airway management in emergency and icu

8/14/2019 Airway Management in emergency and icu

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Airway ManagementAirway Management

in the Emergency Departmentin the Emergency Departmentand ICUand ICU

Mehdi Khosravi, MDMehdi Khosravi, MD Pulmonary/CCM FellowGiuditta Angelini, MDGiuditta Angelini, MD Assistant Professor

Jonathan T. Ketzler, MDJonathan T. Ketzler, MD Associate Professor

Douglas B. Coursin, MDDouglas B. Coursin, MD Professor

Departments of Anesthesiology & Medicine

University of Wisconsin, Madison


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Global AssessmentGlobal Assessment

Assess underlying need for airway control Duration of intubation- Nasal intubation less advantageous for potentially prolonged ventilator

requirements

Permanent support

- Underlying advanced intrinsic lung or neuromuscular disease

Temporary support

Anesthesia

Presence of reversible intrinsic lung or neuromuscular disease

Protection of the airway due to depressed mental status

Presence of reversible upper airway pathology

Patient care needs (e.g., transport, CT scan, etc.)

Significant comorbidities

Aspiration potential or increased respiratory secretions

Hemodynamic issues such as cardiac disease or sepsis

Renal or liver failure


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Pathophysiology of the respiratory failure Hypoxic respiratory failure

- In case of hypoxic respiratory failure, different noninvasive oxygen delivery

devices can be used.

- The severity of hypoxia and presence or absence of underlying disease (such

as COPD) will dictate the device of choice.

Hypercapnic respiratory failure- The noninvasive device of choice for hypercapnic respiratory failure is BIPAP.

Assessment of above mentioned patient characteristics in

conjunction with the mechanism of respiratory distress

leads the clinician to proper choice and duration ofinvasive or noninvasive options for airway management.

Code status should be clarified prior to proceeding.


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Oxygenation Respiratory rate and use of accessory muscles

- Is the patient in respiratory distress?

Amount of supplemental oxygen

- What is the patients oxygen demand?

Pulse oximeter or arterial blood gas

- Is the patient physiologically capable of providing appropriate supply?

Airway Anatomy

- Will this patient be difficult to intubate?

Patency- Is there a reversible anatomical cause of respiratory failure as opposed to

intrinsic lung dysfunction?

Airway device in place

- Is there a nasopharyngeal airway or combitube in place?


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Oxygen Delivery DevicesOxygen Delivery Devices(In order of degree of support)

Nasal Cannula 4% increase in FiO2 for each 1 L of flow (e.g., 4 L flow = 37% or 6 L flow= 45%)

Face tent At most delivers 40% at 10-15 L flow

Ventimask Small amount of rebreathing

8 L flow = 40%, 15 L flow = 60%

Nonrebreather mask Attached reservoir bag allows 100% oxygen to enter mask withinlet/outlet ports to allow exhalation to escape - does not guarantee

100% delivery.


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Oxygen Delivery DevicesOxygen Delivery DevicesNoninvasive Positive Pressure

CPAP is a continuous positive pressure

Indicated in hypoxic respiratory failure and obstructive sleep apnea

BiPAP allows for an inspiratory and expiratory pressure to support and improve

spontaneous ventilation

Mainly indicated in hypercapnic respiratory failure and obstructive sleep apnea

If use of noninvasive modes of ventilation does not result in improved ventilation

or oxygenation in two to three hours, intubation should be considered

These devices can be used if following conditions are met:

Patient is cooperative with appropriate level of consciousness

Patient does not have increased respiratory secretions or aspiration potential

Concurrent enteral feeding is contraindicated.

Facilitates early extubation, especially in COPD patients

Some devices allow respiratory rate to be set.

Up to 10 L of oxygen can be delivered into the mask for 100% oxygen delivery.

Nasal or oral (full face) mask can be used; less aspiration potential with nasal.


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Degree of Respiratory DistressDegree of Respiratory Distress

Respiratory pattern

Accessory muscle use is an indication of distress.

Rate > 30 can indicate need for more support by noninvasive positive

pressure or intubation

Need for artificial airway Tongue and epiglottis fall back against posterior pharyngeal wall

Nasopharyngeal airway better tolerated

Pulse oximetry

O2 saturation less than 92% on 60 - 100% oxygen can suggest the need

for intubation based on whether there is anything immediately reversible

which could improve ventilation.

Arterial blood gas pH < 7.3 can indicate need for more support by noninvasive positive

pressure or intubation.


