An Unanticipated

Difficult Airway
in ICU
Brig Deepak Kr Sreevastava, MD, DNB, MNAMS, PGDHCM
Prof and Head

Dept of Anaesthesiology & Critical Care

Army College of Medical Sciences
Base Hospital, Delhi Cantt - 110010
 Introduction
• Airway Management in ICU
• Amongst the most commonly performed procedures
• Difficult intubation incidence ~ 10%
• Unique challenges with the highest risk of complications

• 4th National Audit Project of the RCA & DAS - 2011

• Significantly higher rate of adverse outcomes
• Several deficiencies of airway management
• In ICUs and EDs compared with OT
Why Intubations in ICU are different!
• Most airway interventions are reactive and emergent
• Standard airway assessment - Difficult
• Logistical challenges being away from OT
• Patient factors
• Hypoxic/obtunded/combative
• Aspiration risk because of functional gastric stasis
• Unstable cardio-pulmonary physiology
• Systemic illnesses (Neuro/Liver/Renal)
• Metabolic acidosis
• Normal airway may become difficult
• Fluid resuscitation/Capillary leak syndrome/Prone ventilation
Why Intubations in ICU are different!
• Awake fiberoptic technique – The Gold Standard in OT
• Not possible in ICU
• A patient dependent on advanced oxygenation techniques
• Can actually worsen the patient’s physiology
• Awakening the patient after failed intubation
• Not an option - Airway must “Come what may”
• FONA – May be difficult to perform
• Failure of ‘first pass success’ - 30% of ICU intubations
• Significantly higher than in the OT
• Strategies with highest rate of first pass success desirable
Why Intubations in ICU are different!
• High incidence of peri-intubation complications
especially after initiation of PPV
• Differences in post-intubation management in ICU
• 82% of ICU airway incidents occur after intubation
• Complex nursing care necessitates positional changes
• A multidisciplinary team lacking the skills for
reintubation
• Higher rate of night time event managed by a
unskilled trainee
 The Types of Difficult Airway in ICU
• Anatomically Difficult Airway
• When BVM/Insertion of SGA/Visualization of Glottis difficult
• Jaw, Neck immobility
• Blood /Vomit in airway
• Cervical immobilization
• Physiologically Difficult Airway but Anatomically ‘Normal’
• Process of induction/Intubation can be life threatening due to
reduced physiological reserves
• Severe COPD/Hypoxaemia
• Fluid resuscitation/ Capillary leak syndromes
• Prone ventilation
A Walk through the DAS Guidelines 2018
• So ..Customised guidelines needed for ICU patients
• What are the differences then…
• Preparation of Multidisciplinary team & Environment
• Modified airway assessment
• Preoxygenation and per-oxygenation
• Peri-intubation haemodynamic management
• Role of Rapid Sequence Induction
• Role of Videolaryngoscopy
• Unification of plan B & C
• Timely institution of FONA
Fig 2
 The Human Factors
• Complications occur due to lack of patient
preparation, equipment check etc
• Important to handle Cognitive Overload
• “The Vortex Approach”
• Airway Team with a Leader - Task allocation
• The Members – well briefed about their role
• Ready to anticipate next task
• Organise equipment/personnel/other resources
• Active followership to avoid “Analysis Paralysis”
• Standardized Airway Trolley must – By the bedside
 Fig 1

British Journal of Anaesthesia 2018 120, 323-352DOI: (10.1016/j.bja.2017.10.021)

Can we predict difficult
intubations in ICU?
• The MACOCHA Score
• Only validated airway assessment tool in
the critically ill
• A score of 3 or more predicts DI
• Optimal negative predictive value
• 97% and 98%
• Sensitivity
• 76% and 73%

