Download Airway Lecture - UTHSCSA

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.