Airway Emergencies

Objectives
•Identify signs and symptoms of an airway
emergency
•Recognize a patient at risk for an airway
emergency
•Use accepted algorithms for team
management of such emergencies

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Intubation Indications Question 1

• Airway protection What should a clinician do if the first
• Depressed level of consciousness attempt to intubate an unstable critically ill
• Requirement for deep sedation patient fails?
• Compromised airway anatomy 1. Try three times before getting help.
• Respiratory failure 2. Get help.
• Inadequate oxygenation 3. Change the type of laryngoscope blade
• Inadequate alveolar ventilation being used.
• Excessive respiratory workload 4. Wake the patient.
• Circulatory failure 5. Try videolaryngoscopy.
• Shock
• Cardiopulmonary arrest

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Question 1: Answer
Airway Philosophy
What should a clinician do if the first
attempt to intubate an unstable critically ill
patient fails? •An awake airway is best.
1. Try three times before getting help. •If first attempt fails, get help.
2. Get help. •If you can’t intubate, use bag mask
3. Change the type of laryngoscope blade ventilation plus alternative airway.
being used. •Can’t intubate, can’t ventilate (CICV): Get
4. Wake the patient. help plus cricothyrotomy.
5. Try videolaryngoscopy.

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 Have a Complete Plan!
• General medical assessment
Don’t Forget the Neck!
• Hemodynamics, comorbidities, and
potassium level Manual in‐line stabilization
• Airway position
• Sniffing, ramp vs. manual in‐line •Remove only anterior portion of cervical
stabilization? collar.
• Cricoid pressure (CP) •Thumbs on mastoid process and cradle head
• Does it really work? with palms.
• Induction agent •Do not apply traction!
• Ketamine, etomidate, propofol, nothing?
• Paralytic
• To paralyze or not to paralyze?
• Laryngoscopy
• Miller, MacIntosh, or videolaryngoscope?
• CICV
7 © 2018• Surgical
Societyvs.
of needle cricothyrotomy 8 © 2018 Society of
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Risk Factors for Difficult Risk Factors for Difficult

Mask
•Mallampati score III or IV
•Limited jaw protrusion
•Decreased thyromental
distance
•Severe oral facial/airway
trauma
•Unstable cervical spine
or limited neck extension
•Thick neck
•BMI ≥ 30 kg/m2
cancer
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Critical Care Medicine
• Age > 57 years
• Edentulous
• History of obstructive
sleep apnea/snoring
• History of head and
neck radiation
• Decreased pulmonary
compliance
• Presence of beard
• Oropharyngeal
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Intubation
• Mallampati score III or • Decreased
IV thyromental distance
• Limited jaw protrusion • History of head and
• Unstable cervical neck radiation
spine
• History of difficult
or limited neck extension
intubation
• Severe oral
• History of tracheal
facial/airway trauma
stenosis
• Thick neck
• Pregnancy
• Decreased neck range • Oropharyngeal cancer
of motion

Question 2 Question 2: Answer

Failure to use capnography/capnometry Failure to use capnography/capnometry
in ventilated patients contributes to what in ventilated patients contributes to what
percentage of deaths from airway percentage of deaths from airway
complications? complications?
1. 5% 1. 5%
2. 10% 2. 10%
3. 20% 3. 20%
4. 40% 4. 40%
5. 70% 5. 70%

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 Monitors
•Continuous ECG
•Pulse oximetry
•Noninvasive blood pressure/arterial line
•Capnography or end‐tidal CO2 detector
Failure to use capnography in ventilated patients
likely contributed to more than 70% of
ICU‐related deaths (from airway complications).
Data from Executive Summary, 4th National Audit Project.
Royal College of Anaesthetists and Difficult Airway Society.
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Positioning: Sniffing
•Sniffing position helps facilitate the alignment
of three axes: oral, pharyngeal, and laryngeal.
Induction
•Goal is to facilitate safe intubating conditions.
•Medical assessment of patient’s
comorbidities, mental status, and
cardiopulmonary status is paramount.
•Induction may involve giving
sedative/hypnotic agents, paralytics, local
anesthetics, or nothing!
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Rapid Sequence Induction

Cricoid Pressure
•Goal is to minimize the time the airway is
unprotected from induction until tracheal •Con
intubation is confirmed. • Esophagus was displaced lateral to
cricoid ring in up to 90% during CP.
•Indicated for all patients with aspiration risk
• Nothing by mouth < 8 hours •Pro
• Patients with small bowel obstruction, • Movement of the esophagus is
ascites, pregnancy, etc. irrelevant to the efficiency of CP.
•Secondary benefits include minimizing time • CP reduces the diameter of the
of apnea, therefore less risk of desaturation. hypopharynx by 35% and likely
obliterates the lumen.
•Should be the rule more than the exception
in the ICU. Data from Smith KJ, Dobranowski J, et
al. Anesthesiology. 2003;99:60‐64, and
1 1 Rice MJ, et al. Anesth
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2009;109:1546‐1552.