• Also – Identify the Cricothy memb

• Assess Haemodynamics
Plan A : Preparation/Oxygenation/Induction
Mask Ventilation & Intubation
• Team Brief- Assign Clear Role
• Pre-intubation Check List
• Positioning – Head Up , Firm Mattress
• Monitoring – Capnography must
• Pre & Peroxygenation
• Induction of Anaesthesia and Choice of Drugs
• Laryngoscopy and Videolaryngoscopy
 Oxygenation Techniques in ICU
• ICU patients likely to desaturate rapidly
• If there is no respiratory failure
• Pre-Oxygenation with a tight fitting mask
• 10 – 15 LPM of 100% O2 for 3 Min
• In hypoxaemic patients
• CPAP 5 – 10 cm of H2O
• Non-invasive positive pressure ventilation
• Insp pressure – 5 to 15 cm, PEEP 5 cm and Vt 6 – 8 ml Kg
• Nasal oxygen - Through out the airway management
 Oxygenation Techniques in ICU
• Per-oxygenation or Apnoeic Oxygenation
• From induction of apnoea till commencement of IPPV
• Principle of mass flow of oxygen across the pressure gradient
• High Flow Nasal Oxygenation (HFNO)- 30 – 70 Lit/min
• Prolongs safe apnea time
• However no evidence to show outcome benefits
• In absence of HFNO – Simple nasal cannula @ 15LPM
• Higher peri-intubation SpO2 and  rate of hypoxaemia
• Combination of NIV for preoxygenation and Apnoeic
oxygenation for per-oxygenation – Better results
 Induction of Anaesthesia &
Laryngoscopy
• Modified Rapid Sequence Induction - Appropriate
• Risk of aspiration
• Lack of starvation
• Intra-abdominal pathology or functional gastric stasis
• Ketamine, co-induction with opiates, Rocuronium
• Laryngoscopy attempts to be limited to 3
• If one attempt fails – Get FONA set
• Videolaryngoscope recommended
• Macintosh type of blade vs hyperangulated device
 Induction of Anaesthesia
• Vast majority will have unstable physiology
• Pre-existing hypoxia
• Ventilation-perfusion mismatch that impairs preoxygenation
• Absolute or relative hypovolemia
• Increased risk of myocardial impairment
• Rapid desaturation from a hypoxic baseline creates
time pressure and demands rapid action.
• Even when airway management is successful the
initiation of positive pressure ventilation may also be
poorly tolerated and lead to immediate or delayed
deterioration.10
Plan B/C :Rescue Oxygenation using SGA or
Facemask after failed intubation
• Failed intubation can occur – 10 – 30%
• Reoxygenation attempted with SGA or FM
• A Second Generation SGA with a drain tube
• Proseal LMA, i-Gel recommended
• Important to continue per-oxygenation while inserting SGA
• A face mask with two person technique
• In case of success of Plan B/C – options are
• Waking the patient
• Waiting for an expert
• An attempt at FOB via SGA
• Proceed to FONA
• Emphasis on the Vortex Approach
Fig 3
 Plan D : Emergency FONA
• Rapid transition is essential
• Avoid procedural reluctance/Task fixation
• After first failure with SGA – Open FONA Set
• Explicit declaration is essential which leads to
Psychological Priming
• Open surgical approach – Scalpel cricothyroidotomy
• Identify Cricothyroid membrane
• Laryngeal Handshake, USS
• Seldinger techniques & TTJV
• Not recommended
 Fig 4

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British Journal of Anaesthesia 2018 120, 323-352DOI: (10.1016/j.bja.2017.10.021)

Peri-intubation Haemodynamic Management
• ICU patients – Significant physiological stress
• Hypoxia
• Vasodilation from anaesthetic agents hypovolemia
• PPV causing reduced venous return
• Decreased sympathetic tone because of sedation
• Lack of sleep
• Increased WOB leading to physiological fatigue
• High risk of haemodynamic instability – 25%
• Cardiac Arrest – 2%
 Is all well after intubation?
Care of the Intubated Patient
• ICU patients - Different from that in OT
• May remain intubated for weeks
• Subject to procedures, complex nursing care, repositioning
• Cared for by a multidisciplinary team & Not One Anaesthetist
• Airway displacement and re-intubation - constant danger
• ICU airway incidents occur after the airway secured
• 25% contributing to the patient’s death
• High degree of vigilance needed
• During transfers/Insertion of gastric tubes/Oeso dopplers /scope
• Prone ventilation
 Is all well after intubation?
Care of the Intubated Patient

