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Airway Management

in the Emergency Department

and ICU
Mehdi Khosravi, MD Pulmonary/CCM Fellow
Giuditta Angelini, MD Assistant Professor
Jonathan T. Ketzler, MD Associate Professor
Douglas B. Coursin, MD Professor
Departments of Anesthesiology & Medicine
University of Wisconsin, Madison
Global Assessment

Assess underlying need for airway control

• Duration of intubation
- Nasal intubation less advantageous for potentially prolonged ventilator
• Permanent support
- Underlying advanced intrinsic lung or neuromuscular disease
• Temporary support
• Anesthesia
• Presence of reversible intrinsic lung or neuromuscular disease
• Protection of the airway due to depressed mental status
• Presence of reversible upper airway pathology
• Patient care needs (e.g., transport, CT scan, etc.)
• Significant comorbidities
 Aspiration potential or increased respiratory secretions
 Hemodynamic issues such as cardiac disease or sepsis
 Renal or liver failure
Global Assessment
Pathophysiology of the respiratory failure
• Hypoxic respiratory failure
- In case of hypoxic respiratory failure, different noninvasive oxygen delivery
devices can be used.
- The severity of hypoxia and presence or absence of underlying disease (such
as COPD) will dictate the device of choice.
• Hypercapnic respiratory failure
- The noninvasive device of choice for hypercapnic respiratory failure is BIPAP.

Assessment of above mentioned patient characteristics in

conjunction with the mechanism of respiratory distress
leads the clinician to proper choice and duration of
invasive or noninvasive options for airway management.
Code status should be clarified prior to proceeding.
Global Assessment
• Respiratory rate and use of accessory muscles
- Is the patient in respiratory distress?
• Amount of supplemental oxygen
- What is the patient’s oxygen demand?
• Pulse oximeter or arterial blood gas
- Is the patient physiologically capable of providing appropriate supply?

• Anatomy
- Will this patient be difficult to intubate?
• Patency
- Is there a reversible anatomical cause of respiratory failure as opposed to
intrinsic lung dysfunction?
• Airway device in place
- Is there a nasopharyngeal airway or combitube in place?
Oxygen Delivery Devices
(In order of degree of support)

Nasal Cannula
• 4% increase in FiO2 for each 1 L of flow (e.g., 4 L flow = 37% or 6 L flow
= 45%)

• Face tent
• At most delivers 40% at 10-15 L flow

• Small amount of rebreathing
• 8 L flow = 40%, 15 L flow = 60%

Nonrebreather mask
• Attached reservoir bag allows 100% oxygen to enter mask with
inlet/outlet ports to allow exhalation to escape - does not guarantee
100% delivery.
Oxygen Delivery Devices
Noninvasive Positive Pressure
CPAP is a continuous positive pressure
• Indicated in hypoxic respiratory failure and obstructive sleep apnea

BiPAP allows for an inspiratory and expiratory pressure to support and improve
spontaneous ventilation
• Mainly indicated in hypercapnic respiratory failure and obstructive sleep apnea

If use of noninvasive modes of ventilation does not result in improved ventilation

or oxygenation in two to three hours, intubation should be considered
These devices can be used if following conditions are met:
• Patient is cooperative with appropriate level of consciousness
• Patient does not have increased respiratory secretions or aspiration potential
• Concurrent enteral feeding is contraindicated.

Facilitates early extubation, especially in COPD patients

Some devices allow respiratory rate to be set.
Up to 10 L of oxygen can be delivered into the mask for 100% oxygen delivery.
Nasal or oral (full face) mask can be used; less aspiration potential with nasal.
Degree of Respiratory Distress
Respiratory pattern
• Accessory muscle use is an indication of distress.
• Rate > 30 can indicate need for more support by noninvasive positive
pressure or intubation

Need for artificial airway

• Tongue and epiglottis fall back against posterior pharyngeal wall
• Nasopharyngeal airway better tolerated

Pulse oximetry
• O2 saturation less than 92% on 60 - 100% oxygen can suggest the need
for intubation based on whether there is anything immediately reversible
which could improve ventilation.

