Icu Emergency Airway Management


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Icu Emergency Airway Management

  1. 1. ICU Emergency AIRWAY MANAGEMENT Dalhousie Critical Care Lecture Series
  2. 2. Introduction <ul><li>Case history </li></ul><ul><li>Airway assessment </li></ul><ul><li>Sedation the KISS approach </li></ul><ul><li>Ventilation vs. Intubation </li></ul><ul><li>Airway adjuncts </li></ul><ul><li>Education </li></ul>
  3. 3. Case History <ul><li>56 y.o. male morbidly obese (BMI=38) with CAP. </li></ul><ul><li>Gradual deterioration over 12 hours </li></ul><ul><li>Failed non-invasive ventilation </li></ul><ul><li>On 100% O2 with O2 sats of 78% and RR of 40 obtunded BP 70/40 </li></ul><ul><li>Now what? </li></ul>
  4. 4. Airway Anatomy….
  5. 5. Airway Exam <ul><li>Mallampatti Score </li></ul>
  6. 6. Airway Exam <ul><li>Thyromental Distance </li></ul><ul><li>(6cm / 3 FB) </li></ul><ul><li>Jaw Subluxation </li></ul><ul><li>Mouth Opening (3 FB) </li></ul><ul><li>Atlanto-Occipital Extension (30 degrees) </li></ul>
  7. 7. Airway Anatomy….
  8. 9. Airway Exam <ul><li>Check old anesthetic records (remember Star Trek) </li></ul><ul><li>IV Access unless in extremis (place tube) </li></ul><ul><li>Sedation if necessary </li></ul>
  9. 10. Cormack-Lehane Laryngeal View
  10. 11. 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
  11. 12. Sedatives In The Ideal World <ul><li>Safe </li></ul><ul><li>Painless route of administration </li></ul><ul><li>Rapid predictable onset </li></ul><ul><li>Predictable duration </li></ul><ul><li>Reversible </li></ul><ul><li>Absence of cardio/respiratory/CNS depression </li></ul>There are no drugs available which achieve these ideals!
  12. 13. Midazolam (Versed®) <ul><li>Short acting benzodiazepine </li></ul><ul><li>used for sedation, anxiolysis, and amnesia </li></ul><ul><li>also used as an induction agent for GA and as an adjunct to regional anesthesia. </li></ul>
  13. 14. Midazolam <ul><li>Onset: 1-3 minutes </li></ul><ul><li>Peak Effect: 3-5 minutes </li></ul><ul><li>Duration of action: 45-60 minutes </li></ul><ul><li>Adverse reactions: Respiratory depression especially with opioids. </li></ul><ul><li>Minimal hemodynamic effects </li></ul><ul><li>Antagonist: Flumazenil </li></ul>
  14. 15. Fentanyl <ul><li>It is a synthetic opioid </li></ul><ul><li>100 times more potent than morphine </li></ul><ul><li>Mu1 receptors produce analgesia and physical dependence </li></ul><ul><li>Mu2 receptors produce respiratory depression, nausea, vomiting, constipation and bradycardia </li></ul>
  15. 16. Fentanyl <ul><li>Onset: Immediate response </li></ul><ul><li>Duration of action: < 60 minutes </li></ul><ul><li>Half life: 2-4 hrs. </li></ul><ul><li>Increased risk of respiratory depression when given with Benzodiazepines </li></ul><ul><li>Antagonist: Naloxone </li></ul>
  16. 17. Etomidate <ul><li>0.3 mg/kg, with a time to effect of 15 to 45 seconds </li></ul><ul><li>duration of action of 3 to 12 minutes </li></ul><ul><li>most hemodynamically neutral of the sedative agents used for RSI </li></ul><ul><li>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 </li></ul>
  17. 18. Etomidate <ul><li>Some researchers have raised concerns regarding the safety of etomidate in the setting of adrenal insufficiency </li></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>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. </li></ul></ul><ul><ul><li>Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation. Care Med 2005 Mar;31(3):388-392 .   </li></ul></ul><ul><li>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 </li></ul>
  18. 19. Topical Anesthesia Each spray = 10 mg of lidocaine Maximum dose = 5 mg/kg i.e. for 70 kg patient =35 sprays!
  19. 20. 3 sprays of lidocaine to each location + 3 sprays behind tongue
  20. 21. Airway Management
  21. 22. 4 Questions <ul><li>Can I oxygenate this patient with a BVM? </li></ul><ul><li>Can I ventilate with a supra-glottic device (SGD) i.e. LMA? </li></ul><ul><li>Can I place a tube in the trachea? </li></ul><ul><li>Can I secure a surgical airway? </li></ul>Murphy et al CJA 2005 52:3
  22. 23. Basic Airway Management <ul><li>Head tilt/chin lift </li></ul><ul><li>Jaw thrust </li></ul><ul><li>Mandibular </li></ul><ul><li>displacement </li></ul>
  23. 24. OPA <ul><li>Oropharyngeal Airway </li></ul><ul><ul><li>What size ? </li></ul></ul><ul><ul><li>Contraindications ? </li></ul></ul>
  24. 25. NPA <ul><li>Nasopharyngeal airway </li></ul><ul><ul><li>What size ? </li></ul></ul><ul><ul><li>Contraindications ? </li></ul></ul>
  25. 26. Mask Ventilation Requires … <ul><li>Patent airway </li></ul><ul><li>Proper fitting mask </li></ul><ul><li>Good technique </li></ul><ul><li>OPA/NPA </li></ul><ul><li>PPV/Oxygen </li></ul>
  26. 27. 2 Handed BVM
  27. 28. Difficult Ventilation <ul><li>MOANS </li></ul><ul><li>M = difficult mask seal (full beard) </li></ul><ul><li>O = obese or airway obstruction </li></ul><ul><li>A = advanced age </li></ul><ul><li>N = no teeth </li></ul><ul><li>S = snore or stiff lungs </li></ul>Hung and Murphy CJA 2004 51:10
  28. 29. Can I ventilate this patient ?? <ul><li>B eard </li></ul><ul><li>O bese </li></ul><ul><li>O ld </li></ul><ul><li>T eeth </li></ul><ul><li>S leep apnea </li></ul>
  29. 30. Predictors of Difficult Intubation <ul><li>Small TM distance-beware the beard </li></ul><ul><li>Poor mouth opening </li></ul><ul><li>High Mallampati score </li></ul><ul><li>84.9% sensitivity </li></ul><ul><li>94.6% specificity </li></ul><ul><li>35.5% PPV </li></ul>Merah NA et al CJA 2005 52
  30. 31. Can’t Intubate/Can’t Ventilate or Holy *@#& Phenomenon <ul><li>Failed laryngoscopic intubations (0.05-0.35%) </li></ul><ul><li>Can’t intubate/can’t ventilate (1:2250) </li></ul>Benumof JL Airway Management Principles and Practice 1996:124.
