Airway Management in the ICU

Jennifer Salotto, MD Trauma, Acute Care Surgery and Critical

Care Fellow University of Colorado, Denver

July 2014

Airway Management in the ICU

• Overview: why do we care?

• Assessing the Airway

• Intubation, Adjuncts and the difficult airway

• The blocked endotracheal tube

• Unplanned extubation

• Extubation of the difficult airway

Airway: Why do we care?

• It’s the A of ABC

– No airway= no life

– brain injury in 4 min, irreversible in 7 minutes

– Cardiac arrest in minutes

• Hospitalized patients outside of the OR frequently require emergency airway management

• ETI in the ICU: high rate of immediate, severe life-threatening complications

Why are ICU airway issues unique?

• Limited physiologic reserve

• Preexisting hemodynamic instability, massive resuscitation

• No time to perform evaluation

• s/p maxillofacial, neck surgery, C-sp injury

– Upper airway edema

– expanding hematoma

Assessing the Airway

• Remember your ABC’s!

• Can the patient speak? – Assess for stridor, hoarseness, breathlessness

• Look, listen, and feel

• Place monitor, HR and O2 sats

• Assess the neck: hematoma, swelling, scars – Remove cervical collar with in-line stabilization

• Pulses, hemorrhage, IVs

Assessing the Airway

• History:

– C-spine immobilization, trauma

– Laryngectomy

– Airway problems

– Surgery?

• Invasive vs. noninvasive support

• Assess for difficult mask ventilation

Assessing the Airway

Indications for Definitive Airway Management

• Respiratory Insufficiency

• Airway Obstruction

• GCS <8

• Severe maxillofacial injury

• Inhalation injury

• Life-threatening agitation

• Expanding neck hematoma

Contraindications to Intubation

• Partial transection of the trachea

• Inability to open mouth

Rapid Sequence Intubation (RSI)

• Goal: to prevent aspiration

– use with suspected full stomach

• The National Emergency Airway Registry

– 7,712 intubations

– RSI success rate >98.5%

RSI: The Six P’s

• Preparation

• Preoxygenation

• Premedication

• Paralysis

• Passage of the ETT

• Postintubation Care

Preparation

• Monitor

• Working IV, suction, oxygen

• Oral and Nasal airways

• Bag Valve Mask

• Blades

• ETT, syringe, CO2 detector

• A SECOND PAIR OF HANDS

Positioning

• Pillows

• Sniff Position: chin lift and jaw thrust

Preoxygenation

• Bag Valve Mask: positive pressure ventilation

• Patients with respiratory failure may not have adequate response

– Baillard et al. demonstrated improved oxygenation with noninvasive positive pressure

Premedication

• Stimulation of the airway (ETT, Laryngoscope) elicits a noxious response, leading to sympathetic discharge-> HTN, tachycardia

• Agents which blunt hypertensive response:

– Opioids

– Lidocaine

• Anti-arrhythmic

– Esmolol

Induction Agents: Sedatives

• Etomidate – Single dose may cause adrenal insufficiency for up to 72 hr – Discouraged in sepsis, seizure DO – No cardiac depression

• Propofol – Rapid onset – May cause hypotension, bradycardia – Not safe in cardiac dysfunction

• Ketamine – Analgesic, sedative, amnestic – Raises HR and BP, caution in elevated ICPs, MI – Does not ablate spontaneous ventilation

• Fentanyl and Versed

– Good choice in cardiac patients

• Always have a vasopressor quickly at hand in case of hypotension

Induction Agents: Sedatives

Paralytics

• Succinylcholine – Drug of choice

– Depolarizing neuromuscular blocker

– T1/2: 5 min

– Contraindications: renal failure, hyperkalemia, burns, history of MH, crush injury, chronic debilitation

• Rocuronium – Only acceptable alternative to succs

– Cochrane review: less favored for longer half life (40 minutes) and less often “excellent” conditions

Passing the ETT

• Cricoid pressure (Sellick’s maneuver)

– introduced in 1961

– “to control regurgitation until intubation with a cuffed endotracheal tube was completed”

– occlusion of upper esophagus by back pressure on the cricoid ring against cervical vertebrae

– Hold until balloon inflated

Passing the ETT

Visualize Vocal Cords

Pass the ETT, Inflate the Balloon, Secure the Airway

Postintubation Care: Confirming Placement

• Auscultate

• ETCO2

• CXR

• bronchoscopy

Intubating with a C-Spine Injury

• Manual in-line immobilization = gold standard

– Ok to remove anterior portion of collar

• All airway maneuvers will cause some degree of neck movement

• Fiberoptic bronchoscope-assisted intubation for limited mobility

• HALO: be prepared for surgical

airway

Intubating with a C-Spine Injury

Complications of Intubation

• Cardiac arrest

• Arrhythmia

• Esophageal Intubation

• Mainstem Intubation

• Aspiration

• Pharyngeal stimulation – Bradycardia, laryngospasm

• Damage to teeth, eyes, lips, vocal cords

• Pneumothorax

Complications of ICU Intubations

– 8% difficult intubations

– 8% esophageal intubations

– 4% aspiration

– 3% mortality within 30 minutes

The Difficult Airway • “A clinical situation in which conventionally

trained anesthesiologists experience difficulty with mask ventilation, tracheal intubation, or both”

