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Endotracheal Intubation in the ICU David Oxman, MD July 12, 2013

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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.

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Objectives Discuss obtaining intubating conditions induction paralytics Discuss Direct Laryngoscopy and tube placement Post-intubation care Overview Rescue Devices

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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

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Who should intubate in the ICU? Chest, December 2012

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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.

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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

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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

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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.

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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

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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

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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

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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

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Assessing the Airway: Identification Difficult Intubation LEMON L ook E valuate 3-3-2 M allampati O bstruction/Obesity N eck mobility

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Assessment for Difficult Intubation Look External Facial trauma Unusual anatomy Internal Foreign body Obstructing mass Sensitive but not specific

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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

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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).

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Assessment for Difficult Intubation: Obesity Redundant tissue in upper airway may obscure glottis. Controversial about how often difficult airway. Proper positioning key.

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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

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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)

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Steps for Endotracheal Intubation 1.The 4Ps: Preparation Pre-oxygenation Positioning Premedication 2.Achieving Intubating Conditions: Laryngoscopy/Intubation 3.Post-intubation Care

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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

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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)

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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

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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.

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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)

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Preparation: Head Positioning Supine Head Elevated Head Elevated and Neck Extending = Sniffing Position

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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

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Preparation: The Need for a Plan Main Airway Algorithm

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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.

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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.

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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

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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

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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

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Laryngoscopes Macintosh Blade Miller Blade

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Laryngoscopy Technique

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Direct Laryngoscopy Opening Mouth and Inserting Blade Opening Mouth with Scissors Technique

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Inserting Laryngoscope Macintosh Blade in Vallecula Miller Blade Under Epiglottis

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Laryngoscopy is a predictable sequence of progressively visualized structures

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Epiglottoscopy Blade inserted with laryngoscope handle pointed at the patients feet. Tongue and jaw are distracted downward to insert the blade. Minimal force required Tip of blade gets around base of tongue, permitting change in angle of lifting and better mechanical advantage. Epiglottis edge lifted off pharyngeal wall. (Epiglottis often camouflaged against mucosa of posterior pharynx). With full insertion of curved blade into vallecula the angle of lifting changes to ~40 degrees from the horizontal. Now the lifting force can be increased as needed. Tip position (not force) is the main determinant of glottic exposure.

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Lifting the Scope Yes No

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Laryngoscopy: Optimizing Glottic View Cormack-Lehane Scoring of Glottic View

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Cricoid Pressure Sellick maneuver or BURP Avoid regurgutation of gastric contents Imaging studies undermine theory May worsen glottic view

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Optimizing Glottic View: Bimanual Laryngoscopy 1) Drives tip of blade into proper position optimizing mechanics of indirect epiglottis elevation. 2) Moves larynx downward into line of sight.

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Inserting Endotracheal Tube Yes, good No, bad

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Inserting Endotracheal Tube

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Proof of Placement Unrecognized esophageal intubation devastating. Clinical indicators alone cannot be relied upon. Capnography gold standard. Beware Esophageal intubation may give transient color change. Need >5 breaths. Cardiac arrest patients can give false negative color change. (Other methods = syringe test)

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Rescue Strategies Return to spontaneous breathing Videolaryngoscopy Extraglottic devices Bougie Cricothyroidotomy (open vs. percutaneous) A

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Parting Thoughts Airway Management/Intubation in intensivists domain of practice. Getting competent requires dedication Procedures for intubation at Jeff Never without attending Anesthesia supervision if not available