Optimise don’t compromise, peri-intubation physiology

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Optimise, Don’t Compromise:
Peri-Intubation Physiology
Todd W. Rice, MD, MSc
Associate Professor of Medicine
Vanderbilt Un...

Mort, TC, et al. J of Cli Anes, 2004
Jaber S, et al. Int Care Med, 2010
Cook TM, et al. BJA, 2011Severe Complications = ca...

Death or
Neurologic
Injury
1 in 3 Complication Rate
Procedure Variables
• Multiple Attempts
• Poor oxygenation strategy
• ...

Case:
45 y.o. male presents with H1N1 ARDS and
worsening hypoxia. His oxygenation deteriorates and
he is currently saturat...

Is this patient at risk for peri-
intubation complications?

Case:
45 y.o. male presents with H1N1 ARDS and
worsening hypoxia. His oxygenation deteriorates
and he is currently saturat...

Video Laryngoscopy Improves Glottic
Visualization
Janz DR, et al. Crit Care Med. 2016.

Video Laryngoscopy Does NOT Increase
First Attempt Success
Janz DR, et al. Crit Care Med. 2016.

Lascarrou JB, et al. JAMA. 2017.
OR 1.12;
(95% CI: 0.71-1.78)
P=0.63

Lascarrou JB, et al. JAMA. 2017.

Huang HB, et al. Chest. 2017.
First Pass Success
RR: 1.08 (0.92-1.26); P=0.35

Huang HB, et al. Chest. 2017.
Time to Intubation
Mean Difference: 4.12 (-15.86-24.09);
P=0.69

Huang HB, et al. Chest. 2017.
Complications
RR: 0.72 (0.30-1.70); P=0.45

Is it better to have seen
and failed, or never to
have seen at all?
http://www.criticalcares.com/2017/01/
25

Case:
45 y.o. male presents with H1N1 ARDS and
worsening hypoxia. His oxygenation deteriorates
and he is currently saturat...

Casey JD, et al. Lancet Resp Med. 2019;Epub March 18, 2019.

Baillard C, et al. AJRCCM. 2006;174:171-177.
Baillard C, et al. Br J Anesth. 2018;120:361-367.
Frat J-P, et al. Lancet Res...

Case:
45 y.o. male presents with H1N1 ARDS and
worsening hypoxia. His oxygenation deteriorates
and he is currently saturat...

Casey JD, et al. NEJM. 2019; 380:811-821.

Casey JD, et al. NEJM. 2019; 380:811-821.

Apneic Oxygenation:
Physiology
FRC 2L
O2
Weingart SD, et al. Ann Emerg Med, 2012

Silva LOJ, et al. Ann Emerg Med. 2017; 70:483-494.
Lowest Oxygen Saturation
Mean Diff: 2.21 (0.81-3.61);
P=0.002

First Pass Success
OR: 1.59 (1.04-2.44); P=0.03
Silva LOJ, et al. Ann Emerg Med. 2017; 70:483-494.

SpO2 < 93%
OR: 0.66 (0.52-0.84); P=0.007
Silva LOJ, et al. Ann Emerg Med. 2017; 70:483-494.

Case:
45 y.o. male presents with H1N1 ARDS and
worsening hypoxia. His oxygenation deteriorates
and he is currently saturat...

Driver BE, et al. JAMA. 2018; 319:2179-2189.

Driver BE, et al. JAMA. 2018; 319:2179-2189.

Case:
45 y.o. male presents with H1N1 ARDS and
worsening hypoxia. His oxygenation deteriorates
and he is currently saturat...

1. Have a plan
2. Have a back up plan
3. Have a back up to the back up plan
4. Pre-oxygenate with NIV
5. Use laryngoscope ...

QUESTIONS????
todd.rice@vanderbilt.edu
@toddrice_icu

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