29
Airway Dr Albert Buchel MD CCFP EM CAC EM. Assistant Professor, Department of emergency medicine Program Director CCFP EM residency University of Manitoba
Airway Dr Albert Buchel MD CCFP EM CAC EM Assistant Professor Department of emergency medicineProgram Director CCFP EM residencyUniversity of Manitoba
CONFLICT OF INTEREST
NONE
AIRWAY TIPSPASSING THE TUBE IS NOT THE ONLY HARD PART
I CAN NOT
Teach you to intubate
Teach you to identify a difficult airway
Teach you to perform a tracheostomy
Teach you about alternative devices such assupra-glottic and rescue devices
ASSUMPTIONS
1 you have basic knowledge of airway assessment and control
2 you have and will likely encounter an emergent or crash intubation
3 intubation will be done via RSI technique or crash intubation
goals1 Review intubating success
rates
2 Define intubation success and difficult airways
3 Discuss the basics in improving first pass success
4 Plug for video laryngoscopy
5 Discuss physiologically difficult airway
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation Marshall SD12 Pandit JJ3
4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub 2015 Dec 16
Take-Home Pointstwo of them
optimize first pass success
do not kill a patient by obtaining an airway- address their physiologic state
Intubation Success
20 defined as difficult airway
3 required a second method
3 to 5 required a second operator
1 failed
15000-110000 canrsquot intubate canrsquot Ventilate
DEFINED ASexcessive force requiredpoor viewmultiple attemptsmultiple operatorsmultiple devices
UTD
POINT 1ALL AIRWAYS SHOULD BE CONSIDERED DIFFICULT
IN ORDER TO MAXIMIXE FIRST PASS SUCCESS
ldquoall practitioners consider the possibility of a difficult airway in every encounter and
plan activelyrdquo
Preoxygenation
Positioning
Video laryngoscopy+-
Pre-oygenation
Apneic Diffusion Oxygenation
Transnasal Humidied Rapid Insufation VentilatoryExchange (THRIVE )
Apneic Diffusion Oxygenation
nasal cannula or an O2 catheter with Up to 15 L o2 in the oropharynxnasal ( as well as the facemask)
significant reduction in incidence of desaturation (SpO2 lt93 ndash 95)Significant reduction in incidence of critical desaturation (SpO2 lt80)Can provide up to 10 min of apneic oxygenationSignificant improvement in first pass intubation success rate
Tip 1-improved first pass
Positioning
the need to reposition a patient in whom there has been a failed or difficult intubation is an
admission of poor planning from the outset
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
CONFLICT OF INTEREST
NONE
AIRWAY TIPSPASSING THE TUBE IS NOT THE ONLY HARD PART
I CAN NOT
Teach you to intubate
Teach you to identify a difficult airway
Teach you to perform a tracheostomy
Teach you about alternative devices such assupra-glottic and rescue devices
ASSUMPTIONS
1 you have basic knowledge of airway assessment and control
2 you have and will likely encounter an emergent or crash intubation
3 intubation will be done via RSI technique or crash intubation
goals1 Review intubating success
rates
2 Define intubation success and difficult airways
3 Discuss the basics in improving first pass success
4 Plug for video laryngoscopy
5 Discuss physiologically difficult airway
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation Marshall SD12 Pandit JJ3
4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub 2015 Dec 16
Take-Home Pointstwo of them
optimize first pass success
do not kill a patient by obtaining an airway- address their physiologic state
Intubation Success
20 defined as difficult airway
3 required a second method
3 to 5 required a second operator
1 failed
15000-110000 canrsquot intubate canrsquot Ventilate
DEFINED ASexcessive force requiredpoor viewmultiple attemptsmultiple operatorsmultiple devices
UTD
POINT 1ALL AIRWAYS SHOULD BE CONSIDERED DIFFICULT
IN ORDER TO MAXIMIXE FIRST PASS SUCCESS
ldquoall practitioners consider the possibility of a difficult airway in every encounter and
plan activelyrdquo
Preoxygenation
Positioning
Video laryngoscopy+-
Pre-oygenation
Apneic Diffusion Oxygenation
Transnasal Humidied Rapid Insufation VentilatoryExchange (THRIVE )
Apneic Diffusion Oxygenation
nasal cannula or an O2 catheter with Up to 15 L o2 in the oropharynxnasal ( as well as the facemask)
significant reduction in incidence of desaturation (SpO2 lt93 ndash 95)Significant reduction in incidence of critical desaturation (SpO2 lt80)Can provide up to 10 min of apneic oxygenationSignificant improvement in first pass intubation success rate
Tip 1-improved first pass
Positioning
the need to reposition a patient in whom there has been a failed or difficult intubation is an
admission of poor planning from the outset
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
