AIRWAY MANAGEMENT IN THE ICU

Rachel Garvin, MD

Assistant Professor, Neurosurgery

Neurocritical Care

October 5, 2012

• Goals of this Lecture

To give you some comfort level with airways and tips to help your patient

Topics to be covered• Why airway is so important• Why patients with neurologic injury have airway issues• Airway Anatomy• Causes of compromised airway• Airway Evaluation• Airway Adjuncts• Drugs

Why is airway management so important in the NeuroICU?• Hypoxemia contributes to secondary brain injury• Brain injured patients have numerous reasons to have

airway compromise• You should have an understanding of basic airway

management to aid in your patient’s care

• Study by Rincon et al looked at ARDS/ALI in TBI• Prevalence of 22% with mortality of 28%• Significant increase in prevalence over the past 20 years• More common in young white males

Neural control• Corticobulbar tract• Lower CN’s• Nucleus ambiguus • Several respiratory centers

• Dorsal medulla• Ventral medulla• Dorsal rostral pons

• C-spine/Upper T-spine

Why do neuro patients have respiratory failure?

• As a result of their primary injury• Due to secondary injury• Other injuries• Development of respiratory infection• Development of ARDS

• Corral et al looked at non-neurologic complications in severe TBI patients

• Respiratory infections in 68% of severe TBI patients• Mortality not increased but hospital LOS, time on

mechanical ventilation increased

Why is it important to understand airway anatomy?• Airway Obstruction – where is it?• Will my rescue devices work?• What is happening in laryngospasm?• What if I need to crich someone?

Concerning Airway

Airway Anatomy

Airway Anatomy

Conditions that can compromise airway

• Degree of wakefulness• Aspiration• Body habitus• Concurrent injuries• Medications• Co-morbidities

Airway Evaluation

Airway Evaluation

Airway Evaluation

Airway Evaluation• Facial Features

• Beard, no teeth, buck teeth, dentures, recessed jaw

• Neck• Short neck, landmarks unclear

• Limited Mobility• C-collar, arthritis

Airway Evaluation

3-3-2 Rule

Quick Assessment: • Mouth: how much can they open it?• Tongue: how much can they protrude it?• Jaw: mobility• Neck: mobility

Airway Adjuncts – what you can do before calling anesthesia• Positioning• Plastic in orifices• Preoxygenate• Jaw Thrust• Check sedation

Positioning

Positioning

Plastic

Placing a nasal trumpet• Placed with bevel towards turbinates• Left sided goes in angled down• Right sided goes in facing upward and then turned

Placing an Oral Airway• Pick the appropriate size

• 3-4 for small adult, 4-5 medium, 5-6 large

• Insert facing upward and then rotate down• Do not use in an awake patient

Preoxygenate

Oxygen Delivery: High vs Low Flow• Nasal Cannula• Simple Face Mask• Nonrebreather Face Mask• Venti Mask

Flow does NOT = FiO2

LMA

BVM Technique

BVM Technique

If all else fails…..

What drugs do you want?• Sedatives• Paralytics

Sedatives• Etomidate• Propofol• Ketamine

Etomidate• GABA like effects• Minimal effect on BP; can lower ICP• Can reduce plasma cortisol levels• Hepatic metabolism; renally excreted• Dose 0.3mg/kg

Propofol• Anesthetic agent• Respiratory and CV depressant can drop BP by as

much as 30%• Vasodilation and negative inotropic effect

• Dose is 1-1.5mg/kg

Ketamine• Anesthetic and dissociative agent• Hepatic metabolism• Can cause laryngeal spasm, hypertension• Emergence reaction give benzo with it• 1-2mg/kg

Paralytics• Succinylcholine• Vecuronium• Rocuronium• Cisatricurium

If you don’t think you can BVM someone, don’t paralyze them!!

Succinylcholine• Only depolarizing NMB• Avoid in hyperkalemia, 24 hour post major burn,

neuromuscular disease, patients with several days of ICU critical illness

• Onset in 60 seconds and lasts around 5 minutes• 1-1.5mg/kg

Rocuronium• Nondepolarizing• Onset about 90 seconds and last 30-40 minutes• Lasts longer in those with hepatic impairment• Dose is 0.6-1mg/kg• Effect is dose dependent

Vecuronium• Similar to rocuronium• Slower onset time (up to 4 minutes)• Lasts 40-60 minutes• 0.08-0.1mg-kg

Conclusion• Appropriate airway management is crucial in patients with

brain injury• Remember your airway anatomy and assessment in

patient evaluation• Use your adjuncts to help you• Be vigilant in the drugs being given to your patients if

intubation is required

Questions?

References• Corral L, Casimiro JF, Ventura JL, Marcos P, Herrero JI, Manez R. Impact of non-neurologic

complications in severe traumatic brain injury outcome. Critical Care 2012; 16:R44.• Karanjia N, Nordquist D, Stevens R, Nyquist P. A Clinical Descriuption of Extubation Failure in

Patients with Primary Brain Injury. Neurocritical Care 2011; 15:4-12.• Rincon F, Ghosh S, Dey S, Maltenfort M, Vibbert M, Urtecho J, McBride W, Moussouttas M, Bell R,

Ratliff J, Jallo J. Impact of Acute Lung Injury and Acute Respiratory Distress Syndrome After Traumatic Brain Injury in the United States. Neurosurgery 2012; 71:795-803.

• Wong E, Yih-Yng Ng. The Difficult Airway in the Emergency Department. Int J Emerg Med, 2008: 1:107-111.