Intensive Care Med (2014) 40:727–729 DOI 10.1007/s00134-014-3261-4
Jarrod M. Mosier J. Adam Law
WHAT’S NEW IN INTENSIVE CA RE
Airway management in the critically ill
Received: 18 February 2014 Accepted: 1 March 2014 Published online: 22 March 2014 Ó Springer-Verlag Berlin Heidelberg and ESICM 2014 J. M. Mosier ()) Department of Emergency Medicine, University of Arizona, Tucson, AZ, USA e-mail: [email protected] J. M. Mosier Section of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ, USA J. A. Law Department of Anesthesia, Dalhousie University, Halifax, NS, Canada J. A. Law Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
Introduction Airway management of the critically ill patient has gained interest in recent years, particularly since the publication of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society (NAP4) in the UK [1]. Several key observations that led to severe complications related to airway management emerged from this audit. Most importantly, a general underappreciation of the anticipated difficult airway was noted, as evidenced by poor airway assessment and poor planning. In the unanticipated difficult airway, there was often a failure to modify the plan, especially in the context of a failed airway.
The perils of multiple attempts at tracheal intubation The findings of the NAP4 audit come on the heels of other recent studies that are consistent in showing that repeated attempts at tracheal intubation in the critically ill population can lead to a higher incidence of airway-related adverse events [2–8]. Some of these studies indicate that as few as two attempts at tracheal intubation are associated with increased complications [7, 9], including significant hypoxemia. This underscores the importance of maximizing first attempt success with interventions that include appropriate patient positioning, use of facilitating pharmacotherapy, and the presence of appropriate equipment and expertise at the bedside.
Avoidance of peri-procedure difficulty While traditional airway assessment prior to intubation in these critically ill patients may be difficult [10, 11], appropriate planning should be part of standard airway management practice, based on predictors of difficulty with tracheal intubation, face mask ventilation, and supraglottic device or surgical airway rescue. In addition, physiologic and contextual issues must be considered in the planning process. Physiologic issues may include a known full stomach, or anticipated rapid oxygen desaturation (as with the morbidly obese patient or one with a significant intrapulmonary shunt), and contextual issues may include an emergency situation [12]. Combined with predictors of difficult airway, such factors may indicate the need for awake tracheal intubation, summoning additional expert help, alternative positioning (i.e., face-to-face) [13], or having additional equipment standing by [14]. In particular, the NAP4 report revealed that morbid obesity was frequently unrecognized as a potential difficult airway predictor. This illustrates the importance of
728
Table 1 Summary of advances in airway management of the critically ill Risk of multiple attempts
Avoidance of peri-procedural difficulty
Airway devices
Airway-related complications are Implementation of a pre-intubation ‘‘bundle’’ can Video laryngoscopy improves first attempt more severe than in the improve identification and reduction of the success rate compared to direct laryngoscopy operating room [1] difficult airway [14, 15] [26] Denitrogenation and apneic oxygenation can A combination of a pre-intubation bundle to More than one attempt is prevent or reduce desaturation during intubation assess for the predicted difficult airway and a associated with an odds of at [18] video laryngoscope can reduce difficult least one complication 3.3–7.5 intubation [26] [2] Hypoxemia is the most common In patients with severe shunt physiology where complication with an incidence rapid desaturation is likely, preoxygenation with of 19–70 % [2, 3, 7, 15] non-invasive positive pressure can improve preoxygenation [19] After the first failed attempt, an alternative ‘‘Plan B’’ approach should be chosen depending on the adequacy of face mask ventilation [12]
pre-intubation evaluation for potential difficulty [15] and appropriate planning and implementation of the plan, e.g., with proper positioning of the obese (or late third trimester) patient in the ramped and sniffing positions to improve airway visualization and ventilation [16]. Secondly, oxygenation prior to and during intubation is of paramount importance. Denitrogenation prior to the intubation attempt has been shown to be useful [17], and should be used routinely in combination with passive oxygenation using high flow oxygen through a nasal cannula during the intubation attempt to extend safe apnea time [18]. Patients with hypoxemic respiratory failure due to pneumonia or acute respiratory distress syndrome may not benefit from passive oxygenation due to significant intrapulmonary shunt. In these patients, preoxygenation with noninvasive positive pressure ventilation has been shown to be successful in improving oxygenation via alveolar recruitment [19]. Additionally, unless contraindicated, patients may have fewer procedure-related complications with the use of a neuromuscular blocker [20].
