Emergent Airway

Management
J eanine P. Wiener-Kronish, MD
Henry Isaiah Dorr Professor of Research and
Teaching in Anaesthetics and Anaesthesia
Harvard Medical School
Department of Anesthesia and Critical Care
Anesthetist-in-Chief
jwiener-kronish@partners.org
Objectives for Talk
Objectives for Talk

Issues to consider in planning airway

Issues to consider in planning airway
management in general
management in general

Important issues regarding airway

Important issues regarding airway
management in emergency situations
management in emergency situations

Techniques to obtain airways

Techniques to obtain airways

Etomidate vs Ketamine
Etomidate vs Ketamine
General Concerns
General Concerns
Management Plans
Is airway management necessary?
Will direct laryngoscopy and tracheal
intubation be straightforward?
Can mask or supralaryngeal ventilation be
used?
Is there an aspiration risk?
In the event of airway failure, will the patient
tolerate an apneic period?
Rosenblatt WH Crit Care Med 2004;32.S186-S192
Indications for Intubation
Indications for Intubation

provide patent airway

provide patent airway

frequent suctioning
frequent suctioning

decrease aspiration
decrease aspiration

facilitate positive pressure ventilation

facilitate positive pressure ventilation

disease involving upper airway

disease involving upper airway
EQUIPMENT
EQUIPMENT
-
-
LOSE
LOSE
-
-
EM
EM

Laryngoscopes! [Videoscopes/LMA]
Laryngoscopes! [Videoscopes/LMA]

Oxygen!
Oxygen!

Suction!
Suction!

Endotracheal tubes
Endotracheal tubes
-
-
variety sizes!
variety sizes!

Emergency medications!!!
Emergency medications!!!

Mask for ventilation!!

Mask for ventilation!!
**
**
IV access
IV access
Verify tube placement
Verify tube placement

visualize tube in glottic opening

visualize tube in glottic opening

no air during gastric ascultation

no air during gastric ascultation

bilateral breath sounds

bilateral breath sounds

compliance of reservoir bag

compliance of reservoir bag

bag movement during spont vent

bag movement during spont vent

condensation of water vapor

condensation of water vapor
carbon dioxide in exhaled gases!!
Complications of laryngoscopy
Complications of laryngoscopy

malpositioning
malpositioning
esophageal esophageal
Endobronchial Endobronchial

airway trauma
airway trauma
tooth damage tooth damage
lip, tongue, mucosa laceration lip, tongue, mucosa laceration

