endotracheal intubation in the icu david oxman, md july 12, 2013

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  • Slide 1
  • Endotracheal Intubation in the ICU David Oxman, MD July 12, 2013
  • Slide 2
  • Objectives Discuss Airway Assessment Assessing for difficult bag mask ventilation Assessing for difficult intubation Specific conditions of critically-ill. Discuss 4 Ps of Pre-intubation: Preparation Pre-oxygenation Positioning Planning.
  • Slide 3
  • Objectives Discuss obtaining intubating conditions induction paralytics Discuss Direct Laryngoscopy and tube placement Post-intubation care Overview Rescue Devices
  • Slide 4
  • Why Intubate Indications for endotracheal intubation 1.inadequate oxygenation or ventilation 2.airway protection in a patient with altered mental status 3.expectation 1 or 2 will develop soon!! Contraindications 1.Laryngeal Trauma 2.Obstructed Airway
  • Slide 5
  • Who should intubate in the ICU? Chest, December 2012
  • Slide 6
  • Why Intensivists Should Intubate Its the A in ABC. Competent to perform vast majority of intubations. Will be expected in many settings. Complications mostly not related to airway itself.
  • Slide 7
  • Airway Assessment Can be more challenging in critically ill. Must avoid the cannot intubate, cannot ventilate scenario. Must assess 1)Risk for difficult mask ventilation 2)Risk for difficult intubation
  • Slide 8
  • Bag Mask Ventilation Crucial airway management skill. Takes practice to perform correctly. Gives time for well-planned approach to definitive airway management. 3 keys: Patent airway Good mask seal Proper ventilation
  • Slide 9
  • Bag Mask Ventilation: Opening Airway Head Tilt and Chin Lift Jaw Thrust One hand applies downward pressure to forehead and index and middle finger of the second hand lift at chin. Lifts tongue from posterior pharynx For unstable cervical spine Place heels of hands on parieto-occipital area Grasp angles of mandible with fingers, and displace jaw anteriorly.
  • Slide 10
  • Adjuncts for Opening Airway Need to size properly Avoid pushing tongue into posterior pharynx. Start with curve of OPA inverted and rotate 180 degrees as tip reaches posterior pharynx. Avoid in awake patient aspiration risk
  • Slide 11
  • Bag Mask Ventilation One-handed technique Two-handed techniques Three facial landmarks that must be covered by mask: 1.Bridge of the nose 2.Two malar eminences 3.Mandibular alveolar ridge Small tidal volumes Squeeze steadily dont force air too quickly 10-12 breaths/minute Assess for rise and of fall chest
  • Slide 12
  • Airway Assessment: Difficult Bag Mask Ventilation Incidence approx 5% MOANS M ask seal: cant approximate mask O besity: redundant tissues impede airflow A ge >55: loss of elasticity tissues N o teeth: mask doesnt sit properly S tiff (lungs/body): need increased pressure
  • Slide 13
  • Airway Assessment: Identification Difficult Intubation Incidence difficult intubation varies. No clear definition. Approximately 5% Corresponds to glottic view Cant intubate/cant ventilate = 1 in 10,000 Strongly associated with adverse outcomes Airway trauma Aspiration Hypoxemia/Anoxic brain injury Hypotension Cardiac arrest and death
  • Slide 14
  • Assessing the Airway: Identification Difficult Intubation LEMON L ook E valuate 3-3-2 M allampati O bstruction/Obesity N eck mobility
  • Slide 15
  • Assessment for Difficult Intubation Look External Facial trauma Unusual anatomy Internal Foreign body Obstructing mass Sensitive but not specific
  • Slide 16
  • Assessment for Difficult Intubation: Evaluate: 3-3-2 Rule Mouth opening Tip of mentum to hyoid bone Thyromental distance Access to airway and obtaining glottic view Can tongue be deflected to accomdate laryngoscope Predicts location larynx to base of the tongue. If larynx high angles difficult
  • Slide 17
  • Assessment for Difficult Intubation: Mallampati Score Validated but not as solitary predictor. Relates amount of mouth opening to size of tongue. Provides estimate of space for oral intubation by direct laryngoscopy. Class I or II : easy laryngoscopy Class III difficult Class IV: extreme difficulty. (10%failure).
  • Slide 18
  • Assessment for Difficult Intubation: Obesity Redundant tissue in upper airway may obscure glottis. Controversial about how often difficult airway. Proper positioning key.