Newer airway equipment and video laryngoscopy in the critically ill
this is likely multifactorial, including difficulty with optimal patient positioning, time constraints for the intubation attempt before oxygen desaturation supervenes, and possibly issues such as failure to use adjuncts such as the tracheal tube introducer (‘bougie’) or a reluctance to optimize conditions with neuromuscular blockade. The good news is that in the critical care setting, as shown in the systematic review De Jong et al., there is evidence that compared with direct laryngoscopy, video laryngoscopy does appear to increase first attempt success and reduce the incidence of difficult intubation, Cormack–Lehane [21] grade 3 and 4 views, and esophageal intubation [22]. However, the same review indicates that severe hypoxemia and hemodynamic collapse were not reduced by the use of video laryngoscopy. This underscores the notion that while potentially helpful, video laryngoscopy is only another tool and that, as discussed earlier, close attention must still be directed to maintenance of oxygenation and perfusion during the intubation process. A second class of device that has gained traction in airway management of the critically ill patient over the last decade is the supraglottic device. While still not appropriate as a longterm or ‘definitive’ airway in this population, they can be used to maintain short-term oxygenation and ventilation following a failure to intubate while a plan is made, equipment is obtained, or additional expertise is summoned to help with translaryngeal tracheal intubation or tracheotomy. In addition, supraglottic devices can be used as a conduit for blind (through the FastrachTM laryngeal mask airway) or flexible bronchoscopic-aided intubation. In a cannot intubate, cannot ventilate situation, placement of a supraglottic device should be strongly considered concurrent with preparations for emergency cricothyroidotomy [23–25].
A significant development in the airway management of critically ill patients in the last 10 years has been the introduction of video laryngoscopy (Table 1). Historically, direct laryngoscopy has been used to facilitate tracheal intubation of most critically ill patients. Alternatives to direct laryngoscopy such as the lighted stylet, intubating laryngeal mask airway, Bullard laryngoscope, or flexible bronchoscope have been available, but were seldom used for intubation outside the operating room (OR). The introduction of video laryngoscopy has made indirect, ‘around-the corner’ Summary laryngoscopy more widely available throughout the hospital in a more user-friendly format. This is a good thing, as out- Successful first attempt intubation of the critically ill of-OR intubations can be particularly risky. The reason for patient is of extreme importance. While these patients are
729
anatomically and physiologically complicated, making intubation particularly risky, several important steps have recently been shown to improve the chances of a safe first attempt success [26]. Proper evaluation, planning, positioning, preoxygenation, and in select patients the use of a neuromuscular blocking agent have all been shown to be useful for minimizing the difficult intubation and intubation-related complications. Additionally, although there
is significant controversy regarding video laryngoscopy, the use of a video laryngoscope as the primary method of intubation has been shown in all cases to be at least as good as, and often more successful than, direct laryngoscopy. Conflicts of interest None for JMM. JAL has sold a patent to Ambu A/S.
References 1. Cook TM, Woodall N, Harper J, Benger J (2011) 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. Br J Anaesth 106(5):632–642 2. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U (2013) The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 20(1):71–78 3. Mort TC (2004) Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg 99(2):607–613 4. Hasegawa K, Shigemitsu K, Hagiwara Y et al (2012) Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med 60(6):749–754 5. Jabre P, Avenel A, Combes X et al (2011) Morbidity related to emergency endotracheal intubation—a substudy of the KETAmine SEDation trial. Resuscitation 82(5):517–522 6. Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S (2011) 3,423 emergency tracheal intubations at a university hospital: airway outcomes and complications. Anesthesiology 114(1):42–48 7. Griesdale DE, Bosma TL, Kurth T, Isac G, Chittock DR (2008) Complications of endotracheal intubation in the critically ill. Intensive Care Med 34(10):1835–1842 8. Jaber S, Amraoui J, Lefrant JY et al (2006) Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med 34(9):2355–2361
