Søren Rudolph talks about the different types of difficulties encountered in airway management in the critically ill and shares many pearls learnt through many years practicing ENT anesthesia and prehospital care and and through researching and teaching airway management with the best of the best. Talk was given at the The Big Sick in Zermatt, 2019. More: https://tbs19.org/ Full set of talks from the conference including the video of this talk will be up at https://scanfoam.org/

2. the PHYSIOLOGICALLY
….difficult airway

3. - ENT & Trauma anaestesia
- Level 1 trauma center
- Trauma manager
- Trauma team leader
- PHEM doctor
Rigshospitalet
DenmarkSøren Steemann Rudolph
@sorenrudolph

4. STOP
SLOW DOWN
…few patients need intubation right

6. Non-OR setting
+
Patient factors
+
Staff

7. Emergency
Non Fasted
Critically ill patients
…..…hypoxaemia
despite preoxygenation
Outside OR

8. unexpected difficult airway
….and an associated high risk for
numerous critical incidents and
adverse events

9. A notably
high rate of failure
of primary intubation attempts

11. Patient factors
- pulmonary shunt
- increased VO2
- critical illness
- obesity
- pregnancy
- small children
-”can’t preOx” patients

12. …may turn ugly

17. RISK of Cardiac Arrest

18. 88/45
sBP < 90 mmHg
SI >1
1,7-4,2%

21. SpO2 < 93- 95%
SpO2 < 70%
> 95 %
91-95 %
< 91 %

22. PreOX - often less effective
-PaO2 67 mmHg
-PaO2104 mmHg

24. Severe metabolic acidosis

25. pH over 7,X ?

26. We MUST have a plan

27. What are you PREPARED to do?

28. ….don’t bring a knife to a gun fight

30. MACOCHA > 3

31. …the ultimate bailout

33. Get HELP

34. ….a bit of Feng Shui

37. Prober SUCTION

38. blind techniqu

40. AIM for ”higher-than-normal” BP
FLUID resuscition
Vasopressor

41. DOSE SMARTAnaesthetics – LOW
Paralytics – HIGH
Vasopressor – INFUSION + PUSH
Local anaesthetics - READY

42. hemodynamic indica

45. 100% - fiO2 0,21 90% - fiO2 0,6-8

46. SpO2 < 93- 95%
SpO2 < 70%
> 95 %
91-95 %
< 91 %

47. induction intubationlaryngoscopy

48. O2
DS
I
Positio
n
ApO
x
CPA
P
PreO
x

49. O2
DS
I
Positio
n
ApO
x
CPA
P
PreO
x

52. safe apnea
time

54. 8 vital-capacity
3 minexhale

55. EtO2 ≈ 90%

57. FiO2
80%100%

58. O2
DS
I
Positio
n
ApO
x
CPA
P
PreO
x

62. SpO2 100 – 95%
20-30% more time

63. O2
DS
I
Positio
n
ApO
x
CPA
P
PreO
x

64. 908990

65. ..perfused
…not ventilated

67. O2
89908990

68. PEEP

69. PEEP vs ZEEP
EtO2
Pao2
PaO2/FiO2 ratio
↑ SAFE APNOE

70. CPAP
PEE
P

71. O2
DS
I
Positio
n
ApO
x
CPA
P
PreO
x

72. ↑ safe apnoea time ↑

74. Spontaneous vs Apneic
2

75. -diffuse respiration
-apnoeic diffussion oxygena
-aventilatory mass flow

76. ..might be implemented
in airway algorithms for
the intubation of
hypoxemic patients

77. Nasal Oxygenation During Efforts Securing ATube
Transnasal Humidified Rapid-Insufflation VEntilatio

78. Nasal Oxygenation During Efforts Securing ATube
Transnasal Humidified Rapid-Insufflation VEntilatio

81. - merely an adjunct
….not a substitute
for effective
preOx

82. Time to SpO2 < 95

83. Incidence of
hypoxaemia
- absolute risk reduction
6,1%

84. strong evidence for benefit
- elective surgical patient
- obese patients
- emergency intubation without respiratory failure.
no significant benefit
- patients with respiratory failure.

85. nasal O2 15
JUST do It

86. O2
DS
I
Positio
n
ApO
x
CPA
P
PreO
x

87. ”can’t preoxygenate”

89. The odds are against you

90. Emergency
Non Fasted
Critically ill
…..…hypoxaemia
despite preoxygenation
Unexpected difficult
airway
….high risk for numerous
critical incidents and
adverse events

91. DESATURATION
..…you FOOL

92. apid Sequence
Intubation

93. elayed Sequence
Intubation

95. Delirious & hypoxic
S-ketamine 0,5-2 mg/kg
IV
Preoxygenate
Administer
paralytic
Intubate
Delayed Sequence
Intubation
2-3 minutes
45-60 sec

96. Added benefit
Positioning
”Awake” intubation
Apnoic oxygenation
NG tube
CPAP / NIV
Tim
eCONTROL

97. significantly
improved SpO2
prior to
intubation

98. PALM
RSA

99. O2
DS
I
Positio
n
ApO
x
CPA
P
PreO
x

100. Patient factors
- pulmonary shunt
- increased VO2
- critical illness
- obesity
- pregnancy
- small children
-”can’t preOx” patients
> 95 %
91-95 %
< 91 %
SpO2
RISK

103. AVOID Intubation
CORRECT acidosis
NO Bicarbonate (will increase CO2 production)
NIPPV to support ventilation

104. If intubation is UNAVOIDABLE
don’t RSI….DSI instead
PreOX with spontaneous/supported mode
be aware of air trapping on the ventilator
PEEP may be problematic

106. What are you PREPARED to do ?
Be aware of the HOp – killers
GET HELP
FENG SHUI
DOSE SMART – awake intubation?
OXYGENATE
AVOID intubation in severe acidosis

107. Patient factors
- pulmonary shunt
- increased VO2
- critical illness
- obesity
- pregnancy
- small children
-”can’t preOx” patients
> 95 %
91-95 %
< 91 %
SpO2

108. Thank you