under emergency conditions can be left in place for up to 72 hours </...
CONTRAINDICATIONS <ul><li>Orotracheal and nasotracheal intubation are not yet attempted  </li></ul><ul><li>Massive trauma ...
PREPARATION/EQUIPMENT <ul><li>Gloves, protective gown, face shield </li></ul><ul><li>Chlorhexidine or povidone iodine </li...
Bassel Ericsoussi, MD.  Pulmonary and Critical Care Fellow
Bassel Ericsoussi, MD.  Pulmonary and Critical Care Fellow
The Initial Incision Should Be Vertical <ul><li>Avoid injury to the recurrent laryngeal nerves </li></ul><ul><li>Allow the...
Bassel Ericsoussi, MD.  Pulmonary and Critical Care Fellow
Bassel Ericsoussi, MD.  Pulmonary and Critical Care Fellow
Bassel Ericsoussi, MD.  Pulmonary and Critical Care Fellow
Bassel Ericsoussi, MD.  Pulmonary and Critical Care Fellow
Bassel Ericsoussi, MD.  Pulmonary and Critical Care Fellow
Bassel Ericsoussi, MD.  Pulmonary and Critical Care Fellow
COMPLICATIONS <ul><li>Esophageal perforation </li></ul><ul><li>Subcutaneous emphysema </li></ul><ul><li>Excessive bleeding...
POSTPROCEDURAL CARE <ul><li>Chest x-ray to confirm placement of the tracheostomy tube.  </li></ul><ul><li>Connect to mecha...
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
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ADVANCED AIRWAY MANAGEMENT IN THE INTENSIVE CARE UNIT: FUNDAMENTALS OF INTUBATION AND DIFFICULT AIRWAY MANAGEMENT

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

  1. 1. 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
  2. 2. ADVANCED AIRWAY MANAGEMENT IN THE INTENSIVE CARE UNIT <ul><li>Positive-pressure Ventilation With a Face Mask and a Bag-valve Device </li></ul><ul><li>Orotracheal Intubation </li></ul><ul><li>ETT Position Assessment with Ultrasound </li></ul><ul><li>The Application of Endotracheal Tube Introducer (The Bougie) </li></ul><ul><li>LMA and the Difficult airway </li></ul><ul><li>Cricothyroidectomy </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  3. 3. RAPID SEQUENCE INDUCTION (RSI) <ul><li>The 7 P’s of Rapid Sequence Induction (RSI) in Critically Ill Patients </li></ul><ul><ul><li>Preparation </li></ul></ul><ul><ul><li>Plan </li></ul></ul><ul><ul><li>Preoxygenation </li></ul></ul><ul><ul><li>Pretreatment and position </li></ul></ul><ul><ul><li>Paralysis after Induction </li></ul></ul><ul><ul><li>Protection </li></ul></ul><ul><ul><li>Placement with proof </li></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  4. 4. PREPARATION <ul><li>Place the pt on monitor </li></ul><ul><li>IV line for drug administration (sedatives, paralytics, and vasopressors) </li></ul><ul><li>BVM with 10L O2, PEEP valve, CO2 detector, laryngoscope (MAC/Miller blades), nasal and oral airways </li></ul><ul><li>ET tube with stylet, 10 cc syringe for balloon check up, ETT holder </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  5. 5. DIRECT LARYNGOSCOPES <ul><li>MACINTOSH </li></ul><ul><li>More effective at visualizing the glottis in a pt with large amounts of obscuring soft tissue in the upper airway </li></ul><ul><li>The end of the blade sit in the vallecula </li></ul><ul><li>MILLER </li></ul><ul><li>More effective in a small and narrow mouth, or if the epiglottis is long </li></ul><ul><li>The end of the blade sit on the tip of the epiglottis </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  6. 6. PREOXYGENATION <ul><li>BVM with 10-15L O2, 8-12 small tidal volumes </li></ul><ul><ul><li>Large volumes may increase the risk of vomiting and aspiration due to gastric insufflation. </li></ul></ul><ul><ul><li>Cricoid pressure may minimize gastric overdistention and aspiration (controversial) </li></ul></ul><ul><li>If O2 sat is slow to rise </li></ul><ul><ul><li>PEEP valve of 10 cm H2O </li></ul></ul><ul><ul><li>Nasal or oral airways </li></ul></ul><ul><li>Increases O2 reserves </li></ul><ul><li>Allows O2 sat > 90% during the apnea of the rapid sequence intubation (RSI) </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  7. 