Difficult airway in the ICU Difficult airway in the ICU Difficult

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					                                                                        Difficult airway in the ICU
                                                            •   difficult intubation
           Difficult airway in the ICU                      •   extubation failure
                                                            •   extubation of patients with difficult airways
                Problems and solutions                      •   unplanned extubation
                             Jan Muller, M.D.               •   swallowing dysfunction
                    Department of Intensive Care Medicine
                        University Hospitals, Leuven

           Difficult airway in the ICU                                  Difficult airway in the ICU
…and solutions…                                             …from an ICU perspective
•   difficult airway protocol                               • emergent intubations and reintubations of unstable
•   prediction of extubation outcome                        • tracheostomy tube changes
•   precautions for extubation failure                      • airway problems due to protracted critical illness
•   prevention of unplanned extubation                      • doctors with lack of training
•   treatment of swallowing dysfunction                     • chaotic environment

           Difficult airway in the ICU                                        Difficult intubation
•   difficult intubation                                    •   incidence
•   extubation failure                                      •   prediction of difficult intubation
•   precautions for extubation failure                      •   should we use RSI in the ICU?
•   unplanned extubation                                    •   difficult airway protocol
•   swallowing dysfunction                                      – choice of techniques and equipment
                                                                – protocol
                                                                – training

                          Difficult intubation                                                   Difficult intubation: incidence
                                                                                      Schwartz DE, e.a. Death and other complications of emergency airway
•   incidence                                                                           management in critically ill adults: a prospective investigation of 297
                                                                                        tracheal intubations. Anesthesiology 1995; 82(2):367-376
•   prediction of difficult intubation
                                                                                      • university hospital; formal training in airway management provided to
•   should we use RSI in the ICU?                                                       all residents and fellows
                                                                                      • 297 intubations in 238 adults
•   difficult airway protocol                                                         • location of intubation
                                                                                          –   52% medical-surgical ICU
     – choice of techniques and equipment                                                 –   26% others ICU’s
     – protocol                                                                           –   15% hospital wards
                                                                                          –   3% ER
     – training                                                                           –   3% other
                                                                                      • complications did not differ by location or time of day

             Difficult intubation: incidence                                                     Difficult intubation: incidence
•   difficult intubation 8% (≥2 attempts at laryngoscopy by skilled physician)        Jaber S, e.a. Clinical practice and risk factors for immediate
     –   274 (92%) oral intubations, 23 (8%) nasal intubations
     –   10 with intubating stylet
                                                                                        complications of endotracheal intubation in the intensive
     –   4 with fiberoptic bronchoscope (1 oral, 3 nasal)                               care unit: a prospective, multi-center study. Crit Care Med
     –   no surgical interventions for airway control                                   2006; 34:2355-61
•   oesophageal intubation 8% (no adverse sequelae)                                   • 7 ICU’s of 2 university hospitals
•   pulmonary aspiration 4% (new pulmonary infiltrates suggestive of aspiration)
•   pneumothorax 1%                                                                   • 253 intubations in 220 patients
•   mortality 3% (during or within 30’ of procedure)                                  • intubations performed by
•   mortality 15% in patients with hypotension (<90 mmHg) vs. 0.85% in patients
    without hypotension, p<0.001                                                          – anesthesiology residents (> 1 y experience)
•   no relationship between adverse outcome (aspiration, malposition, or death) and       – experienced anesthesiologists and intensivists
    difficulty of intubation

             Difficult intubation: incidence                                                     Difficult intubation: incidence
• difficult intubation (≥3 attempts): 30 (12%)                                        • risk factors for serious complications (multivariate
     – fiberoptic laryngoscope: 2/30
• esophageal intubation: 12 (4.6%)
                                                                                        regression analysis)
     – always diagnosed with auscultation                                                 – low blood pressure before intubation
• ≥ 1 severe complication: 71 (28%)                                                       – acute respiratory failure
     –   hemodynamic collaps: 65 (25%)
     –   severe hypoxia: 66 (26%)
                                                                                          – intubation performed by junior physician supervised by
     –   cardiac arrest: 4 (1.6%)                                                           senior: protective factor (2 operators)
     –   death during intubation or within 30’ after: 2 (0.8%)

