Difficult airway in ICU by Dr. Aditya Jindal | JIndal Chest Clinic

A difficult airway is a clinical situation in which a medical professional with training in airway management finds it difficult to use the recommended techniques. This presentation gives an overview on the topic "Difficult airway in ICU". For more information, please contact us: 9779030507.

1. Difficult airway in ICU Dr . Aditya Jindal Interventional Pulmonologist & Intensivist Jindal Clinics SCO 21, Sec 20D, Chandigarh DM Pulmonary and Critical Care Medicine (PGI Chandigarh ), FCCP www.jindalchest.com

2. Introduction D ifficult airway represents a complex interaction between patient factors, the clinical setting, and the skills of the practitioner Most common cause of anesthesia related morbidity and mortality, including airway injury , hypoxic brain injury, and death Difficulties encountered in critical care setting different from routine anaesthesia practice

3. O utline Difficult airway in routine anaesthesia Definitions Difficult airway algorithm Difficult airway in ICU Differences in ICU setting Predictors Managing the difficult airway A nticipated Unanticipated Cannot intubate, cannot ventilate Extubation Solutions Summary

4. Difficult airway in routine anesthesia

5. Definitions Difficult airway: Clinical situation in which a conventionally trained anaesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with tracheal intubation, or both American Society of Anesthesiologists : Practice guidelines for management of the difficult airway: An updated report. Anesthesiology 2013 Difficult mask ventilation (DMV) Inability of an unassisted anaesthesiologist a) to maintain oxygen saturation, measured by pulse oximetry ˃ 92% or b) to prevent or reverse signs of inadequate ventilation during positive-pressure mask ventilation under general anaesthesia 2% - 8% The difficult airway in adult critical care. Lavery G G , McCloskey B V. Crit Care Med 2008

6. Difficult tracheal intubation (DTI) Tracheal intubation requiring multiple intubation attempts in the presence or absence of tracheal pathology 1.5 % - 8.5% impossible in up to 0.5% one in 2,000 in the non-obstetric population one in 300 in the obstetric population The difficult airway in adult critical care. Lavery G G , McCloskey B V. Crit Care Med 2008

7. American Society of Anesthesiologists: Practice guidelines for management of the difficult airway: An updated report. Anesthesiology 2013

8. Difficult airway in ICU

9. Differences in ICU setting Airway interventions more difficult and associated with more complications Progressive illness requiring rapid intubation Reduced time for preparation Hypoxaemia despite preoxygenation Healthy patients: Oxygen x 4 min; 90 mmHg  400 mmHg Critically ill patients: 67 mmHg  104 mmHg Mort TC. Preoxygenation in critically ill patients requiring emergency tracheal intubation. Critical Care Medicine 2005 Increased risk of profound hypotension or cardiac arrest on anaesthetic induction

10. Risk of aspiration due to a full stomach Associated injuries making intubation difficult, ( e.g. maxillofacial trauma, potential cervical injury ) Challenges related to the location Limited range of difficult intubation equipment Less experienced assistance Lack of capnography Limited access to the patient Cannot wake up patient Limited anaesthesia experience Unplanned/ accidental extubations Airway challenges in critical care. Nolan J . P., Kelly F . E . Anaesthesia. 2011

11. Incidence of DTI in critical patients almost twice as high (8% - 12%) Intubation related complications higher 4% - 39 % Severe hypoxaemia Severe hypotension Oesophageal intubation Aspiration Cardiac arrest Death rate from airway complications in ICU  1:2700 patients requiring ventilation, approximately 70-fold higher than the rate in anaesthesia

12. Reported incidence of difficult intubation (˃ 3 attempts) and complications associated with intubation in critically ill patients Airway challenges in critical care. Nolan J. P., Kelly F. E. Anaesthesia. 2011

13. Predictors of difficult airway The difficult airway in adult critical care. Lavery G G , McCloskey B V. Crit Care Med 2008

14. The airway: emergent management for non anesthesiologists. Fowler RA, Pearl RG. West J Med. 2002

15. The airway: emergent management for non anesthesiologists. Fowler RA, Pearl RG. West J Med. 2002 Mallampati classification

16. CL grades 1 (a), 2 (b), 3 (c), and 4 (d) in the SimManTM human patient simulator. a, laryngoscope blade; b, epiglottis; c, glottic opening; d, arytenoid cartilages. Cormack– Lehane classification revisited. R . Krage et al. Br. J. Anaesth . 2010

17. “ accurate prediction of airway difficulty is a myth but the exercise is useful in focusing our attention on potential airway strategy” Yentis SM: Predicting difficult intubation— worthwhile exercise or pointless ritual? Anaesthesia 2002

18. Managing the difficult airway Anticipated Least lethal scenario Time to plan strategy and assess patient Unanticipated Commonly encountered in ICUs Time available short Cannot intubate, cannot ventilate Absolute emergency

19. Anticipated difficult airway Time to plan and assess Have backup ready Follow a structured algorithm and maintain a checklist Difficult airway trolley The difficult airway in adult critical care. Lavery G G , McCloskey B V. Crit Care Med 2008

20. Orotracheal intubation under anesthesia Standard method Awake intubation Fibreoptic scope intubation Retrograde intubation

21. Unanticipated difficult airway Commonly encountered situation in ICUs Significant comorbidities and complicating conditions may be present Important: Stay calm Call for help Teamwork Ideal situation  trained medical personnel and standard operating procedure already in place

22. Bimanual laryngoscopy Stylet Smooth, malleable metal or plastic rod Placed inside an ETT Adjusts curvature into a J or hockey stick shape Allows the tip of the ETT to be directed through a poorly visualized or unseen glottis Gum elastic bougie Blunt-ended, malleable rod J shaped bend introduced at the tip Introduced blindly through the larynx and ETT railroaded over it

23. Laryngoscope blades Macintosh Miller McCoy Lighted Stylet Malleable fiberoptic Light source Introduced into trachea ETT railroaded over Position confirmed by Visibility of light thorough Neck soft tissues Can be combined with LMA A–C, Mackintosh Blades ( sizes 4, 3, and 2). D, Miller blade; E, McCoy blade (tip in “elevated” position). The airway: emergent management for non anesthesiologists. Fowler RA, Pearl RG. West J Med. 2002

24. Fibreoptic intubation Bronchoscope Fibreoptic laryngoscope Video laryngoscope Supraglottic airway devices Laryngeal mask airway (LMA) Combitube (Esophageal-Tracheal Double-Lumen Airway)

25. LMA Allows limited positive pressure ventilation Can be placed by inexperienced operators Risk of aspiration Inadequate seal

26. Cannot intubate, cannot ventilate Absolute emergency Options Review and see if intubating conditions can be improved Use a supraglottic airway Perform a cricothyroidotomy/ tracheostomy

27. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Frerk et al. British Journal of Anaesthesia. 2015

28. Confirmation of the endotracheal tube Complex airway diseases. Patel et al. In Textbook of pulmonary and critical care medicine. Jindal SK (ed.). 2011

29. Extubation Planned extubation  anticipated difficult airway Airway exchange catheters Unplanned/accidental Possible life threatening emergency Urgent recognition and redressal

30. Solutions Proper training Adequate equipment availability Use of intubation bundles Have emergency backup plans in place

31. Summary Airway management in critical care situations differs from routine operating room conditions Training and availability of equipment essential Anticipation of problems and pre-planning required Necessary to keep a calm head, call for help and work as a team

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