Icu Emergency Airway Management

ICU Emergency AIRWAY MANAGEMENT Dalhousie Critical Care Lecture Series

Introduction
Case history
Airway assessment
Sedation the KISS approach
Ventilation vs. Intubation
Airway adjuncts
Education

Case History
56 y.o. male morbidly obese (BMI=38) with CAP.
Gradual deterioration over 12 hours
Failed non-invasive ventilation
On 100% O2 with O2 sats of 78% and RR of 40 obtunded BP 70/40
Now what?

Airway Anatomy….

Airway Exam
Mallampatti Score

Airway Exam
Thyromental Distance
(6cm / 3 FB)
Jaw Subluxation
Mouth Opening (3 FB)
Atlanto-Occipital Extension (30 degrees)

Airway Anatomy….

Airway Exam
Check old anesthetic records (remember Star Trek)
IV Access unless in extremis (place tube)
Sedation if necessary

Cormack-Lehane Laryngeal View

Definition Minimal Sedation -Anxiolysis Conscious sedation is the use of medication to minimally depress the LOC in a patient while allowing the patient to continually and independently maintain a patent A/W and respond appropriately to verbal commands or gentle stimulation. Chet Wyman, University of Maryland School of Medicine

Sedatives In The Ideal World
Safe
Painless route of administration
Rapid predictable onset
Predictable duration
Reversible
Absence of cardio/respiratory/CNS depression
There are no drugs available which achieve these ideals!

Midazolam (Versed®)
Short acting benzodiazepine
used for sedation, anxiolysis, and amnesia
also used as an induction agent for GA and as an adjunct to regional anesthesia.

Midazolam
Onset: 1-3 minutes
Peak Effect: 3-5 minutes
Duration of action: 45-60 minutes
Adverse reactions: Respiratory depression especially with opioids.
Minimal hemodynamic effects
Antagonist: Flumazenil

Fentanyl
It is a synthetic opioid
100 times more potent than morphine
Mu1 receptors produce analgesia and physical dependence
Mu2 receptors produce respiratory depression, nausea, vomiting, constipation and bradycardia

Fentanyl
Onset: Immediate response
Duration of action: < 60 minutes
Half life: 2-4 hrs.
Increased risk of respiratory depression when given with Benzodiazepines
Antagonist: Naloxone

Etomidate
0.3 mg/kg, with a time to effect of 15 to 45 seconds
duration of action of 3 to 12 minutes
most hemodynamically neutral of the sedative agents used for RSI
The hemodynamic stability associated with etomidate makes it the drug of choice for the intubation of hypotensive patients, as well as an attractive option for patients with intracranial pathology, when hypotension must be avoided

Etomidate
Some researchers have raised concerns regarding the safety of etomidate in the setting of adrenal insufficiency
Adrenal insufficiency in meningococcal sepsis: bioavailable cortisol levels and impact of interleukin-6 levels and intubation with etomidate on adrenal function and mortality. AUden Brinker M; Joosten KF; Liem O; de Jong FH; Hop WC; Hazelzet JA; van Dijk M; Hokken-Koelega AC SOJ Clin Endocrinol Metab. 2005 Sep;90(9):5110-7. Epub 2005 Jun 28.
Should we use etomidate as an induction agent for endotracheal intubation in patients with septic shock?: a critical appraisal. AUJackson WL Jr SOChest 2005 Mar;127(3):1031-8.
Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation. Care Med 2005 Mar;31(3):388-392 .
When intubating the critically ill patient with possible adrenal insufficiency, the clinician must weigh the relative risk of cortisol suppression against the hemodynamic instability that may be caused by other induction agents

Topical Anesthesia Each spray = 10 mg of lidocaine Maximum dose = 5 mg/kg i.e. for 70 kg patient =35 sprays!

3 sprays of lidocaine to each location + 3 sprays behind tongue

Airway Management

4 Questions
Can I oxygenate this patient with a BVM?
Can I ventilate with a supra-glottic device (SGD) i.e. LMA?
Can I place a tube in the trachea?
Can I secure a surgical airway?
Murphy et al CJA 2005 52:3

Basic Airway Management
Head tilt/chin lift
Jaw thrust
Mandibular
displacement

OPA
Oropharyngeal Airway
What size ?
Contraindications ?

NPA
Nasopharyngeal airway
What size ?
Contraindications ?

Mask Ventilation Requires …
Patent airway
Proper fitting mask
Good technique
OPA/NPA
PPV/Oxygen

2 Handed BVM

Difficult Ventilation
MOANS
M = difficult mask seal (full beard)
O = obese or airway obstruction
A = advanced age
N = no teeth
S = snore or stiff lungs
Hung and Murphy CJA 2004 51:10

Can I ventilate this patient ??
B eard
O bese
O ld
T eeth
S leep apnea

Predictors of Difficult Intubation
Small TM distance-beware the beard
Poor mouth opening
High Mallampati score
84.9% sensitivity
94.6% specificity
35.5% PPV
Merah NA et al CJA 2005 52

Can’t Intubate/Can’t Ventilate or Holy *@#& Phenomenon
Failed laryngoscopic intubations (0.05-0.35%)
Can’t intubate/can’t ventilate (1:2250)
Benumof JL Airway Management Principles and Practice 1996:124.

Time to intubate . . .
Basic Equipment
PPV (BVM ventilation)
Oxygen
ETT
Suction
Laryngoscope
Bougie
LMA

Position Your Patient
Sniffing Position
Flexion of lower cervical spine
Extension of A-O joint

What Size Endotracheal Tube ?
Adult male
7.5-8.5
Adult female
6.5-7.5
Pediatric
4 + AGE/4

What Laryngoscope ?

Laryngoscopy

Intubation Confirmation !
Bronchoscopy, direct visualization, carbon dioxide
Auscultation, compliance, condensation, chest wall excursion
CXR

Airway Adjuncts

Cricoid Pressure
New data suggests it is better to position larynx with right hand and then demonstrate position
BURP larynx posterior, up and to the patient’s right
C/I in c-spine fracture

Laryngeal Mask Airway
Indication
Alternate to BMV
Difficult airway scenario
Contraindications
Obese
Reflux
Full stomach

Bougie
Tracheal “clicks”
End point
Right turn

Special Cases
Obesity
Rheumatoid arthritis
Head and neck cancer
Trauma/Fractured c-spine

Obesity
Redundant tissue in oropharynx
Thoracic kyphosis
 FRC
Minimal apnea time
i.e. rapid desaturation

Positioning Obese Patients The blue axis = ear to manubrium should be level

Rheumatoid Arthritis
Multisystem disease
C1-C2 subluxation > 5mm clinical significant
Arytenoid disease
Restrictive lung disease

C1 and C2 Anatomy

Head and Neck Cancer
Previous surgery and/or radiotherapy
Tissues are “woody” immobile
Supraglottic masses  unable to see glottis  impossible DL
Or previous laryngectomy and No glottis!
Consider bronchscopy

Head and neck masses Epiglottis Glottic opening Supraglottic mass

C-spine Trauma
Head Injury common
In-line stabilization essential
Maintain oxygenation and BP

In-line Stabilization

What about the Patient with Pneumonia?
How would you manage this scenario?

Answer
This is an emergency situation, Call for HELP
Confirm patient is on 100% O2 !
Take a brief history including drugs (sedatives)
Examine airway for ease of Ventilation and Intubation
Assist ventilation, 2 handed BVM + OPA
Recheck vitals
Position patient for airway management
Do not make patient APNEIC

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Icu Emergency Airway Management

by Andrew Ferguson on Mar 04, 2008

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Icu Emergency Airway Management — Presentation Transcript