Difficult airway in the ICU Difficult airway in the ICU Difficult

Document Sample
Difficult airway in the ICU Difficult airway in the ICU Difficult Powered By Docstoc
					                                                                        Difficult airway in the ICU
                                                            Problems…
                                                            •   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
                                                              patients
•   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




                                                                                                                   1
                          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%)




                                                                                                                                                                  2
           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-
                                                                                           36
•   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




                                                                                                                                                                                   3
                 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




                                                                                                                                                                                                                                4
         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
                                                                                                 (IMS)




                   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
                                                                                                 ventilation
                                                                                               – 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




                                                                                                                                                                                        5
                              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




                                                                                                                                                                                                              6
                 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   http://www.das.uk.com
           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




                                                                                                                                                                            7
                                    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;
              50:1632-8
     – 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
                                                                                               Precautions
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




                                                                                                                                                                                                                        8
                        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
                                                                                          stylet
                                                                                        – no SO2 <90%
                                                                                        – AEC in trachea for 9.4 h (mean; range 15’ – 52h)


                                                     Cook®




                        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




                                                                                                                                                                                                    9
  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
                                                                           intubation
• 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
     intubation
                                                                            – 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




                                                                                                                                         10
Difficult airway in the ICU
        Thank you!




                              11

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:81
posted:12/17/2011
language:
pages:11