7. INDUCTION AGENTS (SEDATIVES) <ul><li>ETOMIDATE </li></ul><ul><ul><li>The drug of choice </li></ul></ul><ul><ul><li>0.3 mg/kg </li></ul></ul><ul><ul><li>A single dose may inhibit adrenal steroidogenesis up to 72 hrs </li></ul></ul><ul><ul><li>Relatively contraindicated in sepsis: empiric coverage with stress dose steroid for 72 hrs after administration </li></ul></ul><ul><ul><li>No significant hypotension or cardiac depression </li></ul></ul><ul><li>PROPOFOL </li></ul><ul><ul><li>1-2 mg/kg </li></ul></ul><ul><ul><li>Significant hypotension, bradycardia </li></ul></ul><ul><ul><li>Not safe in cardiac dysfunction </li></ul></ul><ul><li>MIDAZOLAM (VERCED) </li></ul><ul><ul><li>Slow onset </li></ul></ul><ul><ul><li>Less sedative </li></ul></ul><ul><ul><li>Significant hypotension </li></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  8. 8. PARALYTICS <ul><li>Never paralyze unless you are certain you can ventilate </li></ul><ul><li>SUCCINYLCHOLINE </li></ul><ul><ul><li>The drug of choice </li></ul></ul><ul><ul><li>Depolarizing neuromuscular blocking agent </li></ul></ul><ul><ul><li>1 mg/kg </li></ul></ul><ul><ul><li>Half life 5 min </li></ul></ul><ul><ul><li>Avoid </li></ul></ul><ul><ul><ul><li>Renal failure due to hyperkalemia (K>5.5) </li></ul></ul></ul><ul><ul><ul><li>Neuromuscular disorders </li></ul></ul></ul><ul><ul><ul><li>Burns </li></ul></ul></ul><ul><ul><ul><li>Immobility </li></ul></ul></ul><ul><ul><ul><li>h/o Malignant hypertermia </li></ul></ul></ul><ul><li>ROCURONIUM </li></ul><ul><ul><li>Non-depolarizing neuromuscular blocking agent </li></ul></ul><ul><ul><li>1 mg/kg </li></ul></ul><ul><ul><li>Half life 40 min </li></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  9. 9. RAPID SEQUENCE INDUCTION <ul><li>Rapid administration of sedatives and paralytics followed by immediate tracheal intubation </li></ul><ul><li>BVM ventilation should be avoided in between drug administration and the first attempt at direct laryngoscope if there is no evidence of hypoxemia </li></ul><ul><li>Hypotension is common during induction or after intubation </li></ul><ul><ul><li>Treat with IVF NS bolus, or vasopressors </li></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  10. 10. POSITION <ul><li>Remove the head board and lower the bed side rails. </li></ul><ul><li>Raise bed (pt’s head at the level of the intubator’s xyphoid process) </li></ul><ul><li>Pt’s head in sniffing position: place towel roll underneath pt’s shoulder </li></ul><ul><ul><li>To maintain an open airway </li></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  11. 11. POSITIVE-PRESSURE VENTILATION WITH A FACE MASK AND A BAG-VALVE DEVICE <ul><li>lifesaving maneuver </li></ul><ul><li>Indications </li></ul><ul><ul><li>Respiratory failure (still breathing spontaneously) </li></ul></ul><ul><ul><li>Complete apnea </li></ul></ul><ul><ul><li>Any situation in which spontaneous breathing is failing or has ceased (cardiopulmonary arrest) </li></ul></ul>N Engl J Med 2007;357:e4. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  12. 12. CONTRAINDICATIONS <ul><li>Severe facial trauma and eye injuries </li></ul><ul><li>Foreign material (may lead to aspiration pneumonitis). remove any dental prostheses or other foreign bodies that might be swallowed or aspirated </li></ul><ul><li>In these circumstances endotracheal intubation may be necessary </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow POSITIVE-PRESSURE VENTILATION WITH A FACE MASK AND A BAG-VALVE DEVICE
  13. 13. EQUIPMENT <ul><li>Face mask </li></ul><ul><li>Bag-valve device (nonrebreathing, unidirectional valve) </li></ul><ul><li>Supplemental oxygen is flowing through the bag-valve device </li></ul><ul><li>Suction should be readily available </li></ul>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
