Airway Management in the ICU

Don A. Koenigsberg DO
Chairman, Department of Anesthesia
Saint Agnes Medical Center
Philadelphia, PA
Etiologic Factors in Acute
Respiratory Failure
Thoracic Trauma Fat Embolism
Sepsis Pulmonary Thromboembolism
Acute Pancreatitis Amniotic Fluid Embolism
Aspiration of Gastric Contents Inhalation of Toxic Vapors, Smoke,
Necrotizing Pneumonia Gasses
Near Drowning Fluid Overload
Oxygen FIO2 <60 Disseminated Intervascular
Coagulation
Brain Injury
Altitude
Acquired Immunodeficiency
Syndrome
Drug Overdose
Routes of Endotracheal
Intubation

Nasotracheal
Orotracheal
Pericutaneous Cricothyroidotomy
Tracheotomy
Endotracheal Intubation

Inserted Through Nose or Mouth

Nasal Route Preferred in Awake Patients
Oral Route Preferred in Comatose or
Uncooperative Patients
Tracheotomy Preferred for Long Term
Intubation
Complications of Intubation
Epistaxis
Esophageal Intubation
Nasal, Septal Necrosis
Bacteremia
Dental Trauma
Occlusion from Biting
on Tube
Laryngeal Damage
History of Mechanical
Ventilation
PPV was first developed in the OR to facilitate
anesthesia and thoracic surgery.
The PACU developed and evolved into ICUs in the
1950s.
Concepts of PPV, endotracheal intubation,
sedation/analgesia and neuromuscular blockade
were introduced and accepted.
1960- Acceptance of preset tidal volume to support
patients with respiratory failure.
 Positive Airway Pressure
Therapy
Full vs. Partial Minimal Excursion
Ventilatory Support Ventilation
 Ventilator Modes
Control-Mode
Assist-Control
Pressure-Control
Intermitent Mandatory
Synchronized Intermittent Mandatory
Pressure-Support
 Mimimal-Excursion Ventilation
Permissive Hypercapnia
Elimination of Dead Space
High Frequency Ventilation
Initiation of PPV

Establish Patent Airway

Not Uncommon To Experience
Cardiovascular Instability Following
Establishing the Airway And Beginning of
Positive Pressure Ventilation.
Causes of Cardiovascular
Instability
Decrease in Circulating Catacholamines
Due to a Relief From Respiratory Distress
Cause Vasodilation and Decreased Cardiac
Output .
Decreased Venous Return Related to
Airway Pressure.
Combination of Thereof.
Fighting The Ventilator
When a Ventilated Patient Actively
Attempts to Impede Flow During The
Inspiratory Cycle, The Process is Known As
Fighting the Ventilator.
Breathing Efforts During the Expiratory
Cycle Have Little Detrimental Effect In Most
Patients.
Reasons Patients Fight The
Ventilator

Inadequate Ventilation (Hypercapnea)

Acidemia
Inadequate Oxygenation
CNS Dysfunction
Pain or Anxiety
Sedation and Analgesia

Decreases Stress That can be Detrimental

To Critically Ill Patients.
Human Compassion
Parameters For IV Sedation & Analgesia for Adults in the ICU
According to the Society for Critical Care Medicine (SCCM)

Morphine Sulfate is Midazolam or Propofol for

preferred for critically ill
patients
Fentanyl for critically ill
with hemodynamic
instability or morphine
allergy
Hydromorphone is an
alternative to morphine
short term anxiety <24
hours.
Lorazepam for prolonged
treatment of anxiety in the
critically ill adult
Haloperidol for the
treatment of delirium
 ANALGESIA
Analgesia connotes the absence of sensibility to pain or
noxious stimuli in the conscious patient.
Pain can lead to tachycardia increased myocardial
oxygen consumption, hypercoagulability,
immunosupression, and persistant catabolism.
ICU patients experience pain from diagnostic and
theraputic procedures as well as their pathology.
Intravenous opiates are the mainstay of analgesic
therapy
Common Concerns of Opiates

