Airway Management in ICU and ED

1
Airway Management in ICU and ED

• Dr Neil Orford
• Intensive Care Unit
• The Geelong Hospital

2
Introduction

• Airway management core skill in ED/ICU
• Failure catastrophic
• Challenging environment
• Emergent conditions

3
Issues

• Who to intubate
• Challenges of the ED / ICU
• Devices
• Planning for difficulties

4
Must the airway be controlled

• Must I stop the patient's reliance on his/her own
  physiologic ventilatory control and force
  dependence on the success of my own
  airway/breathing techniques?
• How dangerous might it be to attempt to take
  control of patient's airway/breathing?
• Who will assume airway responsibility?

5
Who to intubate

• Failure to protect airway due impaired
  consciousness
• Failure to exchange gases
• Parenchyma
• Muscle weakness
• Other

6
Challenges of the ED / ICU

• Location
• Outside OR, less equipment
• Limited space, lighting
• Patients
• Unfasted
• Trauma
• Vomitus
• Reduced cardiorespiratory reserve
• Doctor
• Often not anaesthetists

7
Airway Devices

• Pretty simple, get air in and out of lungs, avoid
  stomach

8
Devices

• EAR
• Bag-Mask
• Supraglottic airways
• Guedel
• LMA classic, proseal, intubating
• Laryngeal tube
• Combitube
• Laryngoscope blades
• Curved
• Straight (Miller, Foregger, Philipps, Henderson)
• McCoy
• Fiberoptic devices
• Intubating bronchoscope
• Transtracheal
• Tracheostomy tube
• Cannula
• Seldinger kit

9
Bag-mask Ventilation

• Immediate
• Require expertise
• Gastric insufflation
• Pulmonary aspiration
• Large tidal volumes
• Poor skills
• Decrease LOS tone

10
LMA

• Archie Brain
• Developed 1981-1988
• Casts of human larynx
• Provide hands-free anaesthesia

11
LMA

• 15 million devices in 15 years
• On ASA difficult airway algorithm
• Classic
• Pro-seal
• Intubating
• Disposable

12
LMA

• Supraglottic
• Short learning curve
• Easier than bag-mask when learnt

13
Intubating LMA

• Allows special ETT through LMA and out aperture
  into trachea
• 3,4 LMA 6.0 ETT
• 5 LMA 7.0 ETT

14
Combitube

• 2 lumens and 2 cuffs
• Blue tracheal lumen
• Clear oesophageal lumen
• Inflate blue oropharyngeal lumen with 85 ml air
• Inflate white distal cuff with 10-15ml air
• Syringes provided

15
Bronchoscope

• Requires skill
• High success when trained
• Allows awake intubation

16
Trans-tracheal
17
Tracheostomy

• Many kits.

18
Tracheostomy
19
Tracheostomy
20
Tracheostomy

• 14G cannula
• Oxygen tube
• 3-way tap
• Oxygen source
• or
• Pump set
• Common gas outlet

21
Planning for difficulties
22
Scenario 1

• 52 yr male epileptic arrives ED. Fitting for 1
  hr, received benzos in ambulance. Now some
  residual tonic-clonic activity, unconscious,
  breathing spontaneously.
• Does he need intubating?

23
Scenario 1

• 2 hrs later has had more seizures, received
  further benzos, fiting stopped. Now unconscious,
  breathing spontaneously

24
Scenario 2

• 60 yr male post laser removal glottic tumour.
  Chestpain in recovery and troponin rise. Sent to
  CCU for monitoring and anticoagulation. Asked to
  see him because bleeding from airway, difficulty
  breathing.