physiologic reflexes
physiologic reflexes
Hypertension/hypotension Hypertension/hypotension
intracranial, intraocular hypertension intracranial, intraocular hypertension
bronchospasm bronchospasm
Direct Laryngoscopy?
Mallampati Classification
Sensitive but not specific
Has poor positive predictive value when used
alone
Other predictors of difficult airway:
-Small mouth opening [<4cm]
-Short thyromental distance [<6cm]
-Decreased neck extension
-Inability to prognath
El-Ganzouri AR et al. Anesth Analg 1996;82:1197-1204
Karkouti K et al Can J Anesthes 2000;47:730-739
Sniffing position
Sniffing position
Mask Ventilation
Nasal ventilation reduces airway obstruction
compared to oral-nasal ventilation
Lack of teeth and presence of a beard
increase difficulty of achieving optimal mask
ventilation
Changing position of mask can improve
ventilation
Racine SX et al. Anesthesiology 2010;112:1190-3
Liang Y et al Anesthesiology 2008 ;108:998-1003.
Normal Mask
Racine SX et al. Anesthesiology
2010;112:1190-3
Improved Mask
Racine SX et al. Anesthesiology 2010;112:1190-3
Improved Mask
Racine SX et al. Anesthesiology 2010;112:1190-3
Impossible Mask
4 year period evaluated 53,041 cases in
OR
77 cases [0.15%] of impossible mask
ventilation
Factors included neck radiation, male sex,
sleep apnea, Mallampati III or IV, presence
of a beard
Kheterpal S et al. Anesthesiology 2009;110:891-7
Emergency Intubations
High Risk Patients
Older patients
Patients with severe underlying disease
Patients with unstable hemodynamics; the
lower the SBP the higher the chances for
complications
Complications during endotracheal
intubations were associated with higher
mortalities
Jaber S Crit Care Med 2006;34:2355
Differences between Routine and
Emergent Airways
Significant increase in
morbidity/complications-up to 30%
Significant mortality-up to 3%
Long-term survival of patients is 45-55%
Pre-oxygenation is less effective
Induction agents cause significant
hypotension and can result in cardiac arrest
Preoxygenation
Healthy adults breathing RA <90% sat after 2
minutes of apnea
Healthy adults taking 4 vital capacity breaths of 100
oxygen in 30 seconds have Pa02 of ~369mmHg
Preoxygenation less effective to non-effective in
critically ill patients being intubated-- less time for
intubation!
-Intrapulmonary shunts
-Decreased FRC
-Increased oxygen consumption
Benumof JL et al Anesthesiology 1997;87:979-982
Mort TC et al Crit Care Med 2009;37:68-71
Mort TC et al Crit Care Med 2005;33:2672-2675
Question #1- correct answer
In performing emergency tracheal intubations,
airway and hemodynamic complications are
more likely to occur if:
A. Three or more attempts at laryngoscopy are
performed
B. The patient is given a paralytic agent
C. The patient has an NG tube placed
D. A senior anesthesia resident is performing
the procedure
Emergent Intubations
Increasing complications with increased number of
attempts; after 3 attempts see hypoxemia with
saturations <70% in all cases
In patients requiring 3 or more attempts, nearly 1/4
required a surgical airway
Nearly half of the patients intubated outside the OR
have gastric aspiration
2% cardiac arrest rate in this population-
compared to 0.05% in OR
Mort TC J Clin Anesth 2004;16:508
Persistent Attempts
Report on lawsuits involving difficult
intubations-13% involved patients not in OR
All cases outside of OR led to neurologic
damage or death
One fourth of cases involved endotracheal
tube changes and 1/2 involved nonsurgical
patients
**Outcome worse with persistent attempts
before surgical airway
Peterson GN Anesthesiology 2005;103:33
Standardize
Algorithm for prehospital setting- difficult tracheal
intubation [failure to intubate after 2 attempts]
Use gum elastic bougie [GEB] then use Intubating
LMA [ILMA]. If hypoxic for more than 1 minute and
cannot ventilate, or cannot perform GEB and ILMA,
perform cricothyrotomy
2674 patients in France requiring emergent
intubations- 6% difficult [160]--98% adherence to
algorithm.
-151 GEB attempts; 114/151 +
-37 GEB failures-all ventilated via ILMA
-1 cricothyrotomy
Combes X et al Anesthesiology 2011; 114:105-10.
Resident vs Res+ Attending
Competence vs Expertise
Attendings used more muscle relaxants
and narcotics
Presence of attendings led to decrease
complications in all categories; this had been
found previously--senior help decreases
complications
Boylan JF Anesthesiol 2008;109:945