           Difficult intubation: incidence                                                            Difficult intubation: incidence
• difficult intubation                                                                  Mort TC. Emergency tracheal intubation: complications
                                                                                          associated with repeated laryngoscopic attempts. Anesth
    – incidence not different between anesthesiologists and                               Analg 2004; 99:607-13
      nonanesthesiologists                                                              • Methods
    – multiple attempts: not associated with adverse outcome                                 – 2833 critically ill patients in a teritairy care, level 1 trauma center
                                                                                               requiring emergency intubation outside of the OR
• no relationship between adverse outcome and                                                – only cases completed with conventional laryngoscopy and
                                                                                               intubation, mostly in ICU (69%)
  difficulty of intubation                                                                   – practice analysis by questionaire

           Difficult intubation: incidence                                                            Difficult intubation: incidence
• Results                                                                                  High incidence of
    – 68% of intubations successful on 1st attempt                                           – difficult intubation
    – 10% required 3 or more attempts
                                                                                             – adverse outcome
    – increasing number of intubation attempts associated with increased rate of
      airway related complications (≤2 vs. >2 attempts)                                           •   hypoxemia
                                                                                                  •   esophageal intubation
                                                                                                  •   aspiration
                                                                                                  •   hemodynamic collaps
                                                                                                  •   cardiac arrest
                                                                                                  •   death
                                                                                             – strong association between adverse outcome and difficulty of
                                                              all catagories p <0.001          intubation (>2 laryngoscopy attempts)

                      Difficult intubation                                                            Difficult intubation: prediction
•   incidence                                                                           Difficult mask ventilation
•   prediction of difficult intubation and mask ventilation                             Langeron O, e.a. Prediction of difficult mask ventilation. Anesthesiology 2000; 92:1229-
•   should we use RSI in the ICU?                                                       • prospective, 1502 elective adult patient in OR
•   difficult airway protocol                                                           • DMV 75/1502 = 5% (95% CI = 3.9-6.1%)
    – choice of techniques and equipment
    – protocol
    – training

                 Difficult intubation: prediction                                                                              Difficult intubation: prediction
Difficult mask ventilation                                                                                      Difficult mask ventilation
                                                                                                                Kheterpal S, e.a. Incidence and prediction of difficult and impossible mask ventilation. Anesthesiology 2006;
Langeron O. Prediction of difficult mask ventilation. Anesthesiology 2000; 92:1229-36                               105:885-91
                                                                                                                • prospective, 22,660 adults, mainly elective surgery
                                                                                                                • 14,369 patients included in univariate and multivariate analysis

                 Difficult intubation: prediction                                                                              Difficult intubation: prediction
Difficult mask ventilation                                                                                      Difficult mask ventilation
Kheterpal S, e.a. Incidence and prediction of difficult and impossible mask ventilation. Anesthesiology 2006;   Kheterpal S, e.a. Incidence and prediction of difficult and impossible mask ventilation. Anesthesiology 2006;
    105:885-91                                                                                                      105:885-91
                                                                                                                • ≥3 risk factors incidence grade 3 MV = 5% (0 risk factors 0.26%)

                 Difficult intubation: prediction                                                                              Difficult intubation: prediction
Difficult intubation                                                                                            Difficult intubation: the LEMON airway
                                                                                                                     assessment method
•   airway assesment scores
                                                                                                                • not always easy to apply in the ED
      – low positive predictive value
      Yentis SM. Anaesthesia 2002; 57:105-9
                                                                                                                     resuscitation room
                                                                                                                      – Evaluate en Mallampati not always available
      – no studies in ICU
                                                                                                                            Reed MJ, e.a. Eur J Emerg Med 2004; 11:154-7
•   ED: LEMON method                                                                                            •   validation study in the ED: airway assessment
      – L – Look externaly                                                                                          score 0 – 10 derived from LEMON method
             •   facial trauma; protruding teeth; large                                                               – poor predictor of intubation grade (Cormack
                 incisors; abnormal facial shape;                                                                       and Lehane laryngoscopy grade ≥2)
                 beard or moustache; large tongue;
                                                                                                                            Reed MJ, e.a. Emerg Med J 2005; 22:99-102
                 false teeth
      –   E – Evaluate the 3-3-2 rule
      –   M – Mallampati
      –   O – Obstruction?
      –   N – Neck mobility

             Reed MJ, e.a. Emerg Med J 2005; 22:99-102

         Difficult intubation: prediction                                                                           Difficult intubation
• Predicting difficult mask ventilation en intubation: a                                   •   incidence
  useless ritual?                                                                          •   prediction of difficult intubation
• Let’s try it anyway! with LEMON?                                                         •   should we use RSI in the ICU?
   – forces us to think about the airway                                                   •   difficult airway protocol
   – gives us the chance to prepare for a difficult airway                                     – choice of techniques and equipment
   – remove facial hair if possible                                                            – protocol
                                                                                               – training