Unwarranted concerns about inducing opiate addiction

Respiratory Depression in spontaneously breathing
patients and patients receiving partial ventilator support.
Hypotension - more likely related to hypovolemia
Gastric Retension and Ileus which are common in
critically ill people are enhanced by opiates
 Morphine Sulfate
Intravenous half-life of 1.5-2 hours may vary up or down in ICU
patients due to abnormal protein binding and distribution
May induce histamine release causing hypotension and other
adverse effects
Administer intravenously and titrate to effect. Loading dose of
0.05mg/kg over 5-15 minutes. Most adults require 4-6 mg/hr
after an adequate loading dose.
Bolus therapy should be every 1-2 hours.
Multiple loading doses may be required with continuous
infusion therapy
Causes euphoric effect
 Fentanyl
Preferred agent for critically ill patients with hemodynamic
instability, for patients with symptoms of histamine release or
with morphine allergy
Synthetic opiate with greater potency and lipophilic properties
than morphine.
No histamine release
Half-life of 30-60 minutes
Prolonged administration can accumulate and increase half-
life to 9-16 hours
Little euphoric effect, no active metabolites, no cross reaction
with morphine allergy
 Opiates NOT RECOMMENDED
Meperidine (Demerol) has an active metabolite,
normeperidine, that may accumulate and cause CNS
excitation
Opiate agonist-antagonists (nalbuphine, butorphenol,
buprenorphine)
NSAIDS have no analgesic advantage over opiates and
may cause GI bleeding, platelet inhibition, and renal
insufficiency
Sedative Agents Recommended
Midazolam (Versed) Onset 2-2.5 minutes. lipophilic compound in
the blood that rapidly penetrates the CNS.
Bolus dose of .03 mg/kg and maintenance dose of .03 mg/kg/hr
is recommended
Bolus may be repeated as needed
Propofol (Diprivan) Intravenous general anesthetic that has
sedative, hypnotic, anxiolytic and anterograde amnestic
properties. Onset in 1-2 minutes and effect is for 10-15 minutes.
Give only as a continuous infusion. Infusion rate of 0.5 mg/kg/hr
and titrate rapidly upward in increments of 0.5mg/kg every 5-10
minutes. Typical maintenance doses are 0.5-3.0 mg/kg/hr.
Sedative
Agents
Lorazepam (Ativan) (cont.)acting
is an intermediate
benzodiazepine. It is longer acting than Midazolam,
causes less hypotension, causes equally effective
anterograde amnesia, is lower cost and with prolonged
administration causes more rapid awakening.
Starting dose is 0.44 mg/kg every 2-4 hours but is highly
variable.
Usually administered by intermittent bolus but
continuous infusion is used.
Sedative Agents (cont.)
Haloperidol (Haldol) Preferred for treatment of delirium in
the ICU. Opiates or Benzodiazepines may worsen
symptoms of ICU psychosis.
IV use recommended by the SCCM although it is not
approved by the FDA
Clinical effects seen within 30-60 minutes and may last 4-
8 hours.
May cause QT prolongation so use with caution with other
drugs with similar effects.
Dose is 2-10 mg Intravenously repeated every 2-4 hours
 Sedative Agents
NOT RECOMENDED
Etomidate (Amidate) Long term use associated with
adrenal suppression
Ketamine (Ketlar) May increase blood pressure, heart
rate, and intracranial pressure when used as a sedative .
Thiopental (Pentothal) and Pentobarbital (Nembutal) are
used in the ICU primarily to control intracranial pressure
or as anticonvulsants. They lack amnestic and analgesic
properties and they commonly produce myocardial
depression and vasodilation that result in tachycardia
and hypotension.
Neuromuscular Blocking Agents
Used when patients fight the ventilator
Often the only alternative in protecting the patient from
harm
Neuromuscular blockade should be the last resort after
sedation analgesia and amnesia is provided.
Pancuronium is recommended by the SCCM practice
parameters.
Vecuronium is also used extensively.
Atracurium or Cisatracurium is recommended for patients
with cardiovascular instability,
 Associated With Increased Sensitivity To
Neuromuscular Blocking Agents

Antiarrhythmics Hepatic and Renal diseases

Antibiotics Hypermagnesemia
Anticonvulsants Hypocalcemia
Antirheumatic drugs Hyponatremia
Beta-blockers Hypothermia
Calcium Channel
Steroids
Blockers Neuromuscular Diseases
Diuretics Psychotropic agents
General Anesthetics
Respiratory Acidosis
Prolonged Paralysis and Muscular
Weakness in Critically Ill Patients

Critical Illness Myopathy

Acute Quadriplegic Myopathy
Acute Necrotizing Myopathy
Necrotizing Myopathy of the ICU
Prolonged Reversible Quadriparesis
Corticosteroids and Neuromuscular
Blocking agents together are factors
Acute Quadriplegic Myopathy
Associated With Asthma
9 of 22 Asthma patients treated with
Corticosteroids and Vecuronium infusion
developed myopathies and prolonged
weakness.
>24 hours Treatment with muscle relaxants
associated with prolonged paralysis in the
ICU with or without steroids.
Rehab can take several months.