  14. 14. ONE-HAND TECHNIQUE <ul><li>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) </li></ul><ul><li>Minimize the pressure applied to the submandibular soft tissues (pressure may obstruct the airway by pushing the tongue against the palate) </li></ul><ul><li>Assess adequate ventilation: rising and falling of the chest and breath sounds </li></ul><ul><li>Gastric insufflation : excessive pressure is delivered to the airway </li></ul><ul><ul><ul><li>Epigastric sounds and abdominal distension </li></ul></ul></ul><ul><ul><ul><li>Increased intraabdominal pressure </li></ul></ul></ul><ul><ul><ul><li>Predisposing patients to vomiting or regurgitation. </li></ul></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow POSITIVE-PRESSURE VENTILATION WITH A FACE MASK AND A BAG-VALVE DEVICE
  15. 15. USING OROPHARYNGEAL AND NASOPHARYNGEAL AIRWAYS <ul><li>If difficult or impossible to provide ventilation </li></ul><ul><li>Cough and gag reflexes are absent </li></ul><ul><li>Select the appropriate-sized device (The tip should reach the angle of the mandible) </li></ul><ul><li>Insert the airway upside down and then rotate it 180 degrees as it is being advanced posteriorly </li></ul><ul><li>Nasopharyngeal airways are useful when the patient’s mouth cannot be opened </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow POSITIVE-PRESSURE VENTILATION WITH A FACE MASK AND A BAG-VALVE DEVICE
  16. 16. COMPLICATIONS <ul><li>Corneal abrasions and eye injury </li></ul><ul><li>Injuries to the nose and lips </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow POSITIVE-PRESSURE VENTILATION WITH A FACE MASK AND A BAG-VALVE DEVICE
  17. 17. OROTRACHEAL INTUBATION <ul><li>INDICATIONS </li></ul><ul><ul><li>General anesthesia </li></ul></ul><ul><ul><li>Multisystem disease or injuries </li></ul></ul><ul><ul><li>Cardiac or respiratory arrest </li></ul></ul><ul><ul><li>Protect the airway from aspiration </li></ul></ul><ul><ul><li>Inadequate oxygenation or ventilation </li></ul></ul><ul><ul><li>Existing or anticipated airway obstruction. </li></ul></ul>N Engl J Med 2007;356:e15. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  18. 18. CONTRAINDICATIONS <ul><li>Partial transection of the trachea (the procedure can cause complete tracheal transection and loss of the airway) </li></ul><ul><li>Unstable cervical spine injury is not a contraindication </li></ul><ul><ul><li>In-line stabilization of the cervical spine </li></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION
  19. 19. EQUIPMENT <ul><li>Gloves and protective face shield </li></ul><ul><li>Suction system </li></ul><ul><li>Bag-valve mask attached to an oxygen source </li></ul><ul><li>Laryngoscope blades </li></ul><ul><ul><li>Curved (Macintosh blade) </li></ul></ul><ul><ul><li>Straight (Miller blade) </li></ul></ul><ul><li>Endotracheal tube with stylet (sized according to the internal diameter of the tube) </li></ul><ul><ul><li>Adults: cuffed. </li></ul></ul><ul><ul><ul><li>Size 7, 7.5, 8 mm </li></ul></ul></ul><ul><ul><ul><li>Tube depth: align the 22-cm marking on the tube with the front teeth </li></ul></ul></ul><ul><ul><li>Children: uncuffed. </li></ul></ul><ul><ul><ul><li>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 </li></ul></ul></ul><ul><ul><ul><li>Tube depth (in cm ) [(child’s age in years)/2]+12 </li></ul></ul></ul><ul><li>10-ml syringe (inflate the balloon on the distal end to create a seal between the tube and the tracheal lumen) </li></ul><ul><ul><li>Prevent leakage of air and aspiration of gastric contents. </li></ul></ul><ul><li>Carbon dioxide detector </li></ul><ul><li>Endotracheal-tube holder </li></ul><ul><li>Stethoscope </li></ul>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