• Call for help

• Have a backup plan readily available

• Anesthesiology, Feb 2013

• Inform the patient of risks when possible

• Have an assistant

• Preoxygentate, at least 3 minutes

• Assess for

– Awake vs. GA

– Consider fiberoptics as initial approach

– Need for invasive airway

Difficult Airway Algorithm

Can’t Intubate, Nonemergent Pathway: Adjuncts to Intubation

• LMA

• Bougie

• Flexible Fiberoptics

• Rigid Fiberoptics

Laryngeal Mask Airway

• Extraglottic airway device

• No protection from aspiration

• Place along posterior pharynx into the laryngeal inlet

• May be used as a bridge to tracheostomy

• Do not use: pregnancy >16 wks, MXF trauma

Intubating Stylet (Bougie)

• Gum elastic

• For directional control when the laryngeal inlet cannot be seen

• Blind passage, confirm with clicks on the trachea

• Cheap, easy to use

Can’t Intubate, Can’t Ventilate…

• Emergent invasive airway access

Cricothyroidotomy: Surgical Airway

• An emergent procedure to secure a surgical airway

• Equipment: – Eye protection, mask

– Knife (11 or 10 blade)

– Hemostat

– ETT

– suction

Hardest Parts about a Cric:

1. Knowing when to do it

2. Knowing your anatomy

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&frm=1&source=images&cd=&cad=rja&uact=8&docid=O1JIFBzXIhBMgM&tbnid=A6cv7h0_eSNJVM:&ved=0CAUQjRw&url=http://medicyafac.wordpress.com/2008/06/14/cricothyroidotomy/&ei=aW3FU_XvHom6oQSZ1YL4Cw&bvm=bv.70810081,d.aWw&psig=AFQjCNHCrIJ-bTI6yBnE1Y_xKzBMUJQT2w&ust=1405533903556436

Cricothyroidotomy

• Stand on R of Pt

• Left hand stabilizes

• Initial vertical incision: avoid anterior jugular veins

• There will be blood!

Cricothyroidotomy

• Dissect down to cricothyroid membrane

• Turn knife 90 degrees, make horizontal incision and spread

• Air return will confirm

• Place ETT down, inflate

• Confirm w ETCO2 and secure

Percutaneous Cricothyroidotomy Kits

• Helm et al. 2013 – Cadaveric study

– 30 first year anesthesia residents • Open (n=15), perc (n=15)

• Open: 100% success vs. 67%

• Equal time, greater complications with perc technique

– Conclusion: the inexperienced operator, the standard open technique is safe

Other Airway Issues

• The Expanding Neck Hematoma

• Obstructed ETT

• Unplanned Extubation

• Extubation of the Difficult Airway

Expanding Neck Hematoma

The Obstructed ETT

• Secretions, kinking, biting, blood clots, cuff herniation

• Presents:

– high peak inspiratory pressures

– steadily increasing ETCO2 +/- desats

– Inspiratory volumes don’t = expiratory

Obstructed Endotracheal Tube

• 100% oxygen

• Chin lift/jaw thrust

• Attempt to pass suction catheter, bag ventilate

• If stable: irrigate, pass bronch, c/s airway exchange catheter

• If unstable: remove ETT and reintubate +/- airway exchange catheter

Airway Exchange Catheter

Unplanned Extubation

• Self-Extubation & Accidental Extubation

– 60% require reintubation

– Listello et al: 87% require reintubation within 4 hours

• Associated with longer ICU stay, vent days, morbidity and mortality

• UE incidence considered an indicator of medical and nursing care quality

• UE incidence varies widely:

– 0.5- 14.2% of patients

• 68- 95% are self-extubations

• Major risk factors: agitation, inadequate sedation, decreased patient surveillance

• Restraints controversial

– Can still reach tube, may worsen agitation

Extubation of the Difficult Airway

• Airway complications more likely with extubation

• Obesity, OSA, head/neck/airway surgery= high risk extubation failure

• Routine Extubation Criteria

• Cuff Leak test

• +/- Airway Exchange Catheter

• Steroids- Cochrane Review 2009: – In adults, multiple doses of corticosteroids begun 12-

24 hours prior to extubation do appear beneficial for patients with high risk

Extubation of the Difficult Airway

• Airway obstruction is a primary cause of respiratory distress after extubation

– Incidence 3-30%

– ~7% reintubation

In Conclusion…

• Remember your ABCs

• Call for help early

• Have a back-up plan

• Be mentally prepared for a surgical airway

• Consider all ICU airways high risk until proven otherwise

References • American Society of Anesthesiologists: Practice guidelines for the management of the difficult airway:

an updated report. Anesthesiology 2003; 98: 1269-1277. • Crosby ET. Airway management in adults after cervical spine trauma. Anesthesiology 2006; 104:1293–

1318 • Dosemeci L et al. The routine use of pediatric airway exchange catheter after extubation of adult

patients who have undergone maxillofacial or major neck surgery: a clinical observational study. Crit Care 2004; 8:R385–R390

• Helm et al. Emergency cricothyroidotomy performed by inexperienced clinicians. Emergency Medicine Journal Aug 2013; 30(8): 646-9.

• Jaber S et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple center study. Crit Care Med 2006; 34:2355–2361

• Jaber S et al. Post-extubation stridor in intensive care unit patients: risk factors evaluation and importance of the cuff-leak test. Intensive Care Med 2003; 29:69–74

• Khemani et al. Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Database of Systematic Reviews. 2009.

• Mort TC. Preoxygenation in critically ill patients requiring emergency tracheal intubation. Crit Care Med 2005; 33: 672–2675

• Perry J et al. Rocuronium versus succinylcholine for rapid sequence induction intubation. Cochrane Database Syst Rev (database online). Issue 1, 2003.

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• Schwartz et al. Death and Other Complications of Emergency Airway Management in Critically Ill Adults. Anesthesiology. 82: 367-376, 1995.

• Walz et al. Airway management in critical illness. CHEST 2007; 131:608-620.