Arterial blood gas

• pH < 7.3 can indicate need for more support by noninvasive positive
pressure or intubation.
Temporizing Measures

Naloxone for narcotic overdose

• 40 mcg every minute up to 200 mcg with:
- 45 minutes to one hour duration of action
• 0.4 - 2 mg of naloxone is indicated in patients with respiratory arrest and
history suggestive of narcotic overdose
- There is a potential for pulmonary edema, so large dose is reserved
for known overdose and respiratory arrest
• Caution in patients with history of narcotic dependence
• Naloxone drip can be titrated starting at half the bolus dose used to
obtain an effect
- Manufacturer recommended 2 mg in 500 ml of normal saline or D5
gives 0.004 mg/ml concentration
Temporizing Measures (cont'd)
Flumazenil for benzodiazepine overdose
• 0.2 mg every minute up to 1 mg
• Caution in patients with history of benzodiazepine or alcohol dependence
• Caution in patients with history of seizure disorder as it will decrease the
seizure threshold

Artificial airway for upper airway obstruction in patients

with oversedation
• May be necessary in patients with sleep apnea despite judicious sedation

100% oxygen and maintenance of spontaneous

ventilation in patients with pneumothorax
• Washout of nitrogen may decrease size of pneumothorax
• Positive pressure may cause conversion to tension pneumothorax
Oral/Nasal Airways
Indications for Intubation

• Depressed mental status

• Head trauma patients with GCS 8 or less is an indication for intubation
- Associated with increased intracranial pressure
- Associated with need for operative intervention
- Avoid hypoxemia and hypercarbia which can increase morbidity and
• Drug overdose patients may require 24 - 48 hours airway control.

Upper airway edema

• Inhalation injuries
• Ludwig’s angina
• Epiglottitis
Underlying Lung Disease
Chronic obstructive lung disease
• Application of controlled ventilation may interfere with complete
exhalation, overdistend alveoli, and impair right heart and pulmonary
venous return.

Pulmonary embolus
• Pulmonary artery and right ventricle already have high pressure and
dependent on preload
• Application of controlled ventilation may deteriorate oxygenation and
systemic pressure.

Restrictive lung disease

• May require less than 6 cc/kg Vt to prevent elevated intrapulmonary
• Application of positive pressure may result in barotrauma in addition to
impaired preload.
Airway Anatomy Suggesting Difficult
Length of upper incisors and overriding maxillary teeth
Interincisor (between front teeth) distance < 3 cm (two finger tips)
Thyromental distance < 7 cm
• tip of mandible to hyoid bone (three finger breaths)

Neck extension < 35 degrees

Sternomental distance < 12.5 cm
• With the head fully extended and mouth closed

Narrow palate (less than three finger breaths)

Mallampati score class III or IV
Stiff joint syndrome Prayer Sign
• About one third of diabetics characterized by short stature, joint rigidity, and tight waxy skin
• Positive prayer sign with an inability to oppose fingers

No sign is foolproof to indicate intubation difficulty

Erden V, et al. Brit J Anesth. 2003;91:159-160.

Mallampati Score

Class I: Uvula/tonsillar pillars visible

Class II: Tip of uvula/pillars hidden by tongue
Class III: Only soft palate visible
Class IV: Only hard palate visible

Den Herder, et al. Laryngoscope. 2005;115(4):735-739.

Potential for aspiration requires rapid sequence intubation with
cricoid pressure
• Clear liquids < 4 hours
• Particulate or solids < 8 hours
• Acute injury with sympathetic stimulation and diabetics may have
prolonged gastric emptying time.

Potential for hypotension

• Cardiac dysfunction, hypovolemia, and sepsis
• May need to consider awake intubation with topical anesthesia
(aerosolized lidocaine) as sedation may precipitate hemodynamic
compromise and even arrest.

Organ failure
• Renal and hepatic failure will limit medication used.
• Potential for preexisting pulmonary edema and airway bleeding from
Induction Agents

Sodium Thiopental
• 3 - 5 mg/kg IV
• Profound hypotension in patients with hypovolemia, histamine release,
• Dose should be decreased in both renal and hepatic failure.
• 0.1 - 0.3 mg/kg IV
• Lower dose range for elderly and hypovolemic patients
• Hemodynamic stability, myoclonus
• Caution should be exercised as even one dose causes adrenal
suppression due to similar steroid hormone structure.
• Unlikely to have prolonged effect in organ failure
Induction Agents (cont'd)

• 2 - 3 mg/kg IV
• Hypotension, especially in patients with systolic heart dysfunction,
bradycardia, and even heart block
• Unlikely to have prolonged effect in organ failure
• 1 - 4 mg/kg IV, 5 - 10 mg/kg IM
• Stimulates sympathetic nervous system
• Requires atropine due to stimulated salivation and midazolam for
potential of dysphoria
• Avoid in patients with loss of autoregulation and closed head injury
Neuromuscular Blockers
• 1 - 2 mg/kg IV, 4 mg/kg IM
• Avoid in patients with malignant hyperthermia, > 24 hours out from burn or
trauma injury, upper motor neuron injury, and preexisting hyperkalemia

• 0.6 - 1.2 mg/kg, highest dose required for rapid sequence
• Hemodynamically stable, 10% renal elimination

• 0.1 mg/kg
• Hemodynamically stable, 10% renal elimination

• 0.2 mg/kg
• Mild histamine release, Hoffman degradation, not prolonged in renal or
hepatic failure
Rapid Sequence Intubation

Preoxygenate for three to five minutes prior to induction

• Wash out nitrogen to avoid premature desaturation during intubation.

