Professional Documents
Culture Documents
ICU
David Oxman, MD
July 12, 2013
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.
Objectives
• Discuss obtaining intubating conditions
– induction
– paralytics
• Discuss Direct Laryngoscopy and tube
placement
• Post-intubation care
• Overview Rescue Devices
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
Who should intubate in the ICU?
Chest, December
2012
Why Intensivists Should Intubate
Three facial landmarks that must be covered by mask: Small tidal volumes
1. Bridge of the nose Squeeze steadily – don’t force air too
2. Two malar eminences quickly
3. Mandibular alveolar ridge 10-12 breaths/minute
Assess for rise and of fall chest
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 doesn’t sit properly
• S tiff (lungs/body): need increased
pressure
Airway Assessment:
Identification Difficult Intubation
• Incidence difficult intubation varies.
• No clear definition. Approximately 5%
• Corresponds to glottic view
• Can’t intubate/can’t ventilate = 1 in 10,000
• Strongly associated with adverse outcomes
– Airway trauma
– Aspiration
– Hypoxemia/Anoxic brain injury
– Hypotension
– Cardiac arrest and death
Assessing the Airway:
Identification Difficult Intubation
LEMON
– L ook
– E valuate 3-3-2
– M allampati
– O bstruction/Obesity
– N eck mobility
Assessment for Difficult Intubation
“Look”
• External
– Facial trauma
– Unusual anatomy
• Internal
– Foreign body
– Obstructing mass
• Sensitive but not specific
Assessment for Difficult Intubation:
Evaluate: 3-3-2 Rule
Mouth opening Tip of mentum to hyoid bone Thyromental distance
Supine
Head Elevated
• Blade inserted with • Tip of blade gets around • With full insertion of
laryngoscope handle base of tongue, permitting curved blade into vallecula
pointed at the patient’s change in angle of lifting the angle of lifting changes
feet. and better mechanical to ~40 degrees from the
• Tongue and jaw are advantage. horizontal.
distracted downward to • Epiglottis edge lifted off • Now the lifting force can be
insert the blade. pharyngeal wall. (Epiglottis increased as needed.
• Minimal force required often camouflaged against • Tip position (not force) is
mucosa of posterior the main determinant of
pharynx). glottic exposure.
Lifting the Scope
Yes No
Laryngoscopy:
Optimizing Glottic View
Avoid regurgutation of
gastric contents
Imaging studies
undermine theory
Yes, good
No, bad
Inserting Endotracheal Tube
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)
Rescue Strategies
• Return to spontaneous breathing
• Videolaryngoscopy
A
• Extraglottic devices
• Bougie
• Cricothyroidotomy (open vs.
percutaneous)
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