                   Should we use RSI?                                                                           Should we use RSI?
                                                                                           Should we paralyse our patients?
Four questions                                                                             • no studies in ICU
                                                                                           • some studies in the prehospital setting and ED: RSI (= paralysis)
• should we paralyse our patients?                                                             – higher rates of successful intubation
                                                                                               – lower complication rates
• which NMBA?                                                                              Li J, e.a. Complications of emergency intubation with and without paralysis. Am J
                                                                                               Emerg Med 1999; 17:141-4
• should we use cricoid pressure?                                                          • Methods
                                                                                               – setting: ED of major trauma center
• how about preoxygenation?                                                                    – 116 RSI’s compared with historical control group of 67 intubations without paralysis

                   Should we use RSI?                                                                           Should we use RSI?

     •   Results
                                                                                           So should we paralyse our patients?
                                                                                           • Common sense approach
                                                                                               – difficult airway predicted: preserve spontaneous
                                                                                                 ventilation; paralyse only after successful mask
                                                                                               – if spontaneous ventilation (PSV) after intubation is
                                                                                                 preferred: use propofol with opiate, without NMBA
     •   Comment: usual induction agent
          – RSI: etomidate (+ succinylcholine)
          – IMP: midazolam and lorazepam titrated to effect
     •   Some studies in OR: favourable intubation conditions with propofol and opiates,
         without paralysis, compared with succinylcholine
         Wong AK, e.a. Anaesth Intensive Care 1996; 24:224-30

                              Should we use RSI?                                                                             Should we use RSI?
Which NMBA?                                                                                       Which NMBA?
• succinylcholine: many risks in ICU patients                                                     • rocuronium: favourable intubating conditions during RSI
      – exaggerated potassium release (receptor upregulation)                                     Perry JJ, e.a. Are intubating conditions using rocuronium equivalent to those using
             •    denervation (traumatic; critical illness polyneuropathy; …)                         succinylcholine? Acad Emerg Med 2002; 9:813-23
             •    long-term immobilisation                                                              – meta analysis of RCT’s (not ICU, few emergency intubations); n = 1606
             •    neuromuscular diseases
                                                                                                        – excellent conditions: succinylcholine better than rocuronium (0.6-0.7 and 0.9-1.0 mg/kg together)
             •    muscle trauma
                                                                                                              •   subgroup propofol induction: no difference
             •    burns
                                                                                                              •   subgroup rocuronium 0.9-1.0 mg/kg: no difference
             •    sepsis
             •    acidosis                                                                              – acceptable conditions (good or excellent): no difference
             •    corticosteroids                                                                       – failed intubations: no difference
      – large variability in plasma cholinesterase activity
      – other side effects                                                                            Do not use succinylcholine in the ICU; rocuronium is an acceptable alternative
             • elevated ICP
             • histamine release
             • malignant hyperthermia
      Booij LHDL. Critical care 2001; 5:245-6
•    many intensivists not aware of these dangers
      Hughes M, e.a. Anaesth Intensive Care 1999; 27:636-8

                              Should we use RSI?                                                                             Should we use RSI?
Should we use cricoid pressure?                                                                   How about preoxygenation?
• no studies in the ICU                                                                           • preoxygenation in ICU patients is often ineffective
• review: Ellis DY, e.a. Cricoid pressure in emergency department rapid sequence                     Mort TC. Crit Care Med 2005; 33:2672-5
   tracheal intubations: a risk-benefit analysis. Ann Emerg Med 2007; in press                          –   42 ICU patients
      – evidence for effectiveness to prevent aspiration is contradictory                               –   4 minutes of preoxygenation by bag-valve-mask and assisted ventilation
      – cricoid pressure frequently results in lateral displacement of the esophagus                    –   no statistically significant rise in PaO2
      – mask ventilation: reduced Vt; increased Ppeak; sometimes complete airway obstruction            –   11/42 desaturation <90% during intubation
      – effect on laryngeal view and intubation: conflicting results, most studies showing        •   preoxygenation by non-invasive PSV is more effective
        adverse effects
                                                                                                      Baillard C, e.a. Am J Resp Crit Care Med 2006; 174:171-7
      – majority of OR en ED personnel (doctors and nurses) are unable to apply cricoid
        pressure correctly                                                                              – RCT: 48 critically ill, hypoxic patients
        apply cricoid pressure according to case-by-case risk-benefit analysis                          – higher SpO2 after preoxygenation
        consider removal of cricoid pressure in case of difficult intubation or ventilation             – less desaturation during intubation
•    bimanual laryngoscopy may be the best method to improve laryngeal view
      Levitan RM, e.a. Laryngeal view during laryngoscopy: a randomized trial comparing cricoid
         pressure, backward-upward- rightward pressure, and bimanual laryngoscopy. Ann
         Emerg Med 2006; 47:548-55 (emergency physicians; cadaver model)

