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Preparing for the Critical Airway-not just the Difficult
Airway-in the PICUJeffrey Burns, M.D., M.P.H.
Chief, Division of Critical Care Medicine
Children’s Hospital Boston
Associate Professor of Anesthesia and Pediatrics
Harvard Medical School
Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU
• The critical airway concept
• The difficult airway algorithms
• Predicting a difficult airway
• The intubation checklist
Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU
• The critical airway concept
• The difficult airway algorithms
• Predicting a difficult airway
• The intubation checklist
Preparing for the Critical Airway-not just the Difficult Airway-in the PICU
“Although technical difficulty is the most feared and studied aspect of airway management, it is not the only aspect impacting the progression of events. The outcome of the critical care airway management is the result of many variables not included in difficult airway management algorithms….”
Matioc, Adrian A. MD; Arndt, George MD; Jofee, Aaron MD The critical airway: The difficult airway in the adult critical care. Critical Care Medicine. 37(3):1175-
1176, March 2009.
Preparing for the Critical Airway-not just the Difficult Airway-in the PICU
• “Airway management in the intensive care unit is not a single provider technical event. The critical airway (CA) concept can be used to address organizational needs for airway management in the intensive care unit. CA management starts with the design of the patient's bed, the workplace (intensive care unit room), and the airway device such that it will allow an ergonomic approach to the patient's airway in minimal time. It also assumes training of the “helping” staff and continuous effort from the airway provider to improve clinical and technical skills.”
Matioc, A; Arndt, G; and Jofee, A: The critical airway: The difficult airway in the adult critical care.[Letter]Critical Care Medicine. 37(3):1175-1176, March 2009.
Preparing for the Critical Airway-not just the Difficult Airway-in the PICU
• The difficult airway has been defined as “the clinical situation in which a conventionally trained anesthetist experiences difficulty with mask ventilation of the upper airway, tracheal intubation, or both”
• Yet all patients in the Pediatric ICU should initially be viewed as having a potentially “critical” airway
• Making the critical care environment as conducive to difficult airway management as the operating room requires planning and teamwork.
Increased oxygen consumption in the pediatric patient: less reserve time to manage the airway
Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU
• The critical airway concept
• The difficult airway algorithms
• Predicting a difficult airway
• The intubation checklist
Intubation Checkl ist
CATEGORY
Assign Roles: 1. Assign roles: If personnel availability permits, a separate person should be assigned to each role. Physician leader Laryngoscopist / Airway management: Identify primary and back-up Medication preparation Medication administration Cricoid pressure Respiratory therapist Monitor watcher / patient assessment
Patient Assessment: 2. Difficult Airway? * * If yes, anesthesia or other back-up should be present. Evaluate and identify problems with: Mandible / Tongue / C-spine ROM If available, check previous anesthesia record
3. Full Stomach? Time of last oral intake? If G-tube or NGT present, aspirate gastric contents / vent G-tube. 4. Patient Position Expose patient: Remove clothing or bedding so that the patient’s entire chest and abdomen are
visible. Align external auditory meatus with the clavicle. Remember BURP (Back Upward Right Position) if visualization difficult. 5. Physiologic Status: Cardiovascular: Preload / Afterload concerns?
*If CV status is depressed, have volume drawn up. Neurologic: ICP concerns? Organ Failures?
6. Access IV line to be used for meds Back-up line, if available Flush IV line with 3cc NS
Equipment / Monitors: 7. Monitors ECG leads on, monitor picking up SaO2 probe on, monitor picking up, tones turned on ETCO2 monitor turned on and ready 8. Set-up (use separate table for intubation equipment): Bag / mask Oxygen flow Suction Laryngoscope: check function of bulb ETT (One larger and one smaller sized tube) Oral airway
Medications: 9. Medications: the physician leader will articulate the choice for medications, reviewing any pertinent considerations raised in No. 5 above. Premed(s) Hypnotic(s) NMBD*
*If succinyl choline is used, review contra-indications: Neuromuscular disorders, hyperkalemia, burns, malignant hyperthermia.
Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU
• The critical airway concept
• The difficult airway algorithms
• Predicting a difficult airway
• The intubation checklist
Predicting a Difficult Airway
•Clinical Examination•mouth opening•back of mouth-Mallampati•?lower teeth ride beyond upper teeth
•Movement of the cervical spine•C2-C8 =nodding to and fro•Delikan warning sign
Predicting a Difficult Airway
Anatomical Distance* Critical DistanceThyro-mental distance 6.0 cm(Patil distance)
Sterno-mental distance 12.5 cm(Savva distance)
*Head fully extended on the neck with mouth closed
Causes of a Difficult Airway
•Improper Positioning•Anatomical Abnormalities•Musculoskeletal Problems•Cervical Rigidity•Temporomandibular Joint Disorders•Inflammatory Processes•Neoplasms•Trauma
Causes of a Difficult Airway
•Improper Positioning
Positioning for Tracheal Intubation
Preparing for the Critical Airway-not just the
Difficult Airway-in the PICU
• The critical airway concept
• The difficult airway algorithms
• Predicting a difficult airway
• The intubation checklist
Would you fly with pilots who did not perform the takeoff checklist?
Intubation Checkl ist
CATEGORY
Assign Roles: 1. Assign roles: If personnel availability permits, a separate person should be assigned to each role. Physician leader Laryngoscopist / Airway management: Identify primary and back-up Medication preparation Medication administration Cricoid pressure Respiratory therapist Monitor watcher / patient assessment
Patient Assessment: 2. Difficult Airway? * * If yes, anesthesia or other back-up should be present. Evaluate and identify problems with: Mandible / Tongue / C-spine ROM If available, check previous anesthesia record
3. Full Stomach? Time of last oral intake? If G-tube or NGT present, aspirate gastric contents / vent G-tube. 4. Patient Position Expose patient: Remove clothing or bedding so that the patient’s entire chest and abdomen are
visible. Align external auditory meatus with the clavicle. Remember BURP (Back Upward Right Position) if visualization difficult. 5. Physiologic Status: Cardiovascular: Preload / Afterload concerns?
*If CV status is depressed, have volume drawn up. Neurologic: ICP concerns? Organ Failures?
6. Access IV line to be used for meds Back-up line, if available Flush IV line with 3cc NS
Equipment / Monitors: 7. Monitors ECG leads on, monitor picking up SaO2 probe on, monitor picking up, tones turned on ETCO2 monitor turned on and ready 8. Set-up (use separate table for intubation equipment): Bag / mask Oxygen flow Suction Laryngoscope: check function of bulb ETT (One larger and one smaller sized tube) Oral airway
Medications: 9. Medications: the physician leader will articulate the choice for medications, reviewing any pertinent considerations raised in No. 5 above. Premed(s) Hypnotic(s) NMBD*
*If succinyl choline is used, review contra-indications: Neuromuscular disorders, hyperkalemia, burns, malignant hyperthermia.
Predicting a Difficult Airway
•Clinical History•Clinical Examination
•Mouth Opening-Mallampati Classification•Jaw Movement•Inspection of the Mouth•Cervical Spine Mobility
•Measurements
“BURP” Displace the Thyroid cartilage Backwards, Upwards, and to the Right
Knill RL. Difficult laryngoscopy made easy with a ‘‘BURP’’. Canadian Journal of Anaesthesiology 1993;40:279–82.
Mind what you have learned. Save your patient it can!
