SCCM Resource Library-Airway Management in Critically Ill Patients

Pdf Summary

The document discusses critical care aspects of tracheal intubation (TI) in critically ill patients, highlighting its complexities and high risks, particularly cardiovascular collapse. The INTUBE study data shows significant adverse events during TI. Patients often have a "physiologically difficult airway," exacerbating risks through repeated attempts and anatomic or logistical challenges. Optimal preparation and teamwork are crucial to minimizing complications.<br /><br />Challenges include assessing the airway in the ICU due to factors like patient condition or urgency, leading to poor evaluations. Structural or personnel limitations can exacerbate these difficulties, creating stressful situations for healthcare providers and increasing error risks. Inadequate preparation and protocol deviations, often due to cognitive overload, contribute to medical errors in airway management.<br /><br />The document emphasizes preparation, including team training and use of checklists, although reliability of checklists varies. A well-prepared team should have defined roles and use closed-loop communication. Team and patient preparations focus on preventing complications, like peri-intubation hypoxemia or hypotension, and employing strategies like preoxygenation using noninvasive ventilation methods.<br /><br />In drug selection for TI, agents like ketamine and etomidate are favored for their stable hemodynamic profiles, while neuromuscular blockers improve intubation conditions despite risks of apnea. Video laryngoscopy provides better visualization but, controversially, not always better outcomes compared to direct laryngoscopy. Accurate tube placement confirmation, crucial to prevent severe outcomes, should use capnography.<br /><br />Ultimately, reducing adverse TI events involves anticipation of challenges, effective team dynamics, and careful selection and use of equipment and medications, all aimed at improving patient outcomes.

Asset Subtitle

Pulmonary, Procedures, 2022, 0:11:00

Asset Caption

"This article was first published in the Fall 2022 issue of Critical Connections.

Tracheal intubation (TI) is one of the most common airway management procedures in critically ill patients and is associated with a high risk of complications, most noticeably hemodynamic compromise leading to cardiovascular collapse. The INTUBE study reported periintubation adverse events in 45.2% of patients, including cardiovascular instability in 42.6%, severe hypoxemia in 9.3%, and cardiac arrest in 3.1%. These patients have what is referred to as a “physiologically difficult airway,” wherein the patients’ physiologic perturbations predispose them to a high risk of cardiovascular collapse with TI and conversion to positive pressure ventilation. This baseline physiologic risk is often exaggerated with multiple attempts at TI. Anatomic and logistical challenges with airway management are also common in these patients. Meticulous preparation, teamwork, and optimization of the patient’s physiology before the procedure are important to prevent complications. Reducing repeated attempts at TI, improving periintubation oxygenation, and hemodynamic optimization before the procedure are some steps that can reduce morbidity and mortality.

Critical Connections, the critical care industry's only magazine, provides information on cutting-edge topics in critical care useful to the entire multiprofessional team."

Meta Tag

Content Type Article

Knowledge Area Pulmonary

Knowledge Area Procedures

Knowledge Level Intermediate

Knowledge Level Advanced

Learning Pathway Skills and Procedures

Membership Level Associate

Membership Level Professional

Membership Level Select

Tag Airway Management

Year 2022

Keywords

tracheal intubation

critical care

cardiovascular collapse

physiologically difficult airway

teamwork

checklists

peri-intubation hypoxemia

noninvasive ventilation

video laryngoscopy

capnography

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