This document discusses airway management in the ICU for an obese patient with pneumonia who is deteriorating. It covers assessing the airway, sedation options like midazolam and fentanyl, difficult airway tools like bougies and LMAs, and special considerations for obese, rheumatoid arthritis, head/neck cancer, and trauma patients. The key is to oxygenate, assess ability to ventilate and intubate, call for help, and position the patient while preparing airway adjuncts and securing the airway.

1. ICU Emergency AIRWAY MANAGEMENT Dalhousie Critical Care Lecture Series

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

3. 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?

4. Airway Anatomy….

5. Airway Exam Mallampatti Score

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

7. Airway Anatomy….

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

10. Cormack-Lehane Laryngeal View

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

12. 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!

13. 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.

14. 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

15. 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

16. 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

17. 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

18. 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

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

20. 3 sprays of lidocaine to each location + 3 sprays behind tongue

21. Airway Management

22. 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

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

24. OPA Oropharyngeal Airway What size ? Contraindications ?

25. NPA Nasopharyngeal airway What size ? Contraindications ?

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

27. 2 Handed BVM

28. 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

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

30. 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

31. 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.

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

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

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

35. What Laryngoscope ?

36. Laryngoscopy

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

39. Airway Adjuncts

40. 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

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

43. Bougie Tracheal “clicks” End point Right turn

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

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

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

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

48. C1 and C2 Anatomy

50. 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

51. Head and neck masses Epiglottis Glottic opening Supraglottic mass

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

53. In-line Stabilization

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

55. 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