  20. 20. PREPARATION <ul><li>Inflate the cuff of the endotracheal tube to check for leaks </li></ul><ul><li>Make sure the tip of the stylet does not extend beyond the end of the tube </li></ul><ul><li>The stylet can be used to reshape the endotracheal tube to facilitate intubation </li></ul><ul><li>Obtain intravenous access, and place the patient on a monitor </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION
  21. 21. PREPARATION (cont.) <ul><li>“ sniffing” position: by placing a folded towel under the patient’s neck (optimal visualization of the vocal cords) </li></ul><ul><li>Preoxygenate with through a bag-valve mask for at least 3 minutes before intubation </li></ul><ul><ul><li>Minimize the need for positive-pressure ventilation during intubation, thus reducing the risk of aspiration of gastric contents </li></ul></ul><ul><li>Sellick maneuver (cricoid pressure) firm pressure to the cricoid cartilage. </li></ul><ul><ul><li>Compresses the esophagus between the cricoid cartilage and the cervical vertebrae (preventing regurgitation of gastric contents). Controversial </li></ul></ul><ul><ul><li>Pressure may improve visualization of the glottis </li></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION
  22. 22. SEDATION AND PARALYSIS <ul><li>Improve visualization of the vocal cords, and prevent the patient from vomiting and aspirating gastric contents </li></ul><ul><li>Indicated in difficult intubation </li></ul><ul><ul><li>Limited neck mobility </li></ul></ul><ul><ul><li>Small mandible, </li></ul></ul><ul><ul><li>Limited ability to open the mouth </li></ul></ul><ul><ul><li>Anatomical distortion </li></ul></ul><ul><ul><li>Edema or obstruction of the airway </li></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION
  23. 23. LARYNGOSCOPE BLADE PLACEMENT <ul><li>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. </li></ul><ul><li>Slowly advance the blade and locate the epiglottis (the tip of the blade between the base of the tongue and the epiglottis) </li></ul><ul><li>Keep left elbow against the chest to use shoulder rather than arm muscles, generating more force and limiting muscle fatigue </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION
  24. 24. PROPER ORIENTATION OF THE LIFTING ACTION <ul><li>Lift the laryngoscope upward and forward at a 45-degree angle to expose the vocal cords </li></ul><ul><li>Avoid bending your wrist or rocking the blade against the patient’s teeth </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION
  25. 25. ENDOTRACHEAL TUBE INSERTION <ul><li>The tube should not obstruct your view of the vocal cords </li></ul><ul><li>Pass the tube through the vocal cords until the balloon disappears into the trachea. </li></ul><ul><li>Remove the stylet, and advance the tube until the balloon is 3 to 4 cm beyond the vocal cords. </li></ul><ul><ul><li>21-22 cm at the teeth in females </li></ul></ul><ul><ul><li>22-23 cm at the teeth in males </li></ul></ul><ul><li>Inflate the endotracheal balloon (10 ml air) to prevent air leakage during ventilation. </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION
  26. 26. 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
  27. 27. TROUBLESHOOTING <ul><li>Cannot see the vocal cords or epiglottis </li></ul><ul><ul><li>The blade Inserted too far </li></ul></ul><ul><ul><li>The blade is not in the midline </li></ul></ul><ul><ul><ul><li>Withdraw the blade gradually in the midline </li></ul></ul></ul><ul><ul><ul><li>BURP maneuver: apply firm backward, upward, and rightward pressure </li></ul></ul></ul><ul><ul><ul><li>Gently release the cricoid pressure (compression can sometimes compromise the view) </li></ul></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION
  28. 28. 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