Schmidt UH Anesthesiol 2008;109:973
Jaber S Crit Care Med 2006;34:2355
Question #2-Best answer
You are asked to intubate an acidotic, tachypneic
patient with end-stage cirrhosis, massive ascites
who is hypotensive. You perform a rapid sequence
induction [RSI] and you know:
A. Cricoid pressure occludes the upper esophagus
B. There is agreement as to how to perform RSI
C. Cricoid pressure will improve airway visualization
D. Cricoid pressure can decrease the lower
esophageal sphincter tone
RSI
No standard practice for RSI-incredible variation in
drugs, position
No trials to indicate what is optimal method for
intubation of patients at high risk
Cricoid pressure often displaces esophagus,
makes airway visualization worse, can decrease
lower esophageal sphincter tone, not clear that it
prevents aspiration as fatal aspiration has occurred
even with cricoid pressure
El-Orbany M et al. Anesth Analg 2010;110:1318-25
Hypotension post-
intubation
42-50% in ED intubations developed
hypotension post-intubation
Hypotension post-intubation greatly
influenced by medications given and the
status of patient
Midazolam vs etomidate- 6-10%
incidence with both drugs
Mort T J Intensive Care Med 2007;22:157
Induction Agents and
Hypotension
Mort, Intensive Care Med , 2007
Improve Outcomes
Have more than one person available for airway
management- and preferably person with experience
Have several advanced airway instruments, including
a kit for emergency cricothyrotomy
Initiate positive pressure ventilation carefully as
decrease in preload and afterload may cause
problems with hemodynamics
Consider preoxygenation with NIV in select patients
And do not stop NIV until laryngoscopy
Be ready to initiate CPR and have vasopressors
ready
Use induction agents sparingly-you can always give
more
Techniques
Known Airway Pathology
138 patients s/f upper airway surgery
Topical anesthesia with 100mg of 5%
lidocaine into nares
Performed preoperative endoscopic airway
evaluation [PEAE]--possible SGA?; lesions of
airway??
DL-56%;FOB-43% after PEAE-changed plan
in 26%-- 28 switched to DL and 8 switched to
FOB--reduce attempts in planned airways
Rosenblatt W et al Anesth Analg 2011;112:602-7
Supralaryngeal Ventilation?
Failed tracheal intubation is
inconsequential if ventilation is achieved
by other means
Failure of ventilation by mask should go
to LMA or other technique
Failure to ventilate with LMA, go to
another airway device with visual
capacity or to surgical airway
LMA Not Always Help
Non-fasted patients
Patients with delayed gastric emptying
Patient with severe reflux
A Combitube has esophageal cuff that may
protect against regurgitation
New Proseal LMA has a gastric drain
Combitube and LMA are better than face
mask in preventing gastric insufflation
New Video Devices
Airtraq- battery operated disposable scope;
no alignment of oral, pharyngeal and tracheal
axes needed
LMA C-Trach- video component on the Fast
Trak
McGrath video laryngoscope- single use
blade with video picture; only one blade
Karl Storz video laryngoscope- video
capabilities to laryngoscopes
Glidescope- How Effective?
71,570 intubations at 2 academic centers-
2004 used Glidescope
97% success rate; after failed laryngoscopy-
94% success
Complications in 21/2004 [1%]--6/21 had
dental, pharyngeal, tracheal or laryngeal
injury--keep eyes on ET!
Aziz MF et al. Anesthsiology 2011;114:34-41
Glidescope- How Effective?
60 patients could not be intubated with GVL
-Achieved tracheal intubation with direct
laryngoscopy in 28/60 [47%] or with
-Fiberoptic scope 19/60 [32%] or surgical
airway in 2 [3%]
Failure with GVL: altered neck and throat
anatomy, mass present, surgical scar or
radiation, reduced cervical motion; obesity
not correlate with failure
Aziz MF et al. Anesthsiology 2011;114:34-41
RCT on Airtraq
Prospective, RCT of emergency patients, intubation
by ED or Anesthesiologist
212 patients--success rate with Airtraq was 47% of
106 vs 99% with laryngoscopy
Used Airtraq for 5 cases with manikin--50 intubations
to be facile with laryngoscopy. Manikin not same
VL in the setting of emergency--blood, secretions--
worse than laryngoscopy
Not clear where VL is better than DL with
laryngoscope
Albrecht M et al Crit Care Med 2011;39:591
Trimmel H et al Crit Care Med 2011;39:489-93
Surgical Airways
MGH Algorithm
Gudzenko, Resp Care 2010
Emergency Cricothyrotomy