9. Sakles JC, Chiu S, Mosier J, Walker D, Stolz U (2013) The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 20:71–78 10. Bair AE, Caravelli R, Tyler K, Laurin EG (2010) Feasibility of the preoperative Mallampati airway assessment in emergency department patients. J Emerg Med 38(5):677–680 11. Levitan RM, Everett WW, Ochroch EA (2004) Limitations of difficult airway prediction in patients intubated in the emergency department. Ann Emerg Med 44(4):307–313 12. Law JA, Broemling N, Cooper RM et al (2013) The difficult airway with recommendations for management— part 2—the anticipated difficult airway. Can J Anaesth 60(11):1119–1138 13. Dhonneur G, Zraier S, Sebbah JL, Haouache H (2014) Urgent face-to-face tracheal re-intubation using VideoAirtraq in ICU patients placed in the sitting position. Intensive Care Med. doi:10.1007/s00134-014-3209-8 14. 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 Med 36(2):248–255 15. 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. Am J Respir Crit Care Med 187(8):832–839 16. Murphy C, Wong DT (2013) Airway management and oxygenation in obese patients. Can J Anaesth 60(9):929–945 17. Mort TC (2007) Complications of emergency tracheal intubation: immediate airway-related consequences: part II. J Intensive Care Med 22(4):208–215 18. Weingart SD, Levitan RM (2012) Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med 59(3):165–175 e161
19. Baillard C, Fosse JP, Sebbane M et al (2006) Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med 174(2):171–177 20. Wilcox SR, Bittner EA, Elmer J et al (2012) Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications. Crit Care Med 40(6):1808–1813 21. Cormack RS, Lehane J (1984) Difficult tracheal intubation in obstetrics. Anaesthesia 39(11):1105–1111 22. De Jong A, Molinari N, Conseil M et al (2014) Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis. Intensive Care Med. doi: 10.1007/s00134-014-3236-5 23. Henderson JJ, Popat MT, Latto IP, Pearce AC (2004) Difficult airway society guidelines for management of the unanticipated difficult intubation. Anaesthesia 59(7):675–694 24. Apfelbaum JL, Hagberg CA, Caplan RA et al (2013) Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists task force on management of the difficult airway. Anesthesiology 118(2):251–270 25. Law JA, Broemling N, Cooper RM et al (2013) The difficult airway with recommendations for management— part 1—difficult tracheal intubation encountered in an unconscious/induced patient. Can J Anaesth 60(11):1089–1118 26. De Jong A, Clavieras N, Conseil M et al (2013) Implementation of a combo videolaryngoscope for intubation in critically ill patients: a before-after comparative study. Intensive Care Med 39(12):2144–2152
Jarrod M. Mosier J. Adam Law
WHAT’S NEW IN INTENSIVE CA RE
Airway management in the critically ill
Received: 18 February 2014 Accepted: 1 March 2014 Published online: 22 March 2014 Ó Springer-Verlag Berlin Heidelberg and ESICM 2014 J. M. Mosier ()) Department of Emergency Medicine, University of Arizona, Tucson, AZ, USA e-mail: [email protected] J. M. Mosier Section of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ, USA J. A. Law Department of Anesthesia, Dalhousie University, Halifax, NS, Canada J. A. Law Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
Introduction Airway management of the critically ill patient has gained interest in recent years, particularly since the publication of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society (NAP4) in the UK [1]. Several key observations that led to severe complications related to airway management emerged from this audit. Most importantly, a general underappreciation of the anticipated difficult airway was noted, as evidenced by poor airway assessment and poor planning. In the unanticipated difficult airway, there was often a failure to modify the plan, especially in the context of a failed airway.
The perils of multiple attempts at tracheal intubation The findings of the NAP4 audit come on the heels of other recent studies that are consistent in showing that repeated attempts at tracheal intubation in the critically ill population can lead to a higher incidence of airway-related adverse events [2–8]. Some of these studies indicate that as few as two attempts at tracheal intubation are associated with increased complications [7, 9], including significant hypoxemia. This underscores the importance of maximizing first attempt success with interventions that include appropriate patient positioning, use of facilitating pharmacotherapy, and the presence of appropriate equipment and expertise at the bedside.