                              Should we use RSI?                                                                                 Difficult intubation
1.        Should we paralyse our patients?
      –          when in doubt: only after successful mask ventilation
                                                                                                  •   incidence
      –          consider using propofol and opiate, without NMBA                                 •   prediction of difficult intubation
2.        Which NMBA?
      –          do not use succinylcholine                                                       •   should we use RSI in the ICU?
      –          acceptable intubating conditions with rocuronium
3.        Should we use cricoid pressure?                                                         •   difficult airway protocol
      –          evidence base unconvincing
      –          release cricoid pressure in case of difficult ventilation or intubation
      –          consider bimanual laryngoscopy to improve laryngeal view
4.        How about preoxygenation?
      –          often not very effective
      –          consider using NI-PSV, especially in hypoxic patients

                 Difficult airway protocols                                                                  Difficult airway protocols
•       Lots of difficult airway guidelines!                                             •      Difficult Airway Society (DAS; UK)
    –      USA (ASA): Practice guidelines for management of the difficult airway.        Henderson JJ, e.a. Difficult Airway Society guidelines for management
           Anesthesiology 2003; 98:1269-77                                                      of the unanticipated difficult intubation. Anaesthesia 2004; 59:675-
    –      Canada: Crosby ET, e.a. The unanticipated difficult airway with                      94
           recommendations for management. Can J Anaesth 1998; 45:757-76
    –      France (SFAR): Boisson-Bertrand D, e.a. Intubation difficile. Ann Fr Anesth
           Réanim 1996; 15:207-214                                                           –         unanticipated difficult intubation in adult non-obstetric patients
    –      Italy (SIAARTI): Petrini F, e.a. Recommendations for airway control and           –         simple, clear and definitive guidelines
           difficult airway management. Minerva Anestesiol 2005; 71:617-57                         •       flow charts similar to ALS guidelines
•       No guidelines developed specifically for the ICU                                     –         recommended techniques at every stage
                                                                                                   •       techniques of proven value, easy to learn

                                                                                                           Difficult airway equipment
                                                                                         •       Dedicated difficult airway trolley
                                                                                         •       List of equipment: locally adapted
                                                                                             –         equipment for routine airway management?
                                                                                             –         alternative laryngoscope blade
                                                                                             –         fibreoptic laryngoscope (flexible; Bullard type)
                                                                                             –         ETT: reinforced; small
                                                                                             –         LMA; intubating LMA + tubes
                                                                                             –         other supraglottic airway devices (e.g. CombitubeTM)
                                                                                             –         cricothyroid canula’s
                                                                                             –         surgical cricothyroidotomy kit
                                                                                             –         device for confirming endotracheal intubation

                                    Extubation failure                                                                            Extubation failure
                                                                                               Incidence of extubation failure in the ICU
• Incidence of extubation failure                                                              • no strict definition
                                                                                               • incidence of reintubation: 3 – 19%
• Prediction of an adequate airway after extubation                                            • mortality after reintubation: 10 – 40%
                                                                                                     – high mortality because of greater severity of illness?
• Precautions                                                                                  •   extubation failure is an independent predictor for death and prolonged LOS
     – corticosteroids                                                                                     Epstein SK, e.a. Chest 1997; 112:186-92
                                                                                               •   etiology of extubation failure and time to reintubation are independently associated
     – elective tracheostomy                                                                       with mortality
                                                                                                     – lower mortality for airway causes (upper airway obstruction, aspiration/excess
     – airway exchange catheter                                                                        secretions) than non-airway causes
                                                                                                     – higher mortality (53 vs. 17%) with longer duration of time from extubation to reintubation
                                                                                                       (>12 vs. ≤12 h)
                                                                                                          Epstein SK, e.a. Am J Resp Crit Care Med 1998; 489-93
                                                                                                       timely reinstitution of ventilatory support may reduce the increased mortality

