This document discusses intubation in critical care settings. It notes that ICU intubations carry high risks, with 25% of patients experiencing severe hypoxemia and 60% of airway incidents resulting in death or neurological injury. Difficulties arise from factors relating to the patient, staff, and environment. The MACOCHA score can help predict difficult airways. The Difficult Airway Society guidelines recommend preparation, checklists, backup plans including front-of-neck access, and continuous monitoring after intubation to reduce risks from these high-stakes procedures in critically ill patients.

1. INTUBATION IN CRITICAL
CARE SETTING
DR.MALAKA MUNASINGHE
2018.11.29

2.  6% of ICU patients- predicted difficult airways
 Severe hypoxaemia( SPO2< 80%)- 25% during ICU intubations
 NAP 4 STUDY - 60% of air way incidents in ICU
DEATH OR PERMANENT NEUROLOGICAL INJURY

3. Increased airway difficulty in ICU???
Multifactorial!!!
 Patient related
 Environment related
 Staff related

4. Staff related
 lack of patient preparation
 equipment check failure
 protocol deviation
 poor decision-making
 loss of situation awareness
 Lack of experience in airway management
 Lack of senior help( out of hour intubations)
 Poor team work

5. Patient related
 physiologically and /or Anatomically difficult airways- burns/ cervical spine injuries
 Physiologically difficult airways
 Increased risk of aspiration
 Airway assessment difficult-
 Poor cooperation/low GCS
 Collars/masks
 Limited time

6. Environment related
 Limited access to the patient( monitors/ equipment)
 Monitors in head end
 Suboptimal lighting
 Access to advanced airway devices/ monitoring( Capnography/ End tidal O2)
limited
 Complex equipment or devices - cognitive overload and poor decision making
 Non-availability of surgical staff

7. Predicting difficult airway in ICU
 Only validated assessment tool available currently- MACOCHA score
 SCORE 0- EASY
 >3-DIFFICULT AIRWAY
2017 American Thoracic Society. De Jong et al.54
Factors Points
Factors related to patient
Mallampati class III or IV 5
Obstructive sleep
Apnoea
syndrome
2
Reduced mobility
of
Cervical spine
1
Limited mouth
Opening <3
cm
1
Factors related to pathology
Coma 1
Severe
Hypoxaemia
(SpO2 <80%)
1
Factor related to operator
Non-
Anaesthetist 1
Total 12

8. Difficult Airway Society( DAS) guidelines

9. DAS guidelines
 Team

10. Intubation check list

11. Patient preparation

12. Preparation of equipment

13. Preparation of the team

14. Preparation for difficulty

15. Air way management plan

16. PLAN A

17. PLAN B/C

18. PLAN D

19. FRONT OF NECK ACCESS( FONA)

20. Priming of FONA
 Getting the FONA set to the bedside after one failed intubation attempt
 Opening the FONA set after one failed attempt at facemask or SGA oxygenation
 Immediate use of the FONA set at CICO declaration

21. ISSUES
 AWAKE INTUBATION in ICU?
 WHAT TO USE DURING INDUCTION?
 WHAT IS DELAYED SEQUENCE INDUCTION?
 Can you wake up the patient if intubation fails?

22. Post intubation
 Complications are common- 80% of airway problems occur after intubation
 Continuous monitoring continued
 Care of the tube/ adequate sedation/ physiotherapy
 CXR- to exclude endobronchial intubation/aspiration
 If patient haemodynamically stable but hypoxaemic- recruitment maneuvers
performed

23. SUMMARY
 Morbidity and mortality during ICU intubations are significantly high compared to
elective surgical intubations
 Patient related, staff and environment related factors are contributory factors
 Simplified, protocolized approach would reduce detrimental outcomes during
these airway interventions