AIRWAY TIPSPASSING THE TUBE IS NOT THE ONLY HARD PART
I CAN NOT
Teach you to intubate
Teach you to identify a difficult airway
Teach you to perform a tracheostomy
Teach you about alternative devices such assupra-glottic and rescue devices
ASSUMPTIONS
1 you have basic knowledge of airway assessment and control
2 you have and will likely encounter an emergent or crash intubation
3 intubation will be done via RSI technique or crash intubation
goals1 Review intubating success
rates
2 Define intubation success and difficult airways
3 Discuss the basics in improving first pass success
4 Plug for video laryngoscopy
5 Discuss physiologically difficult airway
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation Marshall SD12 Pandit JJ3
4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub 2015 Dec 16
Take-Home Pointstwo of them
optimize first pass success
do not kill a patient by obtaining an airway- address their physiologic state
Intubation Success
20 defined as difficult airway
3 required a second method
3 to 5 required a second operator
1 failed
15000-110000 canrsquot intubate canrsquot Ventilate
DEFINED ASexcessive force requiredpoor viewmultiple attemptsmultiple operatorsmultiple devices
UTD
POINT 1ALL AIRWAYS SHOULD BE CONSIDERED DIFFICULT
IN ORDER TO MAXIMIXE FIRST PASS SUCCESS
ldquoall practitioners consider the possibility of a difficult airway in every encounter and
plan activelyrdquo
Preoxygenation
Positioning
Video laryngoscopy+-
Pre-oygenation
Apneic Diffusion Oxygenation
Transnasal Humidied Rapid Insufation VentilatoryExchange (THRIVE )
Apneic Diffusion Oxygenation
nasal cannula or an O2 catheter with Up to 15 L o2 in the oropharynxnasal ( as well as the facemask)
significant reduction in incidence of desaturation (SpO2 lt93 ndash 95)Significant reduction in incidence of critical desaturation (SpO2 lt80)Can provide up to 10 min of apneic oxygenationSignificant improvement in first pass intubation success rate
Tip 1-improved first pass
Positioning
the need to reposition a patient in whom there has been a failed or difficult intubation is an
admission of poor planning from the outset
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
I CAN NOT
Teach you to intubate
Teach you to identify a difficult airway
Teach you to perform a tracheostomy
Teach you about alternative devices such assupra-glottic and rescue devices
ASSUMPTIONS
1 you have basic knowledge of airway assessment and control
2 you have and will likely encounter an emergent or crash intubation
3 intubation will be done via RSI technique or crash intubation
goals1 Review intubating success
rates
2 Define intubation success and difficult airways
3 Discuss the basics in improving first pass success
4 Plug for video laryngoscopy
5 Discuss physiologically difficult airway
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation Marshall SD12 Pandit JJ3
4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub 2015 Dec 16
Take-Home Pointstwo of them
optimize first pass success
do not kill a patient by obtaining an airway- address their physiologic state
Intubation Success
20 defined as difficult airway
3 required a second method
3 to 5 required a second operator
1 failed
15000-110000 canrsquot intubate canrsquot Ventilate
DEFINED ASexcessive force requiredpoor viewmultiple attemptsmultiple operatorsmultiple devices
UTD
POINT 1ALL AIRWAYS SHOULD BE CONSIDERED DIFFICULT
IN ORDER TO MAXIMIXE FIRST PASS SUCCESS
ldquoall practitioners consider the possibility of a difficult airway in every encounter and
plan activelyrdquo
Preoxygenation
Positioning
Video laryngoscopy+-
Pre-oygenation
Apneic Diffusion Oxygenation
Transnasal Humidied Rapid Insufation VentilatoryExchange (THRIVE )
Apneic Diffusion Oxygenation
nasal cannula or an O2 catheter with Up to 15 L o2 in the oropharynxnasal ( as well as the facemask)
significant reduction in incidence of desaturation (SpO2 lt93 ndash 95)Significant reduction in incidence of critical desaturation (SpO2 lt80)Can provide up to 10 min of apneic oxygenationSignificant improvement in first pass intubation success rate
Tip 1-improved first pass
Positioning
the need to reposition a patient in whom there has been a failed or difficult intubation is an
admission of poor planning from the outset
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
ASSUMPTIONS
1 you have basic knowledge of airway assessment and control
2 you have and will likely encounter an emergent or crash intubation
3 intubation will be done via RSI technique or crash intubation
goals1 Review intubating success
rates
2 Define intubation success and difficult airways
3 Discuss the basics in improving first pass success
4 Plug for video laryngoscopy
5 Discuss physiologically difficult airway
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation Marshall SD12 Pandit JJ3