Awake Intubation Question 3

1.Early administration of glycopyrrolate Myoclonus is a side effect of which of
(15‐20 min) the following induction agents?
2.Topicalization of airway with 4% lidocaine 1. Propofol
atomizer
2. Etomidate
3.Superior and transtracheal nerve blocks 3. Ketamine
(coagulopathy contraindication)
4. Dexmedetomidine
4.Bite block 5. Barbiturates
5.Fiberoptic intubation
6.Secure endotracheal tube (ETT)

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 Hypnotic Agents for Induction
Question 3: Answer
Hypnoti Dos H M Re Side Effects
Myoclonus is a side effect of which of c Agent age R AP sp
the following induction agents? (mg/
1. Propofol kg)
2. Etomidate
3. Ketamine Propofo 1 ― ↓ ↓ Significant CV
4. Dexmedetomidine l ‐ ↓ ↓ depression, egg
5. Barbiturates 3 ↓ allergy anaphylaxis,
propofol infusion
*Relies primarily on beta elimination syndrome (prolonged
(hepatorenal)
compared to other agents that rely on infusions)
alpha
Etomid 0.2‐ ― 0/ and
elimination (redistribution) ↓therefore
Adrenocortical
has a longer
1 © 2018 Society of 2 ©clinical
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half‐life following a single bolus.
ate 0.7 ↓ suppression, nausea,
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myoclonus

Ketami 1 ↑ ↑ ↓ Salivation, PTSD,

ne* ‐ ↑ elevated ICP,
2 negative inotropic
Ketamine Etomidate properties, increases
pulmonary artery
•Less respiratory depression • Useful in patients with pressure
•Said to have less hemodynamic lability cardiovascular
Midazol 0.1‐ ― instability
0/ ↓ Delayed awakening,
am*• Minimal
0.4CV depression
↓ ↓ delirium
•Can cause hypotension in critically ill
patients with depleted catecholamine • Causes adrenocortical suppression
reserves • Inhibits 11‐β‐hydroxylase activity
•Increased salivation can make intubation • Clinical significance debatable
more difficult • Myoclonic activity
• Consider giving antisialagogue (eg,
glycopyrrolate)

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Question 4 Question 4: Answer

Which of the following is not Which of the following is not
a nondepolarizing agent? a nondepolarizing agent?
1. Rocuronium 1. Rocuronium
2. Atracurium 2. Atracurium
3. Succinylcholine 3. Succinylcholine
4. Curare 4. Curare
5. Vecuronium 5. Vecuronium

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 Depolarizing Neuromuscular Nondepolarizing NMBs
Blockers (NMBs)
Benzylisoquinolinium compounds
• Succinylcholine • Atracurium
• Only depolarizing agent available • Intubation dose 0.5 mg/kg
• Rapid onset, short duration of action • Onset 2.5 min
• Hydrolyzed by plasma butyrylcholinesterase • Intermediate duration of action 30‐50 min
• Infusion 10‐20 µg/kg/min
• Hofmann elimination and ester hydrolysis
• No accumulation
• Useful in ICU

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Nondepolarizing NMBs Nondepolarizing NMBs

Benzylisoquinolinium compounds
Aminosteroidal compounds
• Cisatracurium • Vecuronium
• Intubation dose 0.1‐0.15 mg/kg
• Intubation dose 0.1 mg/kg
• Slower onset than atracurium (3‐6 min)
• Intermediate duration of action (20‐35 min)
• Intermediate duration of action
• Infusion rate 0.8‐1.2 µg/kg/min
• Infusion rate 3 µg/kg/min
• Eliminated unchanged in liver and kidney
• Hofmann elimination 77%
• Metabolized by liver
• Clinical duration unchanged in renal/hepatic • Has active metabolites
disease (3‐deacetylvecuronium)

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Nondepolarizing NMBs NMBs in the ICU

Aminosteroidal compounds • Side effects
•Rocuronium • Prolonged muscle weakness (multifactorial)
• Intubation dose 0.6 mg/kg • Awareness
• Onset 2 min • Monitoring
• At higher doses • NMB should always be monitored
(1.2 mg/kg) faster
onset (60‐90 sec) • Peripheral nerve stimulator
• Alternative to • Train‐of‐four reliable method
succinylcholine
when • Goal 1‐2 twitches
contraindicated
• Intermediate duration of
action
• Infusion rate 10 µg/kg/min
• No significant metabolism
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• Eliminated primarily
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through liver

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 Mask Ventilation Intubation
•Does not protect the airway so only a • Direct laryngoscopy
temporizing measure
• Videolaryngoscopy
•Save more lives (and cells) by being good at
this! • Blind nasal
•Requires minimal equipment and can be • Intubating laryngeal mask airway
readily performed (LMA)
• Fiberoptic intubation
• Other
• Lightwands, combitubes, etc.