Crycoid pressure should be applied from prior to induction

until confirmation of appropriate placement.
Succinylcholine 1 - 2 mg/kg IV will achieve intubation
conditions in 30 seconds; Rocuronium 1.2 mg/kg IV will
achieve intubation conditions in 45 seconds.
• Other muscle relaxants do not produce intubation conditions in less than
60 seconds.

Avoid mask ventilation after induction.

• Potentially can inflate stomach
• Use only if necessary to ensure appropriate oxygenation during
prolonged intubation.
Y BAG PEOPLE (Reference #6)
Cricoid Pressure

Cricoid is circumferential
Pressure obstructs
esophagus to prevent
escape of gastric
Maintains airway patency

Koziol C, et al. AORN. 2000;72(6):1018-1030.

Sniffing Position
Align oral, pharyngeal, and laryngeal axes to
bring epiglottis and vocal cords into view.

Hirsch N, et al. Anesthesiology. 2000;93(5):1366.

Mask Ventilation
Mask ventilation crucial,
especially in patients who are
difficult to intubate
Sniffing position with tight
mask fit optimal
May require two hands
Mask ventilation crucial,
especially in patients who are
difficult to intubate
Sniffing position with tight
mask fit optimal
May require two hands
Laryngoscope Blades and Endotracheal
Mac blade: End of blade should be placed in front of epiglottis in valecula

ETT for Fastrach LMA

Pediatric uncuffed ETT

ETT for blind nasal

Standard ETT

Miller blade: End of blade should be under epiglottis

Graded Views on Intubation

Grade 1: Full glottis visible

Grade 2: Only posterior commissure
Grade 3: Only epiglottis
Grade 4: No glottis structures are visible

Yarnamoto K, et al. Anesthesiology. 1997;86(2):316.

Confirmation of Placement
Direct visualization
Humidity fogging the endotracheal tube
• End tidal CO2 which is maintained after > 5 breaths
• Low cardiac output results in decreased delivery of CO2

Refill in 5 seconds of self-inflating bulb at the end of the

endotracheal tube
Symmetrical chest wall movement
Bilateral breath sounds
Maintenance of oxygenation by pulse oximetry
Absence of epigastric auscultation during ventilation
Additional Considerations

Always have additional personnel and an experienced

provider as backup available for potential failed
Always have suction available
Never give a muscle relaxant if difficult mask ventilation
is demonstrated or expected
Awake intubation should be considered in the following:
• If patient is so hemodynamically unstable that induction drugs cannot be
tolerated (topicalize airway)
• If patient has a history or an exam which suggests difficult mask
ventilation and/or direct laryngoscopy
American Society of Anesthesiologists
Alternative Methods
Blind nasal intubation
• Bleeding may cause problems with subsequent attempts.
• Contraindicated in patients with facial trauma due to cribiform plate disruption or
CSF leak
• Avoid in immune suppressed (i.e., bone marrow transplant)
Eschmann stylet
Fiber optic bronchoscopic intubation
• Awake vs. asleep
Laryngeal mask airway
• Allows ventilation while bridging to more definitive airway
Light wand
Retrograde intubation
• Through cricothyrotomy
Surgical tracheostomy
Eschman Stylet

Use especially if Grade III

view achieved
Direct laryngoscopy is
Place Eschman where
trachea is anticipated
May feel tracheal rings
against stiffness of stylet
Thread 7.0 or 7.5 ETT
over stylet with the
laryngoscope still in place
Fiberoptic Scope
Essentially what is used to do a
Can be used to thread an
endotracheal tube into the
trachea either while the patient
is asleep or on an awake
patient with a topicalized airway
Via laryngeal mask airway in
place due to inability to intubate
with DL:
• Aintree (airway exchange catheter) can
be threaded over the FOB to be placed
into trachea upon visualization
• Wire-guided airway exchange catheter
can also be used with one more step
The Laryngeal Mask Airway (LMA)
LMA Placement

Guide the LMA along the

Eventual position should
be underneath the
epiglottis, in front of the
tracheal opening, with the
tip in the esophagus
FOB placement through
LMA positions in front of

Martin S, et al. J Trauma Injury, Infection Crit Care.

