Chest
Postgraduate Education Corner: Contemporary Reviews in Critical Care MedicineAirway Management in Critical Illness
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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