  29. 29. CONFIRMATION <ul><li>Carbon dioxide detector </li></ul><ul><ul><li>In some patients carbon dioxide may not be present </li></ul></ul><ul><ul><ul><li>In cardiac arrest, gas exchange may not occur. </li></ul></ul></ul><ul><ul><ul><li>In such cases, you may use fiberoptic endoscope to visualize the tracheal rings </li></ul></ul></ul><ul><li>Auscultation </li></ul><ul><ul><li>If breath sounds are diminished on the left side after intubation, the right main bronchus has probably been intubated. </li></ul></ul><ul><ul><li>Gradually withdraw the endotracheal tube until bilateral breath sounds are auscultated </li></ul></ul><ul><li>Chest radiography </li></ul><ul><ul><li>The end of the endotracheal tube should lie in the mid-trachea, 3 to 7 cm above the carina </li></ul></ul><ul><ul><li>ETT length = patient's height (cm)/10 +5 </li></ul></ul>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
  30. 30. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  31. 31. ETT POSITION ASSESSMENT WITH ULTRASOUND <ul><li>Proximal ETT malposition: </li></ul><ul><ul><li>Esophageal. </li></ul></ul><ul><ul><li>ETT too high (can measure distance from vocal cord to tip of tube; in most, tube should not be visible above sternal notch). </li></ul></ul><ul><li>Distal ETT malposition: </li></ul><ul><ul><li>Bilateral lung sliding indicates normal ETT position. </li></ul></ul><ul><ul><li>Unilateral pleural sliding may indicate mainstem intubation. </li></ul></ul><ul><li>Combination of both may eliminate the need for chest x-ray (study underway). </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  32. 32. Transverse view showing ETT Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  33. 33. Longitudinal view showing ETT Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  34. 34. 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
  35. 35. SECURING THE TUBE <ul><li>Endotracheal-tube holder </li></ul><ul><li>Endotracheal-tube tape </li></ul><ul><li>Sedation and hand restraints may be used to prevent the patient from inadvertently removing the tube </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION
  36. 36. COMPLICATIONS <ul><li>Esophageal intubation (hypoxemia, hypercapnia, and death) </li></ul><ul><li>Vomiting and aspiration of gastric contents </li></ul><ul><li>Pharyngeal stimulation </li></ul><ul><ul><li>Bradycardia </li></ul></ul><ul><ul><li>Laryngo/bronchospasm </li></ul></ul><ul><ul><li>Apnea </li></ul></ul><ul><li>Trauma to teeth, lips, and vocal cords </li></ul><ul><li>Exacerbation of cervical spine injuries </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow OROTRACHEAL INTUBATION
  37. 37. INITIAL AIRWAY ASSESSMENT <ul><li>PAST MEDICAL HISTORY </li></ul><ul><ul><li>Decreased cervical mobility: RA, ankylosing spondilitis, cervical fixation device </li></ul></ul><ul><ul><li>Anatomic abnormalities: major neck surgery, acromegaly, epiglittitis, tumors </li></ul></ul><ul><ul><li>h/o airway problem in surgery </li></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  38. 38. 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
  39. 39. THYROMENTAL DISTANCE <ul><li>From upper edge of thyroid cartilage to the chin </li></ul><ul><li><6cm difficult intubation </li></ul><ul><li><7cm a sign of an easy intubation </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  40. 40. 3-3-2 RULE <ul><li>Jaw to neck >3 fingers </li></ul><ul><li>Jaw >3 fingers </li></ul><ul><li>Mouth opening > 2 fingers </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  41. 41. 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
  42. 42. <ul><li>Develop expertise with 1-2 of the following options </li></ul><ul><li>Different blade </li></ul><ul><li>LMA intubation </li></ul><ul><li>Gum elastic bougie </li></ul><ul><li>Video laryngoscope </li></ul><ul><li>Fiberoptic laryngoscope, bronchoscope </li></ul>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
