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.