  31. 32. Time to intubate . . . <ul><li>Basic Equipment </li></ul><ul><ul><li>PPV (BVM ventilation) </li></ul></ul><ul><ul><li>Oxygen </li></ul></ul><ul><ul><li>ETT </li></ul></ul><ul><ul><li>Suction </li></ul></ul><ul><ul><li>Laryngoscope </li></ul></ul><ul><ul><li>Bougie </li></ul></ul><ul><ul><li>LMA </li></ul></ul>
  32. 33. Position Your Patient <ul><li>Sniffing Position </li></ul><ul><ul><ul><li>Flexion of lower cervical spine </li></ul></ul></ul><ul><ul><ul><li>Extension of A-O joint </li></ul></ul></ul>
  33. 34. What Size Endotracheal Tube ? <ul><li>Adult male </li></ul><ul><ul><ul><li>7.5-8.5 </li></ul></ul></ul><ul><li>Adult female </li></ul><ul><ul><ul><li>6.5-7.5 </li></ul></ul></ul><ul><li>Pediatric </li></ul><ul><ul><ul><li>4 + AGE/4 </li></ul></ul></ul>
  34. 35. What Laryngoscope ?
  35. 36. Laryngoscopy
  36. 37. Intubation Confirmation ! <ul><li>Bronchoscopy, direct visualization, carbon dioxide </li></ul><ul><li>Auscultation, compliance, condensation, chest wall excursion </li></ul><ul><li>CXR </li></ul>
  37. 39. Airway Adjuncts
  38. 40. Cricoid Pressure <ul><li>New data suggests it is better to position larynx with right hand and then demonstrate position </li></ul><ul><li>BURP larynx posterior, up and to the patient’s right </li></ul><ul><li>C/I in c-spine fracture </li></ul>
  39. 41. Laryngeal Mask Airway <ul><li>Indication </li></ul><ul><ul><li>Alternate to BMV </li></ul></ul><ul><ul><li>Difficult airway scenario </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Obese </li></ul></ul><ul><ul><li>Reflux </li></ul></ul><ul><ul><li>Full stomach </li></ul></ul>
  40. 43. Bougie <ul><li>Tracheal “clicks” </li></ul><ul><li>End point </li></ul><ul><li>Right turn </li></ul>
  41. 44. Special Cases <ul><li>Obesity </li></ul><ul><li>Rheumatoid arthritis </li></ul><ul><li>Head and neck cancer </li></ul><ul><li>Trauma/Fractured c-spine </li></ul>
  42. 45. Obesity <ul><li>Redundant tissue in oropharynx </li></ul><ul><li>Thoracic kyphosis </li></ul><ul><li> FRC </li></ul><ul><li>Minimal apnea time </li></ul><ul><li>i.e. rapid desaturation </li></ul>
  43. 46. Positioning Obese Patients The blue axis = ear to manubrium should be level
  44. 47. Rheumatoid Arthritis <ul><li>Multisystem disease </li></ul><ul><li>C1-C2 subluxation > 5mm clinical significant </li></ul><ul><li>Arytenoid disease </li></ul><ul><li>Restrictive lung disease </li></ul>
  45. 48. C1 and C2 Anatomy
  46. 50. Head and Neck Cancer <ul><li>Previous surgery and/or radiotherapy </li></ul><ul><li>Tissues are “woody” immobile </li></ul><ul><li>Supraglottic masses  unable to see glottis  impossible DL </li></ul><ul><li>Or previous laryngectomy and No glottis! </li></ul><ul><li>Consider bronchscopy </li></ul>
  47. 51. Head and neck masses Epiglottis Glottic opening Supraglottic mass
  48. 52. C-spine Trauma <ul><li>Head Injury common </li></ul><ul><li>In-line stabilization essential </li></ul><ul><li>Maintain oxygenation and BP </li></ul>
  49. 53. In-line Stabilization
  50. 54. What about the Patient with Pneumonia? <ul><li>How would you manage this scenario? </li></ul>
  51. 55. Answer <ul><li>This is an emergency situation, Call for HELP </li></ul><ul><li>Confirm patient is on 100% O2 ! </li></ul><ul><li>Take a brief history including drugs (sedatives) </li></ul><ul><li>Examine airway for ease of Ventilation and Intubation </li></ul><ul><li>Assist ventilation, 2 handed BVM + OPA </li></ul><ul><li>Recheck vitals </li></ul><ul><li>Position patient for airway management </li></ul><ul><li>Do not make patient APNEIC </li></ul>