Airway management in the critically ill patient is challenging. The incidence of complications when performing intubations in the ICU is much higher than in the operating room. This chapter will discuss how to perform an adequate airway evaluation, various intubating tools and techniques, and complications of intubations. The approach to managing a difficult airway and extubating a patient will be addressed. Methods to increase the safety of airway management in the ICU such as the use of experienced personnel, availability of equipment for the difficult airway, and the importance of protocols for emergency intubations will be outlined.
- Airway management
- Critical care
- Difficult intubation
- Airway complications
- Fiber-optic bronchoscope
- Airway exchange catheter
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Simpson GD, Ross MJ, McKeown DW, Ray DC. Tracheal intubation in the critically ill: a multi-centre national study of practice and complications. Br J Anaesth. 2012;108:792–9.
Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99:607–13.
Rice MJ, Mancuso A, Morey TE, Gravenstein N, Deitte L. The anatomy of the cricoid pressure unit. Surg Radiol Anat. 2010;32:419.
Chung KW, Chung HM. Gross anatomy. 7th ed. Philadelphia: Walter Kluwer/Lippincott Williams & Wilkins; 2011.
Morgan GE, Mikhail MS, Murray MJ. Clinical anesthesiology. 4th ed. New York: Lange Medical Books/McGraw-Hill Medical; 2006.
Finucane BT, Tsui BC, Santora AH. Principles of airway management. New York: Springer Science + Business Media, LLC; 2011.
Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103:429–37.
De Jong A, Molinari N, Terzi N, Mongardon N, Arnal JM, Guitton C, et al. Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study. Am J Respir Crit Care Med. 2013;187:832–9.
Hastings RH, Hon ED, Nghiem C, Wahrenbrock EA. Force and torque vary between laryngoscopists and laryngoscope blades. Anesth Analg. 1996;82:462–8.
Walz JM, Kaur S, Heard SO. Airway management and endotracheal intubation. In: Irwin RS, Rippe JM, Lisbon A, Heard SO, editors. Irwin and Rippe’s procedures, techniques and minimally invasive monitoring in intensive care medicine. Philadelphia: Wolters Kluwer/Lippincot Williams and Wilkins; 2012. p. 1–16.
Vinclair M, Broux C, Faure P, Brun J, Genty C, Jacquot C, et al. Duration of adrenal inhibition following a single dose of etomidate in critically ill patients. Intensive Care Med. 2008;34:714–9.
Chan CM, Mitchell AL, Shorr AF. Etomidate is associated with mortality and adrenal insufficiency in sepsis: a meta-analysis. Crit Care Med. 2012;40:2945–53.
McPhee LC, Badawi O, Fraser GL, Lerwick PA, Riker RR, Zuckerman IH, et al. Single-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database. Crit Care Med. 2013;41:774–83.
Payen JF, Dupuis C, Trouve-Buisson T, Vinclair M, Broux C, Bouzat P, et al. Corticosteroid after etomidate in critically ill patients: a randomized controlled trial. Crit Care Med. 2012;40:29–35.
Jabre P, Combes X, Lapostolle F, Dhaouadi M, Ricard-Hibon A, Vivien B, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009;374:293–300.
Schmidt A, Oye I, Akeson J. Racemic, S(+)- and R(−)-ketamine do not increase elevated intracranial pressure. Acta Anaesthesiol Scand. 2008;52:1124–30.
Plumb JO, Miller RM. Not using neuromuscular blocking agents in emergent intubation should be a rarity. Crit Care Med. 2012;40:3112–3.
Wilcox SR, Bittner EA, Elmer J, Seigel TA, Nguyen NT, Dhillon A, et al. Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications. Crit Care Med. 2012;40:1808–13.
Martyn JA, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states: etiologic factors and molecular mechanisms. Anesthesiology. 2006;104:158–69.
Blanie A, Ract C, Leblanc PE, Cheisson G, Huet O, Laplace C, et al. The limits of succinylcholine for critically ill patients. Anesth Analg. 2012;115:873–9.
Larijani GE, Cypel D, Gratz I, Mroz L, Mandel R, Afshar M, et al. The efficacy and safety of EMLA cream for awake fiberoptic endotracheal intubation. Anesth Analg. 2000;91:1024–6.
Sutherland L, Misita D. Regional and topical anesthesia for endotracheal intubation. 2007 (cited May 21, 2014). In: NYSORA textbook of regional anesthesia and acute pain management (Internet). New York: McGraw-Hill (cited May 21, 2014). Available from: http://www.accessanesthesiology.com/content/3500549.
Aslani A, Ng SC, Hurley M, McCarthy KF, McNicholas M, McCaul CL. Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study. Anesth Analg. 2012;114:987–92.
Mort TC. Preoxygenation in critically ill patients requiring emergency tracheal intubation. Crit Care Med. 2005;33:2672–5.
Mort TC, Waberski BH, Clive J. Extending the preoxygenation period from 4 to 8 min in critically ill patients undergoing emergency intubation. Crit Care Med. 2009;37:68–71.
Baillard C, Fosse JP, Sebbane M, Chanques G, Vincent F, Courouble P, et al. Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med. 2006;174:171–7.
Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the “sniff” and “ramped” positions. Obes Surg. 2004;14:1171–5.
Jaber S, Jung B, Corne P, Sebbane M, Muller L, Chanques G, et al. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med. 2010;36:248–55.
Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984;39:1105–11.
Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia. Lancet. 1961;2:404.
Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PT. Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging. Anesthesiology. 2003;99:60–4.
Rice MJ, Mancuso AA, Gibbs C, Morey TE, Gravenstein N, Deitte LA. Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant. Anesth Analg. 2009;109:1546–52.
Rice MJ, Mancuso AA, Morey TE, Gravenstein N, Deitte L. The anatomical correction of cricoid pressure. Minerva Anestesiol. 2010;76:304.
Zeidan AM, Salem MR, Mazoit JX, Abdullah MA, Ghattas T, Crystal GJ. The effectiveness of cricoid pressure for occluding the esophageal entrance in anesthetized and paralyzed patients: an experimental and observational glidescope study. Anesth Analg. 2014;118:580–6.
De Jong A, Molinari N, Conseil M, Coisel Y, Pouzeratte Y, Belafia F, et al. Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis. Intensive Care Med. 2014;40:629–39.
Walz JM, Zayaruzny M, Heard SO. Airway management in critical illness. Chest. 2007;131:608–20.
Niven AS, Doerschug KC. Techniques for the difficult airway. Curr Opin Crit Care. 2013;19:9–15.
Porhomayon J, El-Solh AA, Nader ND. National survey to assess the content and availability of difficult-airway carts in critical-care units in the United States. J Anesth. 2010;24:811–4.
Hagberg CA. Current concepts in the management of the difficult airway. Anesthesiol News. 2014;11:1–28.
Gercek E, Wahlen BM, Rommens PM. In vivo ultrasound real-time motion of the cervical spine during intubation under manual in-line stabilization: a comparison of intubation methods. Eur J Anaesthesiol. 2008;25:29–36.
Miguel-Montanes R, Hajage D, Messika J, Bertrand F, Gaudry S, Rafat C, Labbé V, Dufour N, Jean-Baptiste S, Bedet A, Dreyfuss D, Ricard JD. Use of high-flow nasal cannula oxygen therapy to prevent desaturation during tracheal intubation of intensive care patients with mild-to-moderate hypoxemia. Crit Care Med. 2015;43:574–83.
Barjaktarevic I, Berlin D. Bronchoscopic intubation during continuous nasal positive pressure ventilation in the treatment of hypoxemic respiratory failure. J Intensive Care Med. 2015;30:161–6.
Yang T, Hou J, Li J, Zhang X, Zhu X, Ni W, et al. Retrograde light-guided laryngoscopy for tracheal intubation: clinical practice and comparison with conventional direct laryngoscopy. Anesthesiology. 2013;118:1059–64.
Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest. 1997;112:186–92.
Rose L, Redl L. Survey of cuff management practices in intensive care units in Australia and New Zealand. Am J Crit Care. 2008;17:428–35.
Kollef MH, Legare EJ, Damiano M. Endotracheal tube misplacement: incidence, risk factors, and impact of a quality improvement program. South Med J. 1994;87:248–54.
Jaber S, Amraoui J, Lefrant JY, Arich C, Cohendy R, Landreau L, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med. 2006;34:2355–61.
Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations. Anesthesiology. 1995;82:367–76.
Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S. 3,423 emergency tracheal intubations at a university hospital: airway outcomes and complications. Anesthesiology. 2011;114:42–8.
Mayo PH, Hegde A, Eisen LA, Kory P, Doelken P. A program to improve the quality of emergency endotracheal intubation. J Intensive Care Med. 2011;26:50–6.
Khemani RG, Randolph A, Markovitz B. Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Database Syst Rev. 2009;8(3): CD001000.
Khemani RG, Randolph A, Markovitz B. Steroids for post extubation stridor: pediatric evidence is still inconclusive. Intensive Care Med. 2010;36:1276–7.
MacIntyre N. Discontinuing mechanical ventilatory support. Chest. 2007;132:1049–56.
Seely AJ, Bravi A, Herry C, Green G, Longtin A, Ramsay T, et al. Do heart and respiratory rate variability improve prediction of extubation outcomes in critically ill patients? Crit Care. 2014;18:R65.
Jaber S, Chanques G, Matecki S, Ramonatxo M, Vergne C, Souche B, et al. Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test. Intensive Care Med. 2003;29:69–74.
Faris K, Zayaruzny M, Spanakis S. Extubation of the difficult airway. J Intensive Care Med. 2011;26:261–6.
Miller RD, editor. Anesthesia. 4th ed. New York: Churchill Livingstone; 1994. p. 1413.
Roberts PR, Todd SR, editors. Comprehensive critical care: adult. Mount Prospect, IL: Society of Critical Care Medicine; 2012. p. 283.
Standring S (Editor-in-Chief). Gray’s anatomy. 40th ed. Madrid: Churchill Livingstone/Elsevier; 2008
Huang H-H, Lee M-S, Shih Y-L, Chu H-C, Huang T-Y, Hsieh T-Y. Modified Mallampati classification as a clinical predictor of peroral esophagogastroduodenoscopy tolerance. BMC Gastroenterol. 2011;11:1.
Barash PG, Cullen BF, Stoelting RK. Clinical anesthesia. 3rd ed. Philadelphia: JB Lippincott; 1997. p. 585.
Civetta JM, Taylor RW, Kirby RR. Critical care. 3rd ed. Philadelphia, PA: Lippincott-Raven; 1997. p. 765.
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Kuza, C., Cosar, E.O., Heard, S.O. (2016). Airway Management in the Intensive Care Unit. In: O'Donnell, J., Nácul, F. (eds) Surgical Intensive Care Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-19668-8_2
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