                                    Extubation failure                                                                            Extubation failure
Prediction of an adequate airway after extubation                                              Prediction of an adequate airway after extubation
                                                                                               • cough strength and secretion volume
• Cuff-leak test: cuff deflation during assist-control ventilation with Vt                     Khamiees M, e.a. Chest 2001; 120:1262-70
   10-12 ml/kg                                                                                       –   91 patients in medical ICU
                                                                                                     –   semi-quantitative assessment of cough strength and secretion volume: predictive of extubation outcome
     – test for prediction of post-extubation stridor
     – various definitions of positive test
            • e.g. 10 or 12% of Vt, leak ≤110, <130 ml
     – positive and negative observational studies
            • positive: Jaber S, e.a. Intensive Care Med 2003; 29:69-74. Sandhu R, e.a. J Am
              Coll Surg 2000; 190:682-7
            • negative: Engoren M. Chest 1999; 116:1029-31. Kriner E, e.a. Respir Care 2005;
     – no interventional studies using CLT to direct management (decision to                         –   poor cough strength + abundant secretions: RR 31.9 (95% CI 4.5-225.3) of extubation failure (9 out of 11
       extubate, preventive treatment of laryngeal edema …)                                              patients)
                                                                                               Smina M, e.a. Chest 2003; 124:262-8
    routine use of CLT not supported by the literature                                               –   95 patients in medical ICU
                                                                                                     –   objective measurement of cough strength by cough peak expiratory flow predicts extubation outcome, morbidity
                                                                                                         and mortality
                                                                                                           •   cough PEF ≤60 l/min: RR 5.1 (95% CI 1.7-15.4) of extubation failure

                                    Extubation failure                                                                            Extubation failure
Prediction of an adequate airway after extubation
• neurologic status, cough and extubation outcome
Salam A, e.a. Intensive Care Med 2004; 30:1334-9
     –   85 patients in medical ICU
                                                                                               • profylactic treatment with corticosteroids
     –   3 parameters:                                                                               – 1999 Cochrane systematic review of 7 studies (251 identified, 7
                cough PEF
                volume of endotracheal secretions (ml/h)
                                                                                                       included, last search 2006):
            •   4 simple tasks: open eyes; follow with eyes; grasp hand; stick out tongue                  • no significant decrease in reintubation rates in neonates and children
                                                                                                           • 3 adult studies: no difference in postextubation stridor or reintubation rates
                                                                                                               – steroids given 30’ – 1 h before extubation
                                                                                                     Markovitz BP, Randolph AG. Corticosteroids for the prevention and treatment of post-
                                                                                                       extubation stridor in neonates, children and adults. Cochrane Database of Systematic
                                                                                                       Reviews 1999, Issue 3. Art. No.: CD001000

     –   all 3 risk factors: failure rate 100% (RR=23.3; 95% CI=3.2-167.2)
•   these result also need replication and interventional studies

                        Extubation failure                                                                      Extubation failure
Precautions                                                                          Precautions
• profylactic treatment with corticosteroids
François B, e.a. Lancet 2007; 369:1083-9                                             • Elective tracheostomy
    –   multicentre RCT, double-blind, placebo-controlled                               – no strict criteria for indications and timing
    –   761 medical and surgical ICU patients, ventilated for >36 h
    –   intervention: methylprednisolon started 12 h before planned extubation          – tracheostomy for patients:
    –   significant reduction of :                                                            •   in need of prolonged mechanical ventilation
         • global incidence of reintubation (4 vs. 8%, p=0.02)
         • proportion of reintubation secondary to laryngeal oedema (8% vs. 54% of
                                                                                              •   with severe upper airway obstruction
           reintubated patients, p=0.005)                                                     •   with severe swallowing dysfunction
• corticosteroids may be effective when started at least 12 h before                          •   with large amount of tracheal secretions
  extubation                                                                            Strumper Groves D, Durbin C. Tracheostomy in the critically ill: indications, timing and techniques. Curr
                                                                                            Opin Crit Care 2007; 13:90-7