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Temporizing MeasuresTemporizing Measures

Naloxone for narcotic overdose 40 mcg every minute up to 200 mcg with:

- 45 minutes to one hour duration of action

0.4 - 2 mg of naloxone is indicated in patients with respiratory arrest and

history suggestive of narcotic overdose

- There is a potential for pulmonary edema, so large dose is reservedfor known overdose and respiratory arrest

Caution in patients with history of narcotic dependence

Naloxone drip can be titrated starting at half the bolus dose used to

obtain an effect

- Manufacturer recommended 2 mg in 500 ml of normal saline or D5gives 0.004 mg/ml concentration


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Temporizing MeasuresTemporizing Measures(cont'd)

Flumazenil for benzodiazepine overdose 0.2 mg every minute up to 1 mg

Caution in patients with history of benzodiazepine or alcohol dependence

Caution in patients with history of seizure disorder as it will decrease the

seizure threshold

Artificial airway for upper airway obstruction in patientswith oversedation May be necessary in patients with sleep apnea despite judicious sedation

100% oxygen and maintenance of spontaneous

ventilation in patients with pneumothorax Washout of nitrogen may decrease size of pneumothorax

Positive pressure may cause conversion to tension pneumothorax


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Oral/Nasal AirwaysOral/Nasal Airways


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Indications for IntubationIndications for Intubation

Depressed mental status Head trauma patients with GCS 8 or less is an indication for intubation

- Associated with increased intracranial pressure

- Associated with need for operative intervention

- Avoid hypoxemia and hypercarbia which can increase morbidity and

mortality

Drug overdose patients may require 24 - 48 hours airway control.

Upper airway edema Inhalation injuries

Ludwigs angina Epiglottitis


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Underlying Lung DiseaseUnderlying Lung Disease

Chronic obstructive lung disease Application of controlled ventilation may interfere with complete

exhalation, overdistend alveoli, and impair right heart and pulmonary

venous return.

Pulmonary embolus

Pulmonary artery and right ventricle already have high pressure anddependent on preload

Application of controlled ventilation may deteriorate oxygenation and

systemic pressure.

Restrictive lung disease May require less than 6 cc/kg Vt to prevent elevated intrapulmonary

pressure

Application of positive pressure may result in barotrauma in addition to

impaired preload.


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Airway Anatomy Suggesting DifficultAirway Anatomy Suggesting Difficult

IntubationIntubation

Length of upper incisors and overriding maxillary teethInterincisor (between front teeth) distance < 3 cm (two finger tips)

Thyromental distance < 7 cm

tip of mandible to hyoid bone (three finger breaths)

Neck extension < 35 degrees

Sternomental distance < 12.5 cm

With the head fully extended and mouth closed

Narrow palate (less than three finger breaths)

Mallampati score class III or IV

Stiff joint syndrome About one third of diabetics characterized by short stature, joint rigidity, and tight waxy skin

Positive prayer sign with an inability to oppose fingers

No sign is foolproof to indicate intubation difficulty

Erden V, et al. Brit J Anesth. 2003;91:159-160.

Prayer Sign


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Mallampati ScoreMallampati Score

Class I: Uvula/tonsillar pillars visible

Class II: Tip of uvula/pillars hidden by tongue

Class III: Only soft palate visible

Class IV: Only hard palate visible

Den Herder, et al. Laryngoscope. 2005;115(4):735-739.


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ComorbiditiesComorbidities

Potential for aspiration requires rapid sequence intubation with

cricoid pressure Clear liquids < 4 hours

Particulate or solids < 8 hours

Acute injury with sympathetic stimulation and diabetics may have

prolonged gastric emptying time.

Potential for hypotension Cardiac dysfunction, hypovolemia, and sepsis

May need to consider awake intubation with topical anesthesia

(aerosolized lidocaine) as sedation may precipitate hemodynamic

compromise and even arrest.

Organ failure Renal and hepatic failure will limit medication used.

Potential for preexisting pulmonary edema and airway bleeding from

manipulation


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Induction AgentsInduction Agents

Sodium Thiopental 3 - 5 mg/kg IV

Profound hypotension in patients with hypovolemia, histamine release,

arteritis

Dose should be decreased in both renal and hepatic failure.

Etomidate 0.1 - 0.3 mg/kg IV

Lower dose range for elderly and hypovolemic patients

Hemodynamic stability, myoclonus

Caution should be exercised as even one dose causes adrenal

suppression due to similar steroid hormone structure.

Unlikely to have prolonged effect in organ failure


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Induction AgentsInduction Agents(cont'd)

Propofol 2 - 3 mg/kg IV

Hypotension, especially in patients with systolic heart dysfunction,

bradycardia, and even heart block

Unlikely to have prolonged effect in organ failure

Ketamine 1 - 4 mg/kg IV, 5 - 10 mg/kg IM

Stimulates sympathetic nervous system

Requires atropine due to stimulated salivation and midazolam for

potential of dysphoria

Avoid in patients with loss of autoregulation and closed head injury


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Neuromuscular BlockersNeuromuscular Blockers

Succinylcholine 1 - 2 mg/kg IV, 4 mg/kg IM

Avoid in patients with malignant hyperthermia, > 24 hours out from burn or

trauma injury, upper motor neuron injury, and preexisting hyperkalemia

Rocuronium 0.6 - 1.2 mg/kg, highest dose required for rapid sequence

Hemodynamically stable, 10% renal elimination

Vecuronium 0.1 mg/kg

Hemodynamically stable, 10% renal elimination

Cisatricurium 0.2 mg/kg

Mild histamine release, Hoffman degradation, not prolonged in renal or

hepatic failure


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Rapid Sequence IntubationRapid Sequence Intubation

Preoxygenate for three to five minutes prior to induction Wash out nitrogen to avoid premature desaturation during intubation.