  43. 43. <ul><li>LMA (1 st choice) </li></ul><ul><li>Esophageal-tracheal combitube </li></ul><ul><li>Tracheal jet ventilation </li></ul><ul><li>Rigid bronchoscopy </li></ul>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 <ul><li>Cricothyroidectomy </li></ul><ul><li>Tracheostomy </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  44. 44. THE APPLICATION OF ENDOTRACHEAL TUBE INTRODUCER (THE BOUGIE) <ul><li>Airway adjunct </li></ul><ul><li>Difficulty in endotracheal tube insertion after laryngoscope blade placement and proper orientation of the lifting action </li></ul><ul><li>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) </li></ul><ul><li>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). </li></ul><ul><li>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) </li></ul><ul><li>Finally remove the bougie </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  45. 45. TROUBLESHOOTING <ul><li>Cannot see the laryngeal inlet </li></ul><ul><ul><li>Feel the tracheal rings while advancing the bougie </li></ul></ul><ul><ul><li>Feel some resistance as it encounters the carina or twist as it enters one of the main bronchi </li></ul></ul><ul><ul><li>Or curve the bougie 60 degree anteriorly and then advance it blindly </li></ul></ul><ul><li>Unable to advance the ETT over the bougie </li></ul><ul><ul><li>Pull back 2 cm then 90 degree counter-clock wise rotation and re-advance </li></ul></ul><ul><ul><li>Counter-clock wise rotation of the ETT as advanced to decrease the chance of the tube to catches on the laryngeal soft tissue </li></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  46. 46. LARYNGEAL MASK AIRWAY (LMA) <ul><li>Supraglottic airway device </li></ul><ul><li>Easy and short time to apply (minimal training) </li></ul><ul><li>1 st line choice in can’t ventilate, can’t intubate scenario </li></ul><ul><li>Not useful in glottic or subglottic obstruction </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  47. 47. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  48. 48. 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
  49. 49. THE INTUBATING LMA (ILMA-FASTRACH) <ul><li>Blind intubation </li></ul><ul><li>Should be considered in can ventilate (mask ventilation), can’t intubate(failed attempts with direct laryngoscopy) </li></ul><ul><li>can facilitate the passage of a size 8.0mm cuffed endotracheal tube (ETT). </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow Advantages Disadvantages <ul><li>Blind placement </li></ul><ul><li>High success rate with minimal training </li></ul><ul><li>Improves outcomes in emergency ventilation </li></ul><ul><li>Not useful for glottic, subglottic obstruction </li></ul><ul><li>Doesn’t protect aspiration </li></ul><ul><li>Limits to use of positive pressure </li></ul>
  50. 50. LMA INTUBATION TECHNIQUES <ul><li>Pt’s head in the neutral position </li></ul><ul><li>Insert the lubricated LMA following the soft palate/posterior pharynx </li></ul><ul><li>The specially designed ETT is passed through the I-LMA to a depth predefined on the tube </li></ul><ul><li>An extender tube is placed to facilitate removal of the I-LMA. </li></ul><ul><li>The I-LMA cuff can be deflated and left in place once the ETT is in its place. </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  51. 51. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  52. 52. CRICOTHYROIDOTOMY (SELDINGER TEQUNICE) <ul><li>OVERVIEW </li></ul><ul><ul><li>Emergency procedure performed on patients with severe respiratory distress in whom attempts at orotracheal or nasotracheal intubation have failed </li></ul></ul><ul><ul><li>Making an incision in the cricothyroid membrane, and inserting a tracheostomy tube into the trachea to allow ventilation </li></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow N Engl J Med 2008;358:e25.
