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
Introduction

• Difficult 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
Outline
• Difficult airway in routine anaesthesia
‒ Definitions
‒ Difficult airway algorithm

• Difficult airway in ICU

‒ Differences in ICU setting
‒ Predictors
‒ Managing the difficult airway
• Anticipated
• Unanticipated
• Cannot intubate, cannot ventilate
‒ Extubation
‒ Solutions

• Summary
Difficult airway in routine anesthesia
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
• 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
American Society of Anesthesiologists: Practice guidelines for management of the difficult airway: An updated report. Anesthesiology
2013
Difficult airway in ICU
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
‒ 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
• 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
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

Predictors of difficult airway

The difficult airway in adult critical care.

Lavery G G, McCloskey B V. Crit Care
Med 2008
The airway: emergent management for non anesthesiologists. Fowler RA, Pearl RG. West
J Med. 2002
Mallampati
classification

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

“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
Managing the difficult airway

1. Anticipated
‒ Least lethal scenario
‒ Time to plan strategy and assess patient

2. Unanticipated
‒ Commonly encountered in ICUs
‒ Time available short

3. Cannot intubate, cannot ventilate

‒ Absolute emergency
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
1. Orotracheal intubation under anesthesia
‒ Standard method

2. Awake intubation

a) Fibreoptic scope intubation

b) Retrograde intubation
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
1. Bimanual laryngoscopy

2. 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

3. Gum elastic bougie

‒ Blunt-ended, malleable rod

‒ J shaped bend introduced at the tip

‒ Introduced blindly through the larynx and ETT railroaded over it

4. Laryngoscope blades
‒ Macintosh

‒ Miller

‒ McCoy

5. Lighted Stylet
‒ Malleable fiberoptic Light source

‒ Introduced into trachea

‒ ETT railroaded over A–C, Mackintosh Blades (sizes 4, 3, and

2). D, Miller blade; E, McCoy blade (tip
‒ Position confirmed by Visibility of light thorough in “elevated” position).

Neck soft tissues

‒ Can be combined with LMA

The airway: emergent management for non anesthesiologists.

Fowler RA, Pearl RG. West J Med. 2002
6. Fibreoptic intubation
‒ Bronchoscope

‒ Fibreoptic laryngoscope

‒ Video laryngoscope

7. Supraglottic airway devices

‒ Laryngeal mask airway
(LMA)
‒ Combitube (Esophageal-
Tracheal Double-Lumen
Airway)
• LMA

‒ Allows limited positive pressure

ventilation

‒ Can be placed by inexperienced operators

‒ Risk of aspiration

‒ Inadequate seal
Cannot intubate, cannot ventilate
• Absolute emergency

• Options

1. Review and see if intubating conditions can be improved

2. Use a supraglottic airway

3. Perform a cricothyroidotomy/ tracheostomy

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

Complex airway diseases. Patel et al. In Textbook of pulmonary and

critical care medicine. Jindal SK (ed.). 2011
Extubation
• Planned extubation  anticipated difficult airway
‒ Airway exchange catheters

• Unplanned/accidental
‒ Possible life threatening emergency

‒ Urgent recognition and redressal

Solutions
1. Proper training

2. Adequate equipment availability

3. Use of intubation bundles

4. Have emergency backup plans in place

Summary
1. Airway management in critical care situations differs from
routine operating room conditions

2. Training and availability of equipment essential

3. Anticipation of problems and pre-planning required

4. Necessary to keep a calm head, call for help and work as a team
THANK YOU