25
6 Questions

• Must the airway be controlled
• Will mask ventilation be difficult
• Will laryngoscopy be difficult
• Can supralaryngeal devices be used if needed
• Is there an aspiration risk
• Will patient tolerate apneic period

26
(No Transcript)
27
Definitions

• difficult airway the clinical situation in
  which a conventionally trained anesthesiologist
  experiences difficulty with mask ventilation,
  difficulty with tracheal intubation, or both.
• difficult mask ventilation
• inability of unassisted anesthesiologist to
  maintain SpO2 gt 90 using 100 oxygen and
  positive pressure mask ventilation in a patient
  whose SpO2 was 90 before anesthetic
  intervention
• or
• inability of the unassisted anesthesiologist to
  prevent or reverse signs of inadequate
  ventilation during positive pressure mask
  ventilation. (Signs include cyanosis, absence of
  chest movement, auscultatory signs of severe
  airway obstruction, gastric entry or gastric
  distension, and hemodynamic changes associated
  with hypoxemia or hypercarbia.)

28

• difficult laryngoscopy not being able to see
  any part of the vocal cords with conventional
  laryngoscopy
• difficult intubation proper insertion with
  conventional laryngoscopy requires either (1)
  more than three attempts or (2) more than ten
  minutes

29
Will mask ventilation be difficult

• Face mask 2 of the following 5 predictive of at
  least minor difficulty
• elderly
• BMI gt 26
• history of snoring
• Edentulous
• facial hair

30
Difficult intubation

• DL currently remains standard of care.We remain
  unable to definitively predict difficult DL.
• Functional assessment
• Goal of DL create line of sight from eye to
  glottis (glottic opening)
• 3 requirements
• some mouth opening
• 'sniff' postion
• displacement of tongue (place to put tongue)

31
Difficult intubation

• Long incisors / overriding upper teeth
• Poor TMJ function, mouth open lt3cm
• Mallampatti 3 or 4
• Small jaw
• Narrow palate
• Thyromental distance lt6cm
• Rigid submandibular space
• Cervical spine immobility
• Pathology - trauma, tumour, infection,
  radiotherapy

32
Mallampatti
33
Can supralaryngeal airway devices be used if
needed

• LMA
• rescued 16 of 17 cannot intubate/cannot ventilate
  patients (the 1 not rescued had clotted trachea )
  factors that may preclude use
• mouth too smallmass lesion in upper
  airwayaspiration risk (stomach not empty) (but
  Proseal-LMA OK?)
• CombitubeWith some experience, the vast majority
  of patients in whom DL is judged to be difficult
  can be adequately managed by one of the above
  three devicesIf use of a SLA device may be
  difficult, then a cannot intubate/cannot
  ventilate situation after induction would be
  predictable and ought be avoided by entering
  awake intubation

34
Is there an aspiration risk

• Controversial, varied opinions regarding what
  defines riskUse experience and evidenced-based
  informationMost important when SLA device is a
  viable alternative to tracheal intubationFace
  mask no protectionLMA low rate of aspiration
  in moderate and high risk patients
• Combitube may be protective
• Possible difficult DL plus aspiration risk
  (stomach full) suggests awake intubation

35
Will the patient tolerate an apneic period

• If patient cannot tolerate then awake Intubation
  if anticipated difficult intubation
• If patient can tolerate apnea until spontaneous
  ventilation resumes or alternative rescue means
  are successful, then enter intubation in ASA
  algorithm
• If uncomfortable with evaluation, then choose
  conservatively and awake intubation

36
The Scenarios
37
Scenario 1

• 52 yr male epileptic arrives ED. Fitting for 1
  hr, received benzos in ambulance. Now some
  residual tonic-clonic activity, unconscious,
  breathing spontaneously.
• Does he need intubating?

38
Scenario 1

• 2 hrs later has had more seizures, received
  further benzos, fiting stopped. Now unconscious,
  breathing spontaneously

39
Scenario 2

• 60 yr male post laser removal glottic tumour.
  Chestpain in recovery and troponin rise. Sent to
  CCU for monitoring and anticoagulation. Asked to
  see him because bleeding from airway, difficulty
  breathing.

40
Summary

• Important airway decision-making factors are
• experience
• judgment
• Human beings, who are almost unique in having
  the ability to learn from the experience of
  others, are also remarkable for their apparent
  disinclination to do so. Douglas Adams