• A set of equipment – Kept readily available

• Depth of Insertion/Cuff pressure – checked repeatedly
• Capnography - Potential to prevent complications
• Humidification/Regular suctioning
• Post-intubation recruitment –
• Intubation attempts worsen pulmonary mechanics
• An inspiratory pressure of 30 – 40 cm of H2O for 25 – 30 sec
• Increases lung volume, oxygenation & decreases atelectasis
• Should be avoided in haemodynamically unstable patients
 Extubation Strategies
• Up to 15% of patients extubated in ICU need
reintubation within 48 h
• Reintubation after prolonged ventilation - more
difficult
• Airway oedema
• Emergent nature of many re-intubations
• Hence extubation should always be planned
• Be ready to reintubate
• Post-extubation stridor occurs in 12 - 37% of patients
• No evidence for steroids
 Extubation Strategies
• If known difficult airways
• To be performed in ‘daytime’ hours.
• Use AECs which can act as a conduit for reintubation.
• However – Low flow oxygen associated with risks of barotrauma.
• Oxygen administration via AEC not recommended.
• Careful observation till stable
• CPAP, NIV, or HFNO can reduce reintubation rates
• Location of extubation
• It may be best to transfer the patient to the operating theatre, or to
bring anaesthetic staff to the patient’s location to facilitate safe
extubation
 The Vortex Approach
• Cognitive overload - A problem during airway crises
• Impairs decision-making and performance
• The ‘Vortex approach’ to Airway Crisis Management
• A simple graphic designed to be easily recalled
• Emphasis on avoidance of repeated attempts with the same
technique when difficulties arise
• Maximum of 3 attempts (Lifelines) permitted each
• Oxygenation via Supraglottic Airway/ Facemask Ventilation/ETT
• Fourth attempt with each device by an expert
• In case of failure of all attempts
• A can't intubate, can't oxygenate situation (CICO) situation exists
• 'CICO Rescue' (Emergency Front-of-neck Access) must be initiated
 The Vortex Approach
Not a traditional algorithm but a graphic
• Any repeated attempt must be further optimized
• Five categories of optimization
• The Green Zone
• Establishment of adequate oxygen delivery results in
movement outwards into circumferential zone
• Green zone also visible in the centre of the vortex-
• Represents ability of CICO rescue to restore oxygenation
• Once in green zone – Options can be
• Maintain the lifeline/Proceed/Wake up
• Convert the lifeline to a preferred technique
• Replace the lifeline with a different one
• Conceptual imprinting • Critical Language
• Circular graphic intended • To promote situational
to look down into a funnel awareness and share a
• Narrowing the funnel mental model
• As in Cardiac arrest scenario
• Diminishing time and
• Completed best effort
options available as one
• In the Green Zone
spirals down into the
• CICO Rescue
Vortex
• Sucked in the Vortex
Intubation Recommendations Bundle
(The Montpellier-ICU Intubation Algorithm)
 The Vortex Approach
• DAS 2015 guidelines
• Plan B as airway rescue using an SGA
• Plan C as a final attempt to achieve oxygenation with FM
• However, as recognized by the ‘Vortex approach’
• Attempts at intubation, SGA placement, Facemask ventilation
form a continuum culminating in
• Success (movement into the green zone)
• Cumulative failure (spiralling further into the Vortex)
• Necessitating transition to FONA.
• One optimal attempt, or a maximum of three attempts
• With SGA or facemask recommended in Plan B/C before declaring
failure.
• One further expert attempt at all three techniques if appropriate.
 The Vortex Approach
• Clinicians fail to perform basic interventions under stress
• Excessive cognitive overload.
• Guidelines are context-specific
• Text dense and difficult to recall in times of crisis
• The Vortex - A high acuity implementation tool
• Three upper airway 'lifelines' (non-surgical techniques) to
establish alveolar oxygen delivery
• Face Mask, Supraglottic Airway & Endotracheal Tube.
• If a 'best effort’ with these lifelines is unsuccessful
• A can't intubate, can't oxygenate situation (CICO) situation exists
• 'CICO Rescue' (emergency front-of-neck access) must be initiated.
 The Vortex Approach
• Clinicians fail to perform basic interventions under stress
• Excessive cognitive overload.
• Guidelines are context-specific
• Text dense and difficult to recall in times of crisis
• The Vortex - A high acuity implementation tool
• Three upper airway 'lifelines' (non-surgical techniques) to
establish alveolar oxygen delivery
• Face Mask, Supraglottic Airway & Endotracheal Tube.
• If a 'best effort’ with these lifelines is unsuccessful
• A can't intubate, can't oxygenate situation (CICO) situation exists
• 'CICO Rescue' (emergency front-of-neck access) must be initiated.
 Special Circumstances
Managing the known or anticipated difficult intubation in the critically ill patient

• In patients with neurophysiologic derangements

• Raised ICP is the key issue
• Fentanyl/Remifentanil – Blunt the response to laryngoscopy
• In Cardiac Cases
• Optimize Preload/Afterload/HR/Contractility
• Assess bedside ECHO
• Aim to avoid precipitation of ischemia
• Etomidate
• Treat atrial arrhythmia to preserve atrial kick as in case of
LVH with poor diastolic compliance
 Special Circumstances
Managing the known or anticipated difficult intubation in the critically ill patient

• In ARDS
• Preoxygenation with NIV/BVM – Likely to less effective
• Presence of RV dysfunction which further deteriorates with
increased intra thoracic pressure because of PPV
• Hence optimize RV after load by
• Inhaled pulmonary vasodilators & Correction of HPV
• Decrease atelectasis by NIV
• In Hepatic Failure
• Raised ICP and Coagulopathy
• Neuroprotective strategy/Avoid nasal intubation
 Special Circumstances
Managing the known or anticipated difficult intubation in the critically ill patient

• In patients with altered Gut function

• Paralytic ileus/Raised IAP/ascites/obstruction
• Risk of aspiration
• RSI – preferred
• Sepsis
• Prone to haemodynamic instability, lactic acidosis,
• Volume resuscitation and Vasopressor – Key components of
airway management
• Renal
• Acidosis, Hyperkalemia - Avoid succinylcholine