  • Slide 19
  • Assessment for Difficult Intubation: Neck Mobility Decreased cervical spine mobility compromises sniffing position. Impairs alignment of axises and glottic view Degenerative or rheumatoid arththritis Cervical immobilzation Test: extending neck/touching chest
  • Slide 20
  • Additional Considerations in Critically Ill Complications intubation higher than ICU (20- 40%.) Limited physiologic reserve Pre-existing hypoxemia or hemodynamic instability. Inability to properly assess airway. Special Considerations in ICI: Three Hs: Hypoxemia H+ Hemodynamics (hypotension/pulmonary hypertension)
  • Slide 21
  • Steps for Endotracheal Intubation 1.The 4Ps: Preparation Pre-oxygenation Positioning Premedication 2.Achieving Intubating Conditions: Laryngoscopy/Intubation 3.Post-intubation Care
  • Slide 22
  • Preparation Airway assessment Signs of difficult bag mask ventilation Signs of difficult intubation Assembling necessary equipment and medications. Developing an airway management plan Back-up plan Back-up to back-up plan
  • Slide 23
  • Preparation Equipment S uction T ools (laryngoscope, blade, extra batteries) O xygen P ostioning/plan M onitors (pulse ox, BP, capnography) A mbu bag, airway devices I ntravenous access D rugs (premeds, induction, NMB)
  • Slide 24
  • Preparation: Preoxygenation Establishment of oxygen reservoir Replace nitrogenous mixture of room air FRC = 30ml/kg Preferable time = 5 minutes Bag mask ventilation not needed if good preoxygenation. Preoxygenation often challenging in ICU NIPPV Elevating head of bed
  • Slide 25
  • Preoxygenation: Apnea Time (V E = 0) -Time from 90% to 0% MUCH shorter than time from 100% to 90%. -Obese and critically- ill desaturate quicker.
  • Slide 26
  • Preparation: Pretreatment Drugs to mitigate adverse effects of intubation L idocaine (reactive airways or elevated ICP) O pioids ( blunts sympathetic response and increased BP) A tropine ( bradycardia mainly kids) D efasiculating Agents (low dose competitive neuromuscular blocker in elevated ICP)
  • Slide 27
  • Preparation: Head Positioning Supine Head Elevated Head Elevated and Neck Extending = Sniffing Position
  • Slide 28
  • Positioning: RAMP In supine patient access to airway obstructed. With patient propped in RAMP position, access to airway improved. Imaginary horizontal line from external auditory meatus to the sternal notch
  • Slide 29
  • Preparation: The Need for a Plan Main Airway Algorithm
  • Slide 30
  • Achieving Intubation Conditions Many ICU patients need very little or no drugs. Crash airway Patient relaxed and unresponsive, similar to conditions with rapid sequence intubation (RSI). May not want to stop spontaneous breathing.
  • Slide 31
  • Induction Agents Purpose: Blunt sympathetic responses, provide amnesia and improve intubating conditions. Rapid Sequence Intubation: simultaneous administration of sedative and a neuromuscular blocking. ICU patients with crash airway or pseudo-crash airway often need very little induction drug or none at all.
  • Slide 32
  • Induction Agents Midazolam: (dosage 0.1-0.3 mg/kg; time to effect >15 minutes; hypotension) Etomidate: (rapid onset; no hypotension; no analgesia; concerns with sepsis unjustified) Propofol: 1.5 to 3 mg/kg; rapid onset; hypotension; no analgesia. Ketamine: sedation and analgesia; no hypotension; bronchodilator effect; respiratory drive preserved; good for awake look. Thiopental: rapid onset; no analgesia; myocardial depressant; severe hypotension
  • Slide 33
  • Neuromuscular Blockade Rapid Sequence Intubation Goal: quickly obtain intubating conditions and quickly secure airway. Avoid BMV and minimize risk of aspiration. NMB standard of care in ED
  • Slide 34
  • Neuromuscular Blockade Succinylcholine Onset 45-60 seconds; duration 6-10 minutes 1-1.5 mg/kg Contraindications: hx of malignant hyperthermia, neuromuscular disease with denervation (MD, stroke > 72 hours, burns >72 hours) rhabdomyolysis, hyperkalemia. Non-depolarizing neuromuscular blockers Rocuronium 0.8 -1.2mg/kg: fast onset, longer duration than succinylocholine; can be reversed Cisatricurium (Nimbex): not for RSI as slow onset Vercuronium
  • Slide 35
  • Laryngoscopes Macintosh Blade Miller Blade
  • Slide 36
  • Laryngoscopy Technique
  • Slide 37
  • Direct Laryngoscopy Opening Mouth and Inserting Blade Opening Mouth with Scissors Technique
  • Slide 38
  • Inserting Laryngoscope Macintosh Blade in Vallecula Miller Blade Under Epiglottis
  • Slide 39
  • Laryngoscopy is a predictable sequence of progressively visualized structures
  • Slide 40
  • Epiglottoscopy Bla

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