1.83 CME

Airway Management in the ICU

Speakers: Dr. Nikhilesh Jain, Dr Nikhilesh jain

Description

Airway management in the ICU is critical for patients with respiratory failure, altered consciousness, or severe illness. Endotracheal intubation is the most common method, often performed using rapid sequence induction with appropriate sedation and neuromuscular blockade. Pre-oxygenation and continuous monitoring of oxygen saturation and hemodynamics are essential. Difficult airway algorithms and tools like video laryngoscopy enhance safety. In some cases, tracheostomy may be needed for prolonged ventilation. Non-invasive ventilation (NIV) can be an alternative in select patients. A multidisciplinary approach and adherence to airway safety protocols are vital to minimize complications and ensure optimal patient outcomes in critical care settings.

Summary

The speaker emphasizes the importance of airway management in the ICU, focusing on intubation and ventilation. They limit the discussion to procedures within the ICU, excluding super-aglottic airway devices and focusing on the specific problems faced in the critical care setting. The key reasons for intubation are failure to maintain a patent airway, ventilation or oxygenation failure, and anticipation of airway worsening.
Initial patient assessment includes evaluating airway patency, level of consciousness, response to voice commands, and ability to manage secretions, particularly to rule out neuromuscular weaknesses. Preemptive intubation is indicated in cases of bullet injuries, neck trauma, anaphylaxis, and burns (thermal or caustic). The speaker also discusses the A, B, C, D, E, F rules, emphasizing that ABGs are not the sole determinant of the need for intervention, as they do not reflect airway protection ability.
The speaker compares intubation in the ICU versus the operating room, highlighting the lack of advance planning and potential for patient, staff, condition, and instrument-related challenges in the ICU. Common problems in ICU patients include immobilization, compromised condition, trauma, acute hypoxemia, hemodynamic instability, and comorbidities like intracranial hypertension or myocardial ischemia. Pre-intubation preparation includes Yankauer suction, bag-valve mask, airway access, assembling the team, positioning the patient, checking endotracheal tubes, and ensuring availability of medications and laryngoscope blades.
Predicting difficult intubation involves assessing indicators such as length of upper incisors, inter-incisor distance, thyromental distance, neck extension, narrow palate, Mallampati score, and joint stiffness. The "rule of 1, 2, 3" and "rule of threes" are presented as practical guides. Pre-oxygenation strategies include face masks, high-flow nasal oxygen (HFNO), non-invasive ventilation (NIV), and a combination of HFNO and NIV. NIV can reduce severe hypoxemia, particularly in patients with PF ratios below 200 ml. The patient should be in a semi-setting position, and oxygen should be set at 100%.
Scores like the MACOCHA score can predict difficult intubation in the ICU, prompting consultation with a senior anesthesiologist. The Montpellier Intubation Protocol is detailed, which involves fluid loading, early vasopressor use, pre-oxygenation in an upright position, and intubation with video laryngoscopy using a bougie. Rapid sequence intubation with etomidate or ketamine, along with succinylcholine or rocuronium, is recommended. Post-intubation, capnography is used to confirm tube placement, vasopressors are titrated, early long-term sedation is initiated, and protective ventilation strategies are implemented.
Various algorithms for intubation are discussed, emphasizing two-operator techniques and Metri-Blade use. Rapid sequence intubation is often necessary. If direct laryngoscopy fails, video laryngoscopy, intubating LMAs, or fiberoptic bronchoscopy may be used. A six-member intubation team is ideal, with assigned roles for intubators, airway management, drug administration, and monitoring. Checklists are vital to ensure proper preparation of the patient, equipment, and team, and to anticipate potential difficulties.
Rapid sequence intubation (RSI) involves simultaneous administration of a potent sedative and neuromuscular blocking agent to induce unconsciousness and motor paralysis. Common hypnotic drugs used are Etomidate, ketamine, and propofol and neuromuscular blocking agents are succinylcholine and rocuronium. Mnemonic devices such as LEMON, MOANS, and RODS are discussed to assess the likelihood of difficult laryngoscopy, mask ventilation, and extraglottic device placement. SMART helps assess the likelihood of a difficult cricothyrotomy.
Crash intubation is described for situations where the patient has low SPO2 levels. Bag-mask ventilation should be attempted, and if unsuccessful, rapid sequence intubation is initiated. The presentation concludes with an algorithm summarizing the integrated approach to crash airway management, difficult airway management, failed airway management, and the incorporation of rapid sequence intubation when appropriate. Confirmation of tube placement is crucial, using methods like direct visualization, auscultation, bag resistance, X-ray, capnography, or fiber optic bronchoscopy.