Avoidance of peri-procedure difficulty While traditional airway assessment prior to intubation in these critically ill patients may be difficult [10, 11], appropriate planning should be part of standard airway management practice, based on predictors of difficulty with tracheal intubation, face mask ventilation, and supraglottic device or surgical airway rescue. In addition, physiologic and contextual issues must be considered in the planning process. Physiologic issues may include a known full stomach, or anticipated rapid oxygen desaturation (as with the morbidly obese patient or one with a significant intrapulmonary shunt), and contextual issues may include an emergency situation [12]. Combined with predictors of difficult airway, such factors may indicate the need for awake tracheal intubation, summoning additional expert help, alternative positioning (i.e., face-to-face) [13], or having additional equipment standing by [14]. In particular, the NAP4 report revealed that morbid obesity was frequently unrecognized as a potential difficult airway predictor. This illustrates the importance of
728
Table 1 Summary of advances in airway management of the critically ill Risk of multiple attempts
Avoidance of peri-procedural difficulty
Airway devices
Airway-related complications are Implementation of a pre-intubation ‘‘bundle’’ can Video laryngoscopy improves first attempt more severe than in the improve identification and reduction of the success rate compared to direct laryngoscopy operating room [1] difficult airway [14, 15] [26] Denitrogenation and apneic oxygenation can A combination of a pre-intubation bundle to More than one attempt is prevent or reduce desaturation during intubation assess for the predicted difficult airway and a associated with an odds of at [18] video laryngoscope can reduce difficult least one complication 3.3–7.5 intubation [26] [2] Hypoxemia is the most common In patients with severe shunt physiology where complication with an incidence rapid desaturation is likely, preoxygenation with of 19–70 % [2, 3, 7, 15] non-invasive positive pressure can improve preoxygenation [19] After the first failed attempt, an alternative ‘‘Plan B’’ approach should be chosen depending on the adequacy of face mask ventilation [12]
pre-intubation evaluation for potential difficulty [15] and appropriate planning and implementation of the plan, e.g., with proper positioning of the obese (or late third trimester) patient in the ramped and sniffing positions to improve airway visualization and ventilation [16]. Secondly, oxygenation prior to and during intubation is of paramount importance. Denitrogenation prior to the intubation attempt has been shown to be useful [17], and should be used routinely in combination with passive oxygenation using high flow oxygen through a nasal cannula during the intubation attempt to extend safe apnea time [18]. Patients with hypoxemic respiratory failure due to pneumonia or acute respiratory distress syndrome may not benefit from passive oxygenation due to significant intrapulmonary shunt. In these patients, preoxygenation with noninvasive positive pressure ventilation has been shown to be successful in improving oxygenation via alveolar recruitment [19]. Additionally, unless contraindicated, patients may have fewer procedure-related complications with the use of a neuromuscular blocker [20].
Newer airway equipment and video laryngoscopy in the critically ill
this is likely multifactorial, including difficulty with optimal patient positioning, time constraints for the intubation attempt before oxygen desaturation supervenes, and possibly issues such as failure to use adjuncts such as the tracheal tube introducer (‘bougie’) or a reluctance to optimize conditions with neuromuscular blockade. The good news is that in the critical care setting, as shown in the systematic review De Jong et al., there is evidence that compared with direct laryngoscopy, video laryngoscopy does appear to increase first attempt success and reduce the incidence of difficult intubation, Cormack–Lehane [21] grade 3 and 4 views, and esophageal intubation [22]. However, the same review indicates that severe hypoxemia and hemodynamic collapse were not reduced by the use of video laryngoscopy. This underscores the notion that while potentially helpful, video laryngoscopy is only another tool and that, as discussed earlier, close attention must still be directed to maintenance of oxygenation and perfusion during the intubation process. A second class of device that has gained traction in airway management of the critically ill patient over the last decade is the supraglottic device. While still not appropriate as a longterm or ‘definitive’ airway in this population, they can be used to maintain short-term oxygenation and ventilation following a failure to intubate while a plan is made, equipment is obtained, or additional expertise is summoned to help with translaryngeal tracheal intubation or tracheotomy. In addition, supraglottic devices can be used as a conduit for blind (through the FastrachTM laryngeal mask airway) or flexible bronchoscopic-aided intubation. In a cannot intubate, cannot ventilate situation, placement of a supraglottic device should be strongly considered concurrent with preparations for emergency cricothyroidotomy [23–25].
A significant development in the airway management of critically ill patients in the last 10 years has been the introduction of video laryngoscopy (Table 1). Historically, direct laryngoscopy has been used to facilitate tracheal intubation of most critically ill patients. Alternatives to direct laryngoscopy such as the lighted stylet, intubating laryngeal mask airway, Bullard laryngoscope, or flexible bronchoscope have been available, but were seldom used for intubation outside the operating room (OR). The introduction of video laryngoscopy has made indirect, ‘around-the corner’ Summary laryngoscopy more widely available throughout the hospital in a more user-friendly format. This is a good thing, as out- Successful first attempt intubation of the critically ill of-OR intubations can be particularly risky. The reason for patient is of extreme importance. While these patients are
729
anatomically and physiologically complicated, making intubation particularly risky, several important steps have recently been shown to improve the chances of a safe first attempt success [26]. Proper evaluation, planning, positioning, preoxygenation, and in select patients the use of a neuromuscular blocking agent have all been shown to be useful for minimizing the difficult intubation and intubation-related complications. Additionally, although there
is significant controversy regarding video laryngoscopy, the use of a video laryngoscope as the primary method of intubation has been shown in all cases to be at least as good as, and often more successful than, direct laryngoscopy. Conflicts of interest None for JMM. JAL has sold a patent to Ambu A/S.
