Chest
Volume 131, Issue 2, February 2007, Pages 608-620
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Postgraduate Education Corner: Contemporary Reviews in Critical Care Medicine
Airway Management in Critical Illness

https://doi.org/10.1378/chest.06-2120Get rights and content

Abstract

Airway management in the ICU can be complicated due to many factors including the limited physiologic reserve of the patient. As a consequence, the likelihood of difficult mask ventilation and intubation increases. The incidence of failed airways and of cardiac arrest related to airway instrumentation in the ICU is much higher than that of elective intubations performed in the operating room. A thorough working knowledge of the devices available for the management of the difficult airway and recommended rescue strategies is paramount in avoiding bad patient outcomes. In this review, we will provide a conceptual framework for airway assessment, with an emphasis on assessment of the patient with limited cervical spine movement or injury and of morbidly obese patients. Furthermore, we will review the devices that are available for airway management in the ICU, and discuss controversies surrounding interventions like cricoid pressure and the use of muscle relaxants in the critically ill patient. Finally, strategies for the safe extubation of patients with known difficult airways will be provided.

Section snippets

Airway Assessment

Assessing a patient's airway prior to performing a potentially difficult endotracheal intubation is challenging in the best of circumstances; in the critically ill patient with severe respiratory distress or failure, it may be virtually impossible. There is some controversy as to what assessment tool has the best predictive value for DI; however, a focused and brief examination of the patient's airway may substantially influence the strategy for airway management and the success of the

Preparation for Endotracheal Intubation

Being prepared for unforeseen complications during endotracheal intubation is of prime importance when instrumenting airway of a critically ill patient. Furthermore, conditions for intubation should be as close to ideal as possible in a busy ICU environment, and should include adequate personnel, optimal patient positioning and lighting, and the necessary equipment for endotracheal intubation. A supply of 100% oxygen, a well-fitting mask with attached bag-valve device (which should be checked

Choices of Drugs

Emergent airway management in the ICU is frequently complicated by the patient's limited physiologic reserve, which will often manifest as hypotension immediately after tracheal intubation. The exact incidence of morbidity and mortality related to airway management facilitated by the use of IV induction agents in the ICU is unknown; however, it is likely to be underreported. Several comprehensive reviews42on pharmacologic agents used for airway management in the ICU have been published; we will

Ways To Establish the Airway

Three principal modalities are available for the delivery of mechanical ventilation to a critically ill patient. These are NIPPV via face mask, extraglottic airway devices (eg, various LMAs, an esophageal-tracheal device [Combitube ETC; Tyco-Healthcare-Kendall USA; Mansfield, MA], or a perilaryngeal airway), or the endotracheal route (eg, ETT or tracheostoma). The most commonly practiced technique for endotracheal intubation is direct laryngoscopy with either a curved blade (Macintosh blade) or

Rescue Strategies

Should initial attempts at endotracheal intubation fail, an alternative strategy for providing ventilation to the patient, and ultimately for securing the airway, must be in place. The implementation of the ASA DAA in the critical care setting is logical and, according to one analysis,6may have decreased the number of failed airways in the ICU environment. Since this airway algorithm was originally developed as a tool for anesthesia providers in the operating room, some minor adaptations for

Extubation of the Difficult Airway

Extubation of the patient with a known difficult airway requires some planning should respiratory failure and the need for reintubation arise. Besides routine extubation criteria, the cuff leak test has been advocated as a tool for predicting postextubation respiratory stridor. However, the data on the utility of this test appear equivocal. While some authors92, 93have suggested that the cuff leak test might be a useful index of clinically significant laryngotracheal narrowing, others94, 95have

Summary

Managing the airway of a critically ill patient poses some unique challenges for the intensivist. The combination of a limited physiologic reserve in the patient and the potential for difficult mask ventilation and intubation mandates careful planning with a good working knowledge of alternative tools and strategies, should conventional attempts at securing the airway fail. If difficulty in managing a patient's airway is anticipated, the use of awake fiberoptic techniques should be strongly

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