4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub 2015 Dec 16
Take-Home Pointstwo of them
optimize first pass success
do not kill a patient by obtaining an airway- address their physiologic state
Intubation Success
20 defined as difficult airway
3 required a second method
3 to 5 required a second operator
1 failed
15000-110000 canrsquot intubate canrsquot Ventilate
DEFINED ASexcessive force requiredpoor viewmultiple attemptsmultiple operatorsmultiple devices
UTD
POINT 1ALL AIRWAYS SHOULD BE CONSIDERED DIFFICULT
IN ORDER TO MAXIMIXE FIRST PASS SUCCESS
ldquoall practitioners consider the possibility of a difficult airway in every encounter and
plan activelyrdquo
Preoxygenation
Positioning
Video laryngoscopy+-
Pre-oygenation
Apneic Diffusion Oxygenation
Transnasal Humidied Rapid Insufation VentilatoryExchange (THRIVE )
Apneic Diffusion Oxygenation
nasal cannula or an O2 catheter with Up to 15 L o2 in the oropharynxnasal ( as well as the facemask)
significant reduction in incidence of desaturation (SpO2 lt93 ndash 95)Significant reduction in incidence of critical desaturation (SpO2 lt80)Can provide up to 10 min of apneic oxygenationSignificant improvement in first pass intubation success rate
Tip 1-improved first pass
Positioning
the need to reposition a patient in whom there has been a failed or difficult intubation is an
admission of poor planning from the outset
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
goals1 Review intubating success
rates
2 Define intubation success and difficult airways
3 Discuss the basics in improving first pass success
4 Plug for video laryngoscopy
5 Discuss physiologically difficult airway
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation Marshall SD12 Pandit JJ3
4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub 2015 Dec 16
Take-Home Pointstwo of them
optimize first pass success
do not kill a patient by obtaining an airway- address their physiologic state
Intubation Success
20 defined as difficult airway
3 required a second method
3 to 5 required a second operator
1 failed
15000-110000 canrsquot intubate canrsquot Ventilate
DEFINED ASexcessive force requiredpoor viewmultiple attemptsmultiple operatorsmultiple devices
UTD
POINT 1ALL AIRWAYS SHOULD BE CONSIDERED DIFFICULT
IN ORDER TO MAXIMIXE FIRST PASS SUCCESS
ldquoall practitioners consider the possibility of a difficult airway in every encounter and
plan activelyrdquo
Preoxygenation
Positioning
Video laryngoscopy+-
Pre-oygenation
Apneic Diffusion Oxygenation
Transnasal Humidied Rapid Insufation VentilatoryExchange (THRIVE )
Apneic Diffusion Oxygenation
nasal cannula or an O2 catheter with Up to 15 L o2 in the oropharynxnasal ( as well as the facemask)
significant reduction in incidence of desaturation (SpO2 lt93 ndash 95)Significant reduction in incidence of critical desaturation (SpO2 lt80)Can provide up to 10 min of apneic oxygenationSignificant improvement in first pass intubation success rate
Tip 1-improved first pass
Positioning
the need to reposition a patient in whom there has been a failed or difficult intubation is an
admission of poor planning from the outset
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
Take-Home Pointstwo of them
optimize first pass success
do not kill a patient by obtaining an airway- address their physiologic state
Intubation Success
20 defined as difficult airway
3 required a second method
3 to 5 required a second operator
1 failed
15000-110000 canrsquot intubate canrsquot Ventilate
DEFINED ASexcessive force requiredpoor viewmultiple attemptsmultiple operatorsmultiple devices
UTD
POINT 1ALL AIRWAYS SHOULD BE CONSIDERED DIFFICULT
IN ORDER TO MAXIMIXE FIRST PASS SUCCESS
ldquoall practitioners consider the possibility of a difficult airway in every encounter and
plan activelyrdquo
Preoxygenation
Positioning
Video laryngoscopy+-
Pre-oygenation
Apneic Diffusion Oxygenation
Transnasal Humidied Rapid Insufation VentilatoryExchange (THRIVE )
Apneic Diffusion Oxygenation
nasal cannula or an O2 catheter with Up to 15 L o2 in the oropharynxnasal ( as well as the facemask)
significant reduction in incidence of desaturation (SpO2 lt93 ndash 95)Significant reduction in incidence of critical desaturation (SpO2 lt80)Can provide up to 10 min of apneic oxygenationSignificant improvement in first pass intubation success rate
Tip 1-improved first pass
Positioning
the need to reposition a patient in whom there has been a failed or difficult intubation is an
admission of poor planning from the outset
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
Intubation Success
20 defined as difficult airway
3 required a second method
3 to 5 required a second operator
1 failed
15000-110000 canrsquot intubate canrsquot Ventilate
