Airway Management in the Critically Ill

1. Airway Management in the Critically Ill Dr. CHAN King-chung June 7, 2006

2. Learning Airway Management

3. Case Scenario • M/65 • Admitted for COAD exacerbation • Put on BiPAP • Found to be unresponsive • SpO2 = 87%. BP = 160/90. HR = 120 • What would you do ?

4. Indication for Airway • Obstruction • Assisted Ventilation • Aspiration • Secretion Clearance

5. Airway Obstruction

6. Head tile, Chin lift Jaw thrust Opening Airway

7. Oropharyngeal Airway

8. Insertion of Oral Airway

9. Nasopharyngeal Airway

10. Mask Ventilation 1-Person: difficult, less effective 2-Person:easier, more effective

11. Difficult Mask Ventilation • Leak around the mask • No clear chest expansion during ventilation • Ventilation possible only with 2-person

12. Prediction (MOANS) • Mask seal • Beard, facial injury • Obese / Obstruction • BMI >26 • Age • >55 years • No teeth • Stiff lung

13. Complications • Gastric distension • Aspiration • Pressure injury to eyes, nose or lips • Facial nerve palsy

14. Bag-Mask Ventilation

15. Rapid Sequence Intubation • Virtually simultaneous administration, after preoxygenation, of a potent sedative agent and a rapidly acting neuromuscular blocking agent to facilitate rapid tracheal intubation without interposed mechanical ventilation

16. Why RSI ? • Minimize risk of aspiration • Optimal intubating condition • High success rate

17. Success Rate

18. 7 Ps • Preparation • Preoxygenation • Pretreatment • Paralysis with induction (Time Zero) • Protection and positioning • Placement with proof • Postintubation management

19. 7 Ps • Preparation (Time -10mins) • Preoxygenation • Pretreatment • Paralysis with induction (Time Zero) • Protection and positioning • Placement with proof • Postintubation management

20. Preparation (T -10mins) • Assess for possible difficult airway • Assemble equipments and prepare drugs • Attach monitors • Establish IV access

21. Preparation (T -10mins) • Assess for possible difficult airway • Assemble equipments and prepare drugs • Attach monitors • Establish IV access

22. Difficult Intubation • Intubationist with >2 years of experience • More than 3 attempts • Intubation time >10 minutes

23. Chances of Difficult Airway

24. Assessment of Airway • The LEMON rule • Look externally • Evaluate 3-3-2 • Mallampati score • Obstruction • Neck Mobility

25. Look Externally • Receding mandible (Micrognathia) • Large tongue (Macroglossia) • Protruding teeth • Short neck • Obese • Head & neck injury

26. Look Externally

27. Evaluate 3-3-2 • Mouth opening • Accommodate 3 fingers • Hyoid-Mental distance • 3 fingers • Thyrohyoid distance • 2 fingers • (Thyromental distance >6 cm)

28. Mallampati Score

29. Assess this Lion

30. Obstruction • Foreign body • Upper airway tumour • Epiglottitis • Peritonsillar abscess • Neck infection • Goitre • Haematoma

31. Neck Mobility • Necessary for a good laryngoscopy view • Sternomental distance <12.5cm (normal 15cm)

32. Preparation (T= -10mins) • Assess for possible difficult airway • Assemble equipments and prepare drugs • Attach monitors • Establish IV access

33. Airway Oral / Nasl Airway Oxygen & Ventilation Oxygen Source Mask (Various Size) Manual Resuscitator Endotracheal Tube 7-9mm ETT Malleable Stylet / Bougie Syringe K-Y Jelly Fixation Adhesive Tape Laryngoscopy Laryngoscope Blade (Size 3 first) Suction Small Pillow Magill Forceps Drugs Sedative Muscle Relaxant Confirmation Stethoscope End-tidal CO2 Oesophageal Detector Equipments for Intubation

34. Hockey Stick To manoeuvre within oral cavity Expect some resistance in removing stylet Lubricate stylet Shape of ETT

35. McCoy Laryngoscope

36. Etomidate 0.2mg/kg More CV stable Adrenal suppression Midazolam 0.1mg/kg Convenient Infusion for sedation Less clear end point of induction Propofol 0.5mg/kg More hypotension Thiopentone 1.5mg/kg Standard for neurosurgical patient Ketamine 1mg/kg Increase BP Sedation for Intubation

37. Suxamethonium 1.5mg/kg 30-45s to full action Last 10 mins Fasciculation Increase K Hyper K to start with Burn >24hrs Spinal injury >24hrs Increase ICP Rocuronium 1mg/kg 60s to full action Last 1 hour No fasciculation Muscle Relaxant

38. 7 Ps • Preparation (Time -10mins) • Preoxygenation (Time -5mins) • Pretreatment • Paralysis with induction (Time Zero) • Protection and positioning • Placement with proof • Postintubation management

39. Preoxygenation (T= -5mins) • 100% oxygen for 5 minutes • 8 vital capacity breath • (Not 100% on SpO2) • Provide store of oxygen during intubation

40. Time to Desaturation

41. Lignocaine 1.5mg/kg Raised ICP Bronchospasm Opioid Fentanyl 1-3ug/kg Raised ICP Coronary heart disease Atropine 0.01mg/kg Age < 10years Defasciculation 10% paralysis dose Rocuronium 0.06mg/kg Raised ICP Pretreatment (T= -3mins)

42. Paralysis with Induction (T= 0s) • Ascertain everyone is ready • Sedative → Relaxant → NS flush • As quickly as possible • Don’t flush between sedative & relaxant

43. Protection & Positioning (T= +30s) • Cricoid Pressure • Position patient • Do not bag unless SpO2<90 • Increase risk of aspiration

44. Cricoid Pressure • Cricoid: cartilage with a complete ring • Also called Sellick’s Manoeuvre • Firm pressure to prevent regurgitation

45. Release ONLY after ET placement confirmed BURP Caution in patient with cervical spine injury May support the back of the neck with another hand Cricoid Pressure

46. Positioning • Sniffing position • Head Extended, Neck Flexed

47. No C-spine injury In-line immobilization Suspected C-spine injury Positioning

48. Check mandible for flaccidity Insert Laryngoscope Intubate, remove stylet May use Bougie instead Confirm placement Release Cricoid Pressure Placement with Proof (T +45s)

49. Laryngoscopy Grading

50. Non-fail-save signs Breath sound in chest No breath sound over stomach Chest rise and fall Moisture condensation on tube in expiration ‘Normal’ compliance on bagging CXR Hearing air exit from tube on chest compression Feeling of cartilage with Bougie Resistance upon passing Bougie / Suction catheter Signs of Successful Intubation