Airway
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Artificial plastic airways are not benign - loss of the airway can be life-threatening.
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Critically-ill patients will have more difficult airways than elective patients undergoing airway procedures
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Critically-ill patients will tolerate intubation less well than elective patients
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Critically-ill patients will be more difficult to extubate than elective surgical patients
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Safety around airways is a key part of the safety culture of good ICUs and ICU teams-this includes simple well rehearsed procedures for airway emergencies
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Patients may be safer without an artificial plastic airway than with one
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Airway obstruction can occur for reasons beyond the airway - this can be more distal (granuloma, tumour, mucous or blood clot) OR it can be more proximal (catheter mount, HME)
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Do not ignore an airway leak in a ventilated patient - it will not just 'go away' or 'get better' - safely establish what the cause is and how it can be resolved
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Sign-posting difficult airways means identifying patients who may be difficult to intubate OR ventilate (by bag-face mask)
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Incorrectly labelling airways as 'difficult' is dangerous
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Airway difficulty is not a fixed parameter - 'normal' airways can become difficult; 'difficult' airways' can become 'normal': physical or electronic system labels must be kept up to date
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End-tidal CO2 is mandatory in ALL critically ill patients at ALL times.
more difficult to pre-oxygenate, more likely to derecruit, more likely to aspirate, less easy to wake up in the context of a failed intubation, less tolerant of the sedation and muscle relaxants required to intubate.
NO TRACE = WRONG PLACE : If a patient is intubated, even in the setting of cardiac arrest, and there is NO End-tidal CO2 trace, the airway must always be assumed to be in the WRONG PLACE and urgent action MUST be taken.
It is also important to consider how the native airway might be affected by devices such as endotracheal tubes or tracheostomies both in the short and long-term. Vocal cord injury and tracheal pathology are common after prolonged ICU airway support.
ICU teams must have clear protocols around managing the airway in the context of critical illness: checklists for intubation, tracheostomy, failed intubation, cant' intubate-can't ventilate and extubation.
Common Acronyms include RSI (=Rapid Sequence Induction), which is the technique for minimising the time between giving sedation and muscle relaxants and securing the airway); CICV (Can't intubate and can't ventilate) and FONA (=Front of Neck Access) which is the generic technique of obtaining an airway if there is a failed oral/nasal intubation, particularly in the setting of inability to ventilate).
Important to know
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This section provides information about the ICU airway which involves the placement and management of cuffed endotracheal and tracheostomy tubes to support critically ill patients. In the UK over 60,000 patients per year receive an airway associated with an ICU admission.
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It is possible to oxygenate and ventilate a patient without intubating them. Beware distraction error. The priority is providing oxygen to the heart and brain.
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The safe and evidenced-base use of airways in the intensive care setting receives a relative lack of attention when compared with ventilation or circulation.
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Airway mangement (suctioning, tracheostomy care/airway weaning) receives less attention within critical care workflow.
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Extubation requires as much attention as intubation, and this must include a clear post-extubation plan.
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Critically ill patients have more difficult airways but less resources-human and equipment than elective anaesthetic patients
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Patients with tracheostomies will require ongoing resource even after discharge from critical care and are recognised as having more risk associated with transfer of care.
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Decisions taken in relation to airway management during a period of supportive care can affect patients for the rest of their lives and airway interventions are not benign.
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The relative contribution of artificial airways to work of breathing is poorly understood both during ventilation and at the time of spontaneous breathing trials. There is a limited evidence base around this and significant uncertainty.
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The inability to communicate, drink & eat when a patient has an ETT or tracheostomy are significant issues for patients and a driver for delirium.
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Adverse events in relation to ICU airways are under reported.
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It is important to identify patients who have a difficult airway in the ICU, and clearly document the nature of the known or predicted difficulty.
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It is possible to examine the airway of a patient in the ICU BEFORE a sedation hold/spontaneous breathing trial in order to visualise the airway with both direct and indirect laryngoscopy. Video and still images should be recorded if possible.
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It is important not to label a patient as having a 'difficult' airway if they do not have a difficult airway, because it may adversely alter behaviour around this patient (eg using more sedation; delayed attempts to perform sedation holds).
Key References
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Young D et al. 2013. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the Trachman randomized trial. JAMA 309: 2121-9. DOI: 10.1001/jama.2013.5154
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Andriolo BNG et al. 2015. Early versus late tracheostomy for critically ill patients. Cochrane Database Syst Rev 1(1): CD007271.DOI: https://doi.org/10.1002/14651858.cd007271.pub3
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Brass P et al. 2016. Percutaneous techniques versus surgical techniques for tracheostomy. Cochrane Database Syst Rev 7(7): CD008045. 10.1002/14651858.CD008045.pub2
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Cook TM et al. 2011. Major complications of airway management in the UK: results of the fourth national audit project of the Royal College of Anaesthetists and The Difficult Airway Society. Part 2: intensive care and emergency departments. Brit J Anaesth 106: 632-42. DOI: 10.1093/bja/aer059