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Direct Laryngoscopy Videolaryngoscopy

•Macintosh blade
•Advantages
• Larger, curved blade yields wider • Does not require straight line of sight
view and is helpful in the following • Likely higher success rate for novices
situations:
• Everyone can share the same view
• Patients with excessive soft
tissue •Disadvantages
• Placing bulky ETT (eg, • Time to set up and intubate
double‐lumen) • Blood and debris can obstruct the lens
• Suctioning debris, blood, or • Fails in patients with altered head and neck
gastric contents while
intubating anatomy
• Does not replace fiberoptic intubation!
•Miller blade
• Smaller, straight blade yields
Data from Aziz MF, Healy D, Kheterpal S, Fu RF, Dillman D,
narrower view but has the following
Brambrink AM. Anesthesiology. 2011;114:34‐41.
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3 Critical Care Medicine • Improves view when patient 4 Critical Care Medicine
has:
• Large, floppy
epiglottis
• Decreased
thryomental
distance (ie,
anterior airway)

Blind Nasal Intubation Fiberoptic Intubation

• Should be AVOIDED in patients presenting •Advantages
with signs or a history suggesting basilar • Gold standard for the difficult airway
skull fracture • Offers the least amount of neck
movement in patients with an unstable
• Raccoon eyes or Battle sign cervical spine
•Disadvantages
• Blood and debris can obstruct the lens
• Expensive equipment
• Not readily available, takes time to
locate and set up the equipment
Battle
sign
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 Laryngeal Mask
•Helpful adjunct as temporary rescue
modality for CICV
•Does not protect the airway against
aspiration
•Problems with positive pressure ventilation
• Associated with leaks and gastric
distention at peak pressures > 20 cm
H2O
Can’t Intubate, Can’t
Ventilate
•Most common risk factors: facial trauma,
bloody airway, multiple laryngoscopy attempts,
head/neck radiation, and burns
•May attempt to place an LMA as a bridge to a
definitive airway
•No absolute contraindication to
cricothyrotomy in adult who is dying and CICV
•Cricothyrotomy is a relative contraindication
in a pediatric patient (age < 12 years)

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Why the Cricothyroid?

•Superficial location
•Absence of critical structures (thyroid, nerves,
vessels, distance from mediastinum)
•Less risk of esophageal perforation
(circumferential cricoid cartilage)
•Faster and easier to do than tracheostomy
•May have higher incidence of airway stenosis
(especially in children) compared to
tracheostomy, but this is controversial
Needle Cricothyrotomy
1.Neck extension
2.Locate cricothyroid membrane
3.Syringe half‐filled with saline attached to
large‐bore needle (14G)
4.Advance needle in caudal direction while
aspirating until bubbles appear
5.Advance catheter off needle into trachea

Data from Janet Fong. Cricothyroidotomy. 2010.

http://www.aic.cuhk.edu.hk/web8/cricothyroidotomy.htm
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Surgical Cricothyrotomy Complications

1.Neck extension • Needle
• Catheter kinking
2.Locate cricothyroid membrane • Inadequate ventilation
3.Vertical (or horizontal) skin incision • Barotrauma from air trapping
• Subcutaneous emphysema
4.Horizontal cricothyroid membrane incision
• Surgical
5.Mayo scissors or scalpel handle may be used • Bleeding
to dilate the incision
• Passage of the tube through a false tract
6.Insert something (6.0 ETT, cuffed ETT, etc.)! • Infection
• Subglottic stenosis

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 NAP4 CICV Postintubation Hypotension
Recommendations
• Loss of sympathetic drive
•Fourth National Audit Project • Myocardial infarction
• Limit number of intubation attempts (3)
• Tension pneumothorax
• If CICV and waking patient is not an
option, give paralytics • Auto‐PEEP
• Supraglottic airway device (eg, LMA)
should be attempted
• Both surgical and needle cricothyrotomy
should be taught and practiced
Data from 4th National Audit Project. Royal
College of Anaesthetists and Difficult Airway
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