Crycoid pressure should be applied from prior to induction

until confirmation of appropriate placement.

Succinylcholine 1 - 2 mg/kg IV will achieve intubationconditions in 30 seconds; Rocuronium 1.2 mg/kg IV will

achieve intubation conditions in 45 seconds. Other muscle relaxants do not produce intubation conditions in less than

60 seconds.

Avoid mask ventilation after induction. Potentially can inflate stomach

Use only if necessary to ensure appropriate oxygenation during

prolonged intubation.


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Y BAG PEOPLEY BAG PEOPLE(Reference #6)


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Cricoid PressureCricoid Pressure

Cricoid is circumferential

cartilage

Pressure obstructs

esophagus to preventescape of gastric

contents

Maintains airway patency

Koziol C, et al. AORN. 2000;72(6):1018-1030.


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Sniffing PositionSniffing Position

Align oral, pharyngeal, and laryngeal axes to

bring epiglottis and vocal cords into view.

Hirsch N, et al. Anesthesiology. 2000;93(5):1366.


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Mask VentilationMask Ventilation

Mask ventilation crucial,

especially in patients who aredifficult to intubate

Sniffing position with tight

mask fit optimal

May require two hands

Mask ventilation crucial,

especially in patients who are

difficult to intubate

Sniffing position with tight

mask fit optimal

May require two hands


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Laryngoscope Blades and EndotrachealLaryngoscope Blades and Endotracheal

TubesTubes

Miller blade: End of blade should be under epiglottis

Mac blade: End of blade should be placed in front of epiglottis in valecula

ETT for Fastrach LMA

Pediatric uncuffed ETT

ETT for blind nasal

Standard ETT


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Graded Views on IntubationGraded Views on Intubation

Grade 1: Full glottis visible

Grade 2: Only posterior commissureGrade 3: Only epiglottis

Grade 4: No glottis structures are visible

Yarnamoto K, et al. Anesthesiology. 1997;86(2):316.


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Additional ConsiderationsAdditional Considerations

Always have additional personnel and an experiencedprovider as backup available for potential failed

intubation

Always have suction available

Never give a muscle relaxant if difficult mask ventilationis demonstrated or expected

Awake intubation should be considered in the following: If patient is so hemodynamically unstable that induction drugs cannot be

tolerated (topicalize airway) If patient has a history or an exam which suggests difficult mask

ventilation and/or direct laryngoscopy


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American Society of Anesthesiologists

www.asahq.org


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Alternative MethodsAlternative Methods

Blind nasal intubation

Bleeding may cause problems with subsequent attempts. Contraindicated in patients with facial trauma due to cribiform plate disruption or

CSF leak

Avoid in immune suppressed (i.e., bone marrow transplant)

Eschmann stylet

Fiber optic bronchoscopic intubation Awake vs. asleep

Laryngeal mask airway Allows ventilation while bridging to more definitive airway

Light wand

Retrograde intubation Through cricothyrotomy

Surgical tracheostomy

Combitube


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Eschman StyletEschman Stylet

Use especially if Grade IIIview achieved

Direct laryngoscopy isperformed

Place Eschman wheretrachea is anticipated

May feel tracheal ringsagainst stiffness of stylet

Thread 7.0 or 7.5 ETTover stylet with thelaryngoscope still in place


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Fiberoptic ScopeFiberoptic Scope

Essentially what is used to do a

bronchoscopy

Can be used to thread anendotracheal tube into thetrachea either while the patientis asleep or on an awakepatient with a topicalized airway

Via laryngeal mask airway inplace due to inability to intubatewith DL:

Aintree (airway exchange catheter) canbe threaded over the FOB to be placedinto trachea upon visualization

Wire-guided airway exchange cathetercan also be used with one more step


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The Laryngeal Mask Airway (LMA)The Laryngeal Mask Airway (LMA)


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LMA PlacementLMA Placement

Guide the LMA along thepalate

Eventual position should

be underneath the

epiglottis, in front of thetracheal opening, with the

tip in the esophagus

FOB placement through

LMA positions in front oftrachea

Martin S, et al. J Trauma Injury, Infection Crit Care.

1999;47(2):352-357.