Get a kit and practice; practice on

Get a kit and practice; practice on
mannequins associated with improved
mannequins associated with improved
comfort using cricothyrotomy kits
comfort using cricothyrotomy kits

If nothing else, 14 gauge angiocath into

If nothing else, 14 gauge angiocath into
cricothyroid membrane, connect to barrel of
cricothyroid membrane, connect to barrel of
syringe, place small endotracheal tube
syringe, place small endotracheal tube

Cut iv barrel in half and stick into airway

Cut iv barrel in half and stick into airway
Wong DT Anesth Analg 2005;100:1439 Wong DT Anesth Analg 2005;100:1439- -46 46
Platts Platts- -Mills TF. Wilderness and Environmental Medicine 2006;17:81 Mills TF. Wilderness and Environmental Medicine 2006;17:81- -6 6
Drugs for Intubation
Give Less
Always give small (trivial) quantities of
medications-you can give more!
If unsure you can secure airway, do not give
a paralytic agent (especially long acting)
Do awake intubations with topical lidocaine
and minimal sedation
Paralytic agents in routine intubations do
improve conditions, may decrease injury to
larynx and may improve oxygenation in
ARDS
Anesthesiol 2003;98: 1049-56;Crit Care Med 2004;32:113-119
Etomidate
Hemodynamic stability via preservation of
sympathetic outflow and maintenance of HR,
SV, cardiac index
Enhances neuromuscular blockade created
by paralytic agents
Reduced dose required in elderly
One dose can be associated with adrenal
suppression for 48 h or longer in trauma
victims, critically-ill patients
Vinclair M et al. Intensive Care Med 2008;34:714-719
Cotton BA et al. Arch Surg 2008;143:62-67
Question #3
Choose the correct answer regarding etomidate
compared to ketamine for emergent intubations:
A. More of the patients receiving ketamine found to
have adrenal insufficiency
B. There were no differences in the intubating
conditions between ketamine and etomidate
C. There was a significant mortality benefit to the
patients receiving ketamine
D. More vasopressors were needed after ketamine
administration
Ketamine vs Etomidate #1
Prospective randomized, controlled, single-blinded
investigation in emergency and ICU services in France
Patients required emergent intubation; randomized 1:1 ratio to
etomidate 0.3mg/kg iv bolus or ketamine 2mg/kg iv bolus
Sch used on all patients; 1mg/kg iv bolus
Sedation after intubation used midazolam 0.1mg/kg/h with
fentanyl 2-5 micrograms/kg/h
Adrenal insufficiency defined as random cortisol of < 276
nmol/L or a difference from baseline concentration of less
than 250nmol/L after 30 or 60 min after adrenocrticotropin
hormone stimulation
Jabre P et al. Lancet 2009;374;293-300
Ketamine vs Etomidate
Ketamine vs Etomidate
Ketamine vs Etomidate
Ketamine vs Etomidate
Ketamine
Structural analogue of phencyclidine
Mechanism of action involves NMDA receptor
Has several metabolites which are somewhat active
Dose-dependent increase in HR and BP but does not
affect responsiveness to carbon dioxide and
preserves the central respiratory drive
Lower doses appears to decrease psychomimetic
adverse effects
Increases cerebral blood flow and ICP--not used in
Neuro ICU patients
Soliman MG et al. Can Anaesth Soc J 1975;22:486-494
Sch vs Sugammadex
Interindividual variability in response to Sch --
range of 5.5 -10.5 minutes for spontaneous
90% recovery from NM blockade
Very little interindividual variability in
recovery times after sugammadex
Comparable recovery times between
sugammadex and Sch
Cannot reverse Sch
Sugammadex
Modified gamma cyclodextrin that encapsulates
aminosteroid, nondepolarizing muscle relaxing
agents
2-4 molecules of sugammadex are required to bind
each molecule of rocuronium-- see increased plasma
concentrations of rocuronium as it comes off
receptors to be bound by sugammadex
Prevents binding to nicotinic receptor at NM
Recovery from profound rocuronium-induced NMB
significantly faster [2.9 min] with sugammadex
[4mg/kg] vs neostigmine [50.4 min]
SparrHJ Anesthesiol 2007; 106: 935; Fields AM Curr Op Anaesth
2007;20:307; Ploeger BA Anesthesiol 2009;110:95; Jones RK Anesthesiol
2008;109:816
Sugammadex #2
Speed of recovery is dose dependent; no
recurarization
No binding to muscarinic receptors--so does not have
the side-effects that anticholinesterase inhibitors
have
Duration of rocuronium paralysis is prolonged in
infants compared to children; recovery times after
dose of 2.0mg/kg sugammadex were similar in
children, adolescents and adults
SparrHJ Anesthesiol 2007; 106: 935; Fields AM Curr Op Anaesth 2007;20:307;
Ploeger BA Anesthesiol 2009;110:95; Plaud B Anesthesiol 2009;110:284
2 Molecules
... A Perfect Fit
CONCLUSIONS

How much time do we have?

How much time do we have?

Be prepared
Be prepared
-
-
have
have
3 plans
3 plans
-
-
involving
involving
only 2 attempts at laryngoscopy
only 2 attempts at laryngoscopy
to
to
secure the airway and have all the
secure the airway and have all the
equipment you need
equipment you need

Evaluate the patient quickly, keep the

Evaluate the patient quickly, keep the
patient breathing if you are worried
patient breathing if you are worried

Titrate sedation to patient

Titrate sedation to patient

s condition
s condition