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Chapter 28 - Airway Management in the Critically Ill

from Section 2 - Airway Management: Clinical Settings and Subspecialties

Published online by Cambridge University Press:  03 October 2020

Tim Cook
Affiliation:
Royal United Hospital, Bath, UK
Michael Seltz Kristensen
Affiliation:
Rigshospitalet, Copenhagen University Hospital, Denmark
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Summary

Many studies from around the world, especially NAP4 in the UK, have demonstrated that airway management in critically ill patients, whether in the intensive care unit, emergency department or general wards, is fraught with danger. Serious morbidity or mortality may be 50-fold more common than in anaesthetic practice. This chapter describes the essential features of airway management specific to critical care intubation. The importance of an intubation bundle approach is emphasised, such as the UK’s Difficult Airway Society guidelines for tracheal intubation in the critically ill adult. Components include: (i) deliberate and thoughtful application of human factors science to optimise team performance and sharing the airway plan; (ii) assessment of potential difficulty based on the MACOCHA scoring system; (iii) pre-oxygenation using continuous positive airway pressure (CPAP) or non-invasive ventilation, high flow nasal oxygen, or a combination of these; (iv) a modified rapid sequence induction with continuous peroxygenation; (v) optimising laryngoscopy and intubation with early videolaryngoscopy by a trained operator; (vi) airway rescue with an amalgamated Plan B/C, borrowing from the Vortex approach; (vii) use of second generation supraglottic airways (SGAs); (viii) priming for front of neck airway (FONA) and (ix) a scalpel-bougie-tube cricothyroidotomy when managing cannot intubate, cannot oxygenate (CICO).

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Publisher: Cambridge University Press
Print publication year: 2020

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References

Further Reading

Baillard, C, Fosse, JP, Sebbane, M, et al. (2006). Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. American Journal of Respiratory and Critical Care Medicine, 174, 171177.CrossRefGoogle ScholarPubMed
Chrimes, N. (2016). The Vortex: a universal ‘high-acuity implementation tool’ for emergency airway management. British Journal of Anaesthesia, 117(Suppl 1), i20i27.CrossRefGoogle ScholarPubMed
Cook, TM, Woodall, N, Harper, J, Benger, J. (2011). Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. British Journal of Anaesthesia, 106, 632642.CrossRefGoogle Scholar
De Jong, A, Molinari, N, Pouzeratte, Y, et al. (2015). Difficult intubation in obese patients: incidence, risk factors, and complications in the operating theatre and in intensive care units. British Journal of Anaesthesia, 114, 297306.CrossRefGoogle ScholarPubMed
De Jong, A, Molinari, N, Terzi, N, et al. (2013). Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study. American Journal of Respiratory and Critical Care Medicine, 187, 832839.CrossRefGoogle Scholar
Higgs, A. (2018). Airway management in intensive care medicine. In: Hagberg, CA, Artime, CA, Aziz, MF (Eds.), Hagberg and Benumof’s Airway Management. 4th ed. Philadelphia: Elsevier. pp. 754780.Google Scholar
Higgs, A, McGrath, B, Goddard, C, et al.; Difficult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. (2018). Guidelines for the management of tracheal intubation in the critically ill adult. British Journal of Anaesthesia, 120, 323352.CrossRefGoogle Scholar
Jaber, S, Jung, B, Corne, P, et al. (2010). An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Medicine, 36, 248255.CrossRefGoogle ScholarPubMed
Lascarrou, J. B., Boisrame-Helms, J, Bailly, A, et al. (2017). Video laryngoscopy vs direct laryngoscopy on successful first-pass orotracheal intubation among ICU patients: a randomized clinical trial. JAMA, 317, 483493.CrossRefGoogle ScholarPubMed
Mosier, JM, Hypes, CD, Sakles, JC. (2017). Understanding preoxygenation and apneic oxygenation during intubation in the critically ill. Intensive Care Medicine, 43, 226228.CrossRefGoogle ScholarPubMed

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