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The FastrachThe FastrachTMTM LaryngealLaryngeal

Mask AirwayMask Airway

Reinforced LMA allows for

passage of ETT without

visualization of trachea.

10% failure rate in

experienced hands

20% failure rate in

inexperienced


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The Light WandThe Light Wand

Transillumination of

trachea with light at distalend

Trachea not visualizeddirectly

Should not be used withtumors, trauma, or foreignbodies of upper airway

Minimal complication

except for mucosal bleed10% failure rate on firstattempt in experiencedhands


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Retrograde IntubationRetrograde Intubation

Puncture of thecricothyroid membrane

with retrograde passage of

a wire to the trachea

Endotracheal tube guidedendoscopically over the

wire through the trachea

Catheter through the

cricothyroid can be usedfor jet ventilation if

necessary.

Wesler N, et al. Acta Anaes Scan. 2004;48(4):412-416.


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CombitubeCombitube

Emergency airway used mostly by

paramedics and emergencyphysicians for failed endotracheal

intubation

Ventilation confirmed through blind

blue tube Combitube is in the esophagus and salemsump can be placed through white tube

Ventilation confirmed through white

(clear) tube with patent distal end

Combitube is in the trachea and salem sumpshould be placed outside of combitube into

esophagus

Fiber optic exchange can be accomplished

through combitube


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CombitubeCombitube(cont'd)

Should be changed to endotracheal tube (ETT) or

tracheostomy to prevent progressive airway edema

If in esophagus, take down pharyngeal cuff and attempt direct

laryngoscopy (DL) or fiber optic bronchoscope (FOB)

placement around combitube

Failed exchange attempt can be solved with operative

tracheostomy

Placement of combitube can produce significant airway

trauma Removal prior to DL or FOB should be done with caution after thorough airway

evaluation

Cricoid pressure should be maintained and emergency tracheostomy equipment

available


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TracheostomyTracheostomy

Surgical airway throughthe cervical trachea

Emergent procedurecarries risk of bleeding

due to proximity ofinnominate artery

Can be difficult and timeconsuming in emergent

situations

Sharpe M, et al. Laryngoscope. 2003;113(3):530-536.


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Case Scenario #1Case Scenario #1

The patient is 70 kg with a 20-year history of diabetes.

On exam, the patient has intercisor distance of 4 cm,

thyromental distance is 8 cm, neck extension is 45

degrees, and mallampati score is 1.

Your staff wants to use thiopental and pancuronium.

Do you have any further questions for this patient or

would you proceed with your staff?


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Case Scenario #1 - AnswerCase Scenario #1 - Answer

A diabetic for 20 years needs assessment for stiff jointsyndrome.

You should have the patient demonstrate the prayer sign.

If the patient is unable to oppose their fingers, you should

not give pancuronium.

You may want to proceed with an LMA and FOB at your

disposal.

If the patient has a history of gastroparesis, you may wantto consider an awake FOB.


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43-year-old patient with HIV, likely PCP pneumonia who

had been prophylaxed with dapsone

RR is 38, oxygen saturation is 90% on 100% NRB mask

The patient is on his way to get a CT scan.

Is it appropriate to proceed without intubation?


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Dapsone will produce some degree ofmethemoglobinemia.

Therefore, some degree of desaturation may not be

overcome.

The patient is in significant respiratory distress and will

be confined in an area without easy access.

Intubation should be considered as an extra measure of

safety, especially as this patient is likely to get worse.


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40-year-old, 182-kg man has a history of sleep apnea

and systolic ejection fraction of 25%. He has a Strep

pneumonia in his left lower lobe and progressive

respiratory insufficiency.

He extends his neck to 50 degrees and has a mallampati

score of 2.

Would you proceed with an awake FOB?


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The patients airway anatomy is not suggestive ofdifficulty.

However, with supine position, subcutaneous tissue may

impair your ability to visualize or ventilate.

Use of gravity, including a shoulder roll, extreme sniffing

position, and reverse trendelenburg may be helpful with

asleep DL.

Prudent to have some accessory equipment, includingan LMA and FOB, for back up


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ReferencesReferences

Caplan RA, et al. Practice guidelines for management of the

difficult airway.Anesthesiology. 1993;78:597-602. Langeron O, et al. Predictors of difficult mask ventilation.

Anesthesiology. 2000;92:1229-36.

Frerk CM, et al. Predicting difficult intubation.Anaesthesia.

1991;46:1005-08. Tse JC, et al. Predicting difficult endotracheal intubation in

surgical patients scheduled for general anesthesia.

Anesthesia & Analgesia. 1995;81:254-8.

Benumof JL, et al. LMA and the ASA difficult airway

algorithm. Anesthesiology. 1996;84:686-99.

Reynolds S, Heffner J. Airway management of the critically

ill patient. Chest. 2005;127:1397-1412.

airway management in emergency and icu

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