A question you always want to know about tracheal intubation:

What to do if I can’t intubate a patient?

Outcomes of the difficult intubation in malpractice claims

DifficultAirway Claims

(n=283)

Other claims(n=4176)

Death *131 (46%) 1293 (31%)

Brain damage 31 (11%) 504 (12%)

Airway Injury *97 (34%) 169 (4%)

Aspiration 19 (7%) 139 (3%)

Cost 135000 $ 100000 $

My own experience

• I couldn’t intubate a patient with respiratory arrest on my first duty in ICU. Retrograde intubation was performed successfully.

• In a patient with severe airway obstruction emergency tracheostomy was made

• Difficult intubation before elective surgical procedure. Blind nasal intubation failed. The patient was intubated by a chief of the department

• A cuff of the tube was ruptured in the middle of an operation. Re-intubation after 3rd attempt

Is it real in our every day life?

• A call was received by the medical director of the clinic: a worker from a major construction company fell down from the height. They are in 10 min from the clinic, accompanied by a nurse from the company. The nurse is very nervous: the man can’t b breath and she’s trying to ventilate him by mask.

• A patient admitted to our holding room: He’s severely obtunded. T-40C, RR-36’, HR-140’, SO2-72%, improved to 78% on 12 l/min of oxygen. CXR- bilateral pneumonia.

Continue

• A doctor from the clinic escorts an unconscious patient to the hospital. The patient’s condition deteriorates, SO2 drops despite supplementary oxygen inhalation.

• In the medical unit of SVO2, the staff tried to manage an unconscious patient in apparent respiratory distress who admitted about 5 minutes ago

• Air evacuations: 5 intubations were performed.

Emergency intubation vs elective one

Emergency Elective

Difficult intubation isusually unpredictable

Predictable in about 60 %of cases

No time for preparation Enough time forpreparation

Experienced staff isunavailable

Experienced staff isavailable

Full stomach Empty stomach

Patient's condition isunstable

Stable

Reasons for intubation in emergency situation

• Hypoxia

• Hypoventilation ( hypercapnia)

• Unconscious patient who’s unable to protect his/her airway

• Too labored breathing put patient's condition in danger

• Unstable patient

• A patient who can’t be managed without intubation

Make a decision on the base of the whole picture!

• 18 y.o. girl with APL admitted to the ICU. She is very weak and disoriented. VS: RR-28’, HR-120’, BP-120/80, SaO2-40%. PaO2- 32, PaCO2- 32. Breathing is unlabored.

• 46 y. o. man admitted to the ICU due to long-term respiratory failure. VS: RR-24, BP-140/90, SaO2 -40, PaO2-44, PaCO2-55

Continue

• 10 years old boy with blunt head trauma and mandibular fracture after car accident. He was hospitalized to an ICU, 36 hours before arrival our evacuation team. GCS-7. VS: RR-22’, HR=120’, BP-110/80, SaO2-92% on room air. Breathing spontaneously. There is blood in the oral cavity. Tympanic membrane on the left with hemorrhage.

Physiology (a little)

• Hypoxia: hyperventilation will be pronounced when the PaO2 falls to 40.2 mm Hg, coma occurs when PaO2 is below 32.7 mm Hg (BMJ: ABC of oxygen transport)

• Hypercapnia: A healthy person will bear PaCO2 75 mm Hg without any damage

• In case of apnoea when airway are open and oxygen is the ambient mask, the patient can theoretically survive 100 minutes (JF Nunn)

Principal stores of body oxygen

While breathingair

While breathing100% oxygen

In the lungs(FRS)

450 ml 3000 ml

In the blood 850 ml 950 ml

Dissolved intissue

50 ml 100

Combined withmyoglobin

200 ml 200 ml

Total 1550 ml 4250 ml

Fully preoxygenated patient can survive up to 8 min without becoming hypoxic

Types of translaryngeal intubation

disadvantagelack of patient's com fort

laryngospazmdiff icu lt to perform

advantagep resevation of b reath ing

very low risk of asp iration

b lind nasal itubation

conventional intubation

Aw aken intubationlocal anesthesia

consciouss sedation

disadvantageasp iration

adverse effects of m uscle re laxantslong recovery

advantagegood re laxation

no laryngospazmpatient's com fort

in tubation w ith m uscle paralys is

disadvantagediff icu lt v isualization of vocal cordsrisk of asp iration and laryngospazm

advantagelow risk of asp iration

p reservation of b reath ing

Intubation w ithout m uscle paralys is(spontaneous b reath ing is p reserved)

Translaryngeal in tubation

Multiple choice questions:Smart thoughts before the start

• Why I didn’t go to the business school instead of medical university?

• Should I ask for help?

• They don’t pay me enough

• The clinic is unprepared for this, nurses poorly trained, medical director… and etc

• What should I do before?

• Do I have a plan?

Answers

• Measures before: a) how to improve oxygenation, ventilation and protect airway? b) Do I monitor the patient properly?

• Heeeelp (will not work): who to ask, when and what to ask

• What about a plan?

If you failed…?

Every boxer had a plan until he missed first strong punch

Mike Tyson (philosopher)

Better don’t say that I’m wrong

If you failed

• mask ventilation is possible

• continue ventilation• protect airway• make another attempt• don’t forget about

external maneuvers

• mask ventilation isn’t possible

• Try jaw thrust• oral or nasal airway• clean secretion

Continue

• Intubation failed, but mask ventilation is possible-consider

• Continue mask ventilation until help is available

• Retrograde intubation• Transtracheal ventilation

with oral airway

• Remember Tyson?• Transtracheal

ventilation• Combi tube• Open cricotomy

Practice will help