This session will cover:

A pragmatic approach to airway management when the airway looks difficult, the patient sick, the environment challenging, or all of the above

The choice of drugs and equipment, the roles of team members, use of checklists and how to plan for failure

An approach to planning for airway management which considers:

  • Personnel
  • Positioning
  • Pre-oxygenation
  • Use of a checklist
  • Drugs
  • Granular detail on planned airway techniques:
    • Plan A – Endotracheal tube
    • Plan B – Supraglottic Airway
    • Plan C – Facemask ventilation
    • Plan D – Neck rescue

To prepare for this session you should read the three references below (or at the very least, the highlights!)

FOAM RESOURCES

Difficult Airway Society Guidelines for the management of tracheal intubation in critically ill adults

The highlights

Failed intubation occurs in 10-30% of critically ill patients and should be anticipated. Emphasis is placed on the role of the airway team, a shared mental model, planning and communication

A modified RSI techniques is recommended:

  • Preoxygenation: tight fitting facemask with CPAP, in head up or ramped position. NIV may offer benefit.
  • Intravenous induction: strong consideration of ketamine, rapid-onset neuromuscular blocking agent (rocuronium preferred over suxamethonium)
  • Precautions against pulmonary aspiration: aspiration of gastric contents via gastric tube where feasible, use of cricoid force unless active vomiting, obstructing view or inserting supraglottic airway
  • Peroxygenation: high flow nasal oxygen or standard nasal cannulae at 15L/min
  • Facemask ventilation during onset of neuromuscular blockade with CPAP
  • Laryngoscopic techniques aimed at maximizing first-pass success: Early use of videolaryngoscope, with a screen visible to all
  • Mandatory waveform capnography to confirm successful tracheal intubation

Their algorithm incorporates elements of the Vortex approach with facemask ventilation and supraglottic airway in non-linear arrangement so can be used in any order

For airway rescue, they recommend a second generation supraglottic airway and facemask ventilation using a 2 person technique with adjuncts

A scalpel-bougie technique is recommended for neck rescue and the importance of priming for this procedure is emphasised

Emphasis is placed on peri-intubation haemodynamic management

Methods are described to avoid complications occurring after tracheal tube and tracheostomy insertion such as bedhead signage, documentation, communication, humidification of inspired gases, and waveform capnography

This guideline also covers extubation in critically ill patients – this is covered in more detail in the Extubation section of the website

There are sections on obesity and burns which are essential reading.

Airway Management of the Critically Ill Patient – Tim Leeuwenberg

An excellent summary of why critically ill patients need to be treated differently during airway management.

The Physiologically Difficult Airway – Jarrod Mosier

A landmark paper summarising the main issues to consider when the patient whose airway you are managing is sick – focusing on the key areas of hypoxaemia, hypotension, severe metabolic acidosis and right ventricular failure.

Airway management in patients with suspected or confirmed traumatic spinal cord injury

The highlights

There is little evidence to suggest that laryngoscopy for intubation in patients with cervical spine injury is likely to cause secondary spinal cord injury.

There are insufficient data to suggest that videolaryngoscopy or videobronchoscope-guided intubation offer any advantage.

Videolaryngoscopy reduces the incidence of failed intubation, especially if manual in-line stabilisation (MILS) is used.

There is no evidence that MILS improves spinal stabilisation during intubation, and evidence that it increases the incidence of difficult and failed tracheal intubation. As a result, its use should be challenged.

The author recommends that clinicians use the tracheal intubation technique with which they are most proficient and that is most likely to minimise cervical spine movement in that particular patient and clinical setting. This includes awake and asleep techniques, direct laryngoscopy and videolaryngoscopy/videobronchoscope-guided intubation.

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