                        Extubation failure                                                                      Extubation failure
                                                                                     • Studies in adults using no. 11 Cook AEC
Precautions                                                                             Loudermilk EP. A prospective study of te safety of tracheal extubation using a
                                                                                          pediatric airway exchange catheter for patients with a known difficult airway.
• Airway exchange catheter (AEC)                                                          Chest 1997; 111:1660-65
                                                                                        – 40 surgical ICU patients with at least 1 risk factor for difficult intubation
    – introduction of AEC before extubation                                                   •   airway edema secondary to surgical manipulation
    – leaving it in place until the need for tracheal reintubation                            •
                                                                                                  airway edema secondary to volume resuscitation or positioning
                                                                                                  anticipated difficult intubation
      becomes unlikely                                                                        •   unanticipated difficult intubation
                                                                                              •   cervical immobility or instability
                                                                                              •   morbid obesity (BMI >40)
                                                                                        – 3 patients needed reintubation (1 patient twice), all successful using EAC as
                                                                                        – no SO2 <90%
                                                                                        – AEC in trachea for 9.4 h (mean; range 15’ – 52h)


                        Extubation failure                                                                      Extubation failure
• Studies in adults using no. 11 Cook AEC                                            • Pediatric study
    Dosemeci L. The routine use of pediatric airway exchange catheter after             Wise-Faberowski L. Utility of airway exchange catheters in pediatric patients with
      extubation of adult patients who have undergone maxillofacial or major neck         a known difficult airway. Pediatr Crit Care Med 2005; 6:454-456
      surgery: a clinical observational study. Critical Care 2004; 8:R385-R390          – 20 patients, median age 114 ± 75 months (range 3 d – 17y)
    – 36 patients                                                                       – mostly after surgical procedures for facial malformations
    – 4 reintubations, using the AEC                                                    – 5 reintubations in 4 patients (3 patients upper airway obstruction), all with AEC
    – duration of AEC (h) 10.4 ± 4.2 (mean ± SD; range 4-24) in patients not            – Cook AEC
      requiring reintubation                                                                  • size 8 (ID 1.6 mm) for ETT 3.5-4.5
                                                                                              • size 11 (ID 2.3 mm) for ETT 5.0-6.0
                                                                                              • size 14 (ID 3.0 mm) for ETT 6.5-7.0

  Airway exchange catheters: practical                                     Airway exchange catheters: practical
               aspects                                                                  aspects
• Functions of the AEC                                                   • Dangers
   – administration of oxygen
       • insufflation                                                       – perforations of tracheobronchial tree
       • manual ventilation                                                     • do not insert AEC against resistance
       • jet ventilation                                                        • avoid excessive depth of insertion
   – measurement of PETCO2 from trachea                                              – align cm markings on AEC and ETT
   – stylet for reintubation                                                – jet ventilation: barotrauma
• What size?                                                                    • pre-set jet ventilator at 25 psi
   – advantages of large-diameter AEC                                           • use short inspiratory and long expiratory time
       • best chance of reintubation succes
       • ease of manual or jet ventilation                                      • avoid excessive depth of insertion
   – advantages of small-diameter AEC
       • ease of spontaneous ventilation
       • reintubation capnography through ETT

  Airway exchange catheters: practical                                     Difficult airway in the ICU: take home
               aspects                                                                   messages (1)
• Reintubation                                                           • High incidence of difficult airway and complications of
   – use a laryngoscope, if possible                                       airway management in ICU
   – if tip of ETT doesn’t pass laryngeal inlet
                                                                         • Use a method for predicting difficult mask ventilation and
          90° counterclockwise rotation of ETT
• After reintubation                                                        – prepare for difficult airway if test is positive
   – confirm tracheal intubation
       • auscultation, capnography, bronchoscopy
                                                                            – know that positive predictive values of tests are low
  Benumof JL. Chest 1997; 111(6):1483-1486                               • Try to restrict number of laryngoscopy attempts to 2

  Difficult airway in the ICU: take home                                   Difficult airway in the ICU: take home
                messages (2)                                                             messages (3)
• Use rapid sequence induction with care                                 • Choose a difficult airway protocol
   – paralyse patients with suspected difficult airways only after          – adapt it to your local needs and circumstances
     successful mask ventilation                                            – prepare a dedicated difficult airway trolley
   – do not use succinylcholine                                             – train using the protocol and the equipment
   – release cricoid pressure in case of difficult mask ventilation or   • Consider extubation failure
                                                                            – cough strength, volume of secretions, neurologic status
   – use bimanual laryngoscopy instead
                                                                            – no predictive tests of proven value
• Consider preoxygenation by non-invasive PSV                               – possible preventive measures
                                                                                • corticosteroids (if started >12 h before extubation)
                                                                                • tracheostomy
                                                                                • airway exchange catheter

Difficult airway in the ICU
        Thank you!


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