  53. 53. WHO CAN PEROFORME THE PROCEDURE <ul><li>Should be performed by physicians fully trained and skilled </li></ul><ul><ul><li>Emergency physicians </li></ul></ul><ul><ul><li>Surgeons </li></ul></ul><ul><ul><li>Intensivists. </li></ul></ul><ul><ul><ul><li>If you think about it, do it! Surgeon not required </li></ul></ul></ul><ul><ul><ul><li>High success rate for minimal skill </li></ul></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow CRICOTHYROIDOTOMY
  54. 54. INDICATIONS <ul><li>The inability to establish an airway through orotracheal or nasotracheal intubation </li></ul><ul><ul><li>Difficult patient anatomy </li></ul></ul><ul><ul><li>Excessive blood in the mouth or nose </li></ul></ul><ul><ul><li>Massive facial trauma </li></ul></ul><ul><ul><li>Airway obstruction </li></ul></ul><ul><ul><ul><li>Angioedema </li></ul></ul></ul><ul><ul><ul><li>Trauma </li></ul></ul></ul><ul><ul><ul><li>Burns </li></ul></ul></ul><ul><ul><ul><li>Foreign body </li></ul></ul></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow CRICOTHYROIDOTOMY
  55. 55. FOR HOW LUNG CAN BE LEFT IN PLACE? <ul><li>Performed under emergency conditions can be left in place for up to 72 hours </li></ul><ul><ul><li>Subglottic stenosis </li></ul></ul><ul><ul><li>Damage to the thyroid and cricoid cartilages </li></ul></ul><ul><li>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) </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow CRICOTHYROIDECTOMY
  56. 56. CONTRAINDICATIONS <ul><li>Orotracheal and nasotracheal intubation are not yet attempted </li></ul><ul><li>Massive trauma to the larynx cricoid cartilage </li></ul><ul><li>Burn or infection over entry side </li></ul><ul><li>Inability to identify the cricothyroid membrane </li></ul><ul><li>Children < 8 years </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow CRICOTHYROIDOTOMY
  57. 57. PREPARATION/EQUIPMENT <ul><li>Gloves, protective gown, face shield </li></ul><ul><li>Chlorhexidine or povidone iodine </li></ul><ul><li>Gauze pads </li></ul><ul><li>1% or 2% lidocaine with epinephrine </li></ul><ul><li>Radiopaque airway catheter (3.5,4,6 mm) </li></ul><ul><li>Taper curved dilator (with a handle design to fit in the airway catheter) </li></ul><ul><li>Wire-guide (with a single flexible end) </li></ul><ul><li>Scalpel </li></ul><ul><li>6-ml syringe with a 25-gauge needle </li></ul><ul><li>Introducer needle (18 gauge) </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow CRICOTHYROIDECTOMY
  58. 58. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  59. 59. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  60. 60. The Initial Incision Should Be Vertical <ul><li>Avoid injury to the recurrent laryngeal nerves </li></ul><ul><li>Allow the extension of the incision as needed </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  61. 61. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  62. 62. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  63. 63. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  64. 64. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  65. 65. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  66. 66. Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow
  67. 67. COMPLICATIONS <ul><li>Esophageal perforation </li></ul><ul><li>Subcutaneous emphysema </li></ul><ul><li>Excessive bleeding or hemorrhage </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow CRICOTHYROIDOTOMY
  68. 68. POSTPROCEDURAL CARE <ul><li>Chest x-ray to confirm placement of the tracheostomy tube. </li></ul><ul><li>Connect to mechanical ventilator </li></ul><ul><li>Surgical consult for definitive tracheostomy </li></ul><ul><li>Can be left in place for up to 72 hours. </li></ul>Bassel Ericsoussi, MD. Pulmonary and Critical Care Fellow CRICOTHYROIDOTOMY

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