The FastrachTM Laryngeal
Mask Airway

Reinforced LMA allows for

passage of ETT without
visualization of trachea.
10% failure rate in
experienced hands
20% failure rate in
The Light Wand
Transillumination of
trachea with light at distal
Trachea not visualized
Should not be used with
tumors, trauma, or foreign
bodies of upper airway
Minimal complication
except for mucosal bleed
10% failure rate on first
attempt in experienced
Retrograde Intubation

Puncture of the
cricothyroid membrane
with retrograde passage of
a wire to the trachea
Endotracheal tube guided
endoscopically over the
wire through the trachea
Catheter through the
cricothyroid can be used
for jet ventilation if

Wesler N, et al. Acta Anaes Scan. 2004;48(4):412-416.

Emergency airway used mostly by
paramedics and emergency
physicians for failed endotracheal
Ventilation confirmed through blind
blue tube
• Combitube is in the esophagus and salem
sump can be placed through white tube

Ventilation confirmed through white

(clear) tube with patent distal end
• Combitube is in the trachea and salem sump
should be placed outside of combitube into
• Fiber optic exchange can be accomplished
through combitube
Combitube (cont'd)

Should be changed to endotracheal tube (ETT) or

tracheostomy to prevent progressive airway edema
If in esophagus, take down pharyngeal cuff and attempt direct
laryngoscopy (DL) or fiber optic bronchoscope (FOB)
placement around combitube
Failed exchange attempt can be solved with operative
Placement of combitube can produce significant airway
• Removal prior to DL or FOB should be done with caution after thorough airway
• Cricoid pressure should be maintained and emergency tracheostomy equipment

Surgical airway through

the cervical trachea
Emergent procedure
carries risk of bleeding
due to proximity of
innominate artery
Can be difficult and time
consuming in emergent

Sharpe M, et al. Laryngoscope. 2003;113(3):530-536.

Case Scenario #1

The patient is 70 kg with a 20-year history of diabetes.

On exam, the patient has intercisor distance of 4 cm,
thyromental distance is 8 cm, neck extension is 45
degrees, and mallampati score is 1.
Your staff wants to use thiopental and pancuronium.
Do you have any further questions for this patient or
would you proceed with your staff?
Case Scenario #1 - Answer

A diabetic for 20 years needs assessment for stiff joint

You should have the patient demonstrate the prayer sign.
If the patient is unable to oppose their fingers, you should
not give pancuronium.
You may want to proceed with an LMA and FOB at your
If the patient has a history of gastroparesis, you may want
to consider an awake FOB.
Case Scenario #2

43-year-old patient with HIV, likely PCP pneumonia who

had been prophylaxed with dapsone
RR is 38, oxygen saturation is 90% on 100% NRB mask
The patient is on his way to get a CT scan.
Is it appropriate to proceed without intubation?
Case Scenario #2 - Answer

Dapsone will produce some degree of

Therefore, some degree of desaturation may not be
The patient is in significant respiratory distress and will
be confined in an area without easy access.
Intubation should be considered as an extra measure of
safety, especially as this patient is likely to get worse.
Case Scenario #3

• 40-year-old, 182-kg man has a history of sleep apnea

and systolic ejection fraction of 25%. He has a Strep
pneumonia in his left lower lobe and progressive
respiratory insufficiency.
He extends his neck to 50 degrees and has a mallampati
score of 2.
Would you proceed with an awake FOB?
Case Scenario #3 - Answer

The patient’s airway anatomy is not suggestive of

However, with supine position, subcutaneous tissue may
impair your ability to visualize or ventilate.
Use of gravity, including a shoulder roll, extreme sniffing
position, and reverse trendelenburg may be helpful with
asleep DL.
Prudent to have some accessory equipment, including
an LMA and FOB, for back up
• Caplan RA, et al. Practice guidelines for management of the
difficult airway. Anesthesiology. 1993;78:597-602.
• Langeron O, et al. Predictors of difficult mask ventilation.
Anesthesiology. 2000;92:1229-36.
• Frerk CM, et al. Predicting difficult intubation. Anaesthesia.
• Tse JC, et al. Predicting difficult endotracheal intubation in
surgical patients scheduled for general anesthesia.
Anesthesia & Analgesia. 1995;81:254-8.
• Benumof JL, et al. LMA and the ASA difficult airway
algorithm. Anesthesiology. 1996;84:686-99.
• Reynolds S, Heffner J. Airway management of the critically
ill patient. Chest. 2005;127:1397-1412.