References 1. Cook TM, Woodall N, Harper J, Benger J (2011) 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. Br J Anaesth 106(5):632–642 2. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U (2013) The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 20(1):71–78 3. Mort TC (2004) Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg 99(2):607–613 4. Hasegawa K, Shigemitsu K, Hagiwara Y et al (2012) Association between repeated intubation attempts and adverse events in emergency departments: an analysis of a multicenter prospective observational study. Ann Emerg Med 60(6):749–754 5. Jabre P, Avenel A, Combes X et al (2011) Morbidity related to emergency endotracheal intubation—a substudy of the KETAmine SEDation trial. Resuscitation 82(5):517–522 6. Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S (2011) 3,423 emergency tracheal intubations at a university hospital: airway outcomes and complications. Anesthesiology 114(1):42–48 7. Griesdale DE, Bosma TL, Kurth T, Isac G, Chittock DR (2008) Complications of endotracheal intubation in the critically ill. Intensive Care Med 34(10):1835–1842 8. Jaber S, Amraoui J, Lefrant JY et al (2006) Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med 34(9):2355–2361
9. Sakles JC, Chiu S, Mosier J, Walker D, Stolz U (2013) The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 20:71–78 10. Bair AE, Caravelli R, Tyler K, Laurin EG (2010) Feasibility of the preoperative Mallampati airway assessment in emergency department patients. J Emerg Med 38(5):677–680 11. Levitan RM, Everett WW, Ochroch EA (2004) Limitations of difficult airway prediction in patients intubated in the emergency department. Ann Emerg Med 44(4):307–313 12. Law JA, Broemling N, Cooper RM et al (2013) The difficult airway with recommendations for management— part 2—the anticipated difficult airway. Can J Anaesth 60(11):1119–1138 13. Dhonneur G, Zraier S, Sebbah JL, Haouache H (2014) Urgent face-to-face tracheal re-intubation using VideoAirtraq in ICU patients placed in the sitting position. Intensive Care Med. doi:10.1007/s00134-014-3209-8 14. 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 Med 36(2):248–255 15. 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. Am J Respir Crit Care Med 187(8):832–839 16. Murphy C, Wong DT (2013) Airway management and oxygenation in obese patients. Can J Anaesth 60(9):929–945 17. Mort TC (2007) Complications of emergency tracheal intubation: immediate airway-related consequences: part II. J Intensive Care Med 22(4):208–215 18. Weingart SD, Levitan RM (2012) Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med 59(3):165–175 e161
19. Baillard C, Fosse JP, Sebbane M et al (2006) Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med 174(2):171–177 20. Wilcox SR, Bittner EA, Elmer J et al (2012) Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications. Crit Care Med 40(6):1808–1813 21. Cormack RS, Lehane J (1984) Difficult tracheal intubation in obstetrics. Anaesthesia 39(11):1105–1111 22. De Jong A, Molinari N, Conseil M et al (2014) Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis. Intensive Care Med. doi: 10.1007/s00134-014-3236-5 23. Henderson JJ, Popat MT, Latto IP, Pearce AC (2004) Difficult airway society guidelines for management of the unanticipated difficult intubation. Anaesthesia 59(7):675–694 24. Apfelbaum JL, Hagberg CA, Caplan RA et al (2013) Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists task force on management of the difficult airway. Anesthesiology 118(2):251–270 25. Law JA, Broemling N, Cooper RM et al (2013) The difficult airway with recommendations for management— part 1—difficult tracheal intubation encountered in an unconscious/induced patient. Can J Anaesth 60(11):1089–1118 26. De Jong A, Clavieras N, Conseil M et al (2013) Implementation of a combo videolaryngoscope for intubation in critically ill patients: a before-after comparative study. Intensive Care Med 39(12):2144–2152