DEFINED ASexcessive force requiredpoor viewmultiple attemptsmultiple operatorsmultiple devices
UTD
POINT 1ALL AIRWAYS SHOULD BE CONSIDERED DIFFICULT
IN ORDER TO MAXIMIXE FIRST PASS SUCCESS
ldquoall practitioners consider the possibility of a difficult airway in every encounter and
plan activelyrdquo
Preoxygenation
Positioning
Video laryngoscopy+-
Pre-oygenation
Apneic Diffusion Oxygenation
Transnasal Humidied Rapid Insufation VentilatoryExchange (THRIVE )
Apneic Diffusion Oxygenation
nasal cannula or an O2 catheter with Up to 15 L o2 in the oropharynxnasal ( as well as the facemask)
significant reduction in incidence of desaturation (SpO2 lt93 ndash 95)Significant reduction in incidence of critical desaturation (SpO2 lt80)Can provide up to 10 min of apneic oxygenationSignificant improvement in first pass intubation success rate
Tip 1-improved first pass
Positioning
the need to reposition a patient in whom there has been a failed or difficult intubation is an
admission of poor planning from the outset
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
POINT 1ALL AIRWAYS SHOULD BE CONSIDERED DIFFICULT
IN ORDER TO MAXIMIXE FIRST PASS SUCCESS
ldquoall practitioners consider the possibility of a difficult airway in every encounter and
plan activelyrdquo
Preoxygenation
Positioning
Video laryngoscopy+-
Pre-oygenation
Apneic Diffusion Oxygenation
Transnasal Humidied Rapid Insufation VentilatoryExchange (THRIVE )
Apneic Diffusion Oxygenation
nasal cannula or an O2 catheter with Up to 15 L o2 in the oropharynxnasal ( as well as the facemask)
significant reduction in incidence of desaturation (SpO2 lt93 ndash 95)Significant reduction in incidence of critical desaturation (SpO2 lt80)Can provide up to 10 min of apneic oxygenationSignificant improvement in first pass intubation success rate
Tip 1-improved first pass
Positioning
the need to reposition a patient in whom there has been a failed or difficult intubation is an
admission of poor planning from the outset
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
Preoxygenation
Positioning
Video laryngoscopy+-
Pre-oygenation
Apneic Diffusion Oxygenation
Transnasal Humidied Rapid Insufation VentilatoryExchange (THRIVE )
Apneic Diffusion Oxygenation
nasal cannula or an O2 catheter with Up to 15 L o2 in the oropharynxnasal ( as well as the facemask)
significant reduction in incidence of desaturation (SpO2 lt93 ndash 95)Significant reduction in incidence of critical desaturation (SpO2 lt80)Can provide up to 10 min of apneic oxygenationSignificant improvement in first pass intubation success rate
Tip 1-improved first pass
Positioning
the need to reposition a patient in whom there has been a failed or difficult intubation is an
admission of poor planning from the outset
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
Pre-oygenation
Apneic Diffusion Oxygenation
Transnasal Humidied Rapid Insufation VentilatoryExchange (THRIVE )
Apneic Diffusion Oxygenation
nasal cannula or an O2 catheter with Up to 15 L o2 in the oropharynxnasal ( as well as the facemask)
significant reduction in incidence of desaturation (SpO2 lt93 ndash 95)Significant reduction in incidence of critical desaturation (SpO2 lt80)Can provide up to 10 min of apneic oxygenationSignificant improvement in first pass intubation success rate
Tip 1-improved first pass
Positioning
the need to reposition a patient in whom there has been a failed or difficult intubation is an
admission of poor planning from the outset
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
Apneic Diffusion Oxygenation
nasal cannula or an O2 catheter with Up to 15 L o2 in the oropharynxnasal ( as well as the facemask)
significant reduction in incidence of desaturation (SpO2 lt93 ndash 95)Significant reduction in incidence of critical desaturation (SpO2 lt80)Can provide up to 10 min of apneic oxygenationSignificant improvement in first pass intubation success rate
Tip 1-improved first pass
Positioning
the need to reposition a patient in whom there has been a failed or difficult intubation is an
admission of poor planning from the outset
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
Positioning
the need to reposition a patient in whom there has been a failed or difficult intubation is an
admission of poor planning from the outset
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
Position number 1Patients Position
SNIFFING
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
From Benumof JL Conventional (laryngoscopic) orotracheal and nasotracheal intubation (single lumen type) In Benumof JL (ed) Clinical Procedures in Anesthesia and Intensive Care Philadelphia JB Lippincott Co 1992 p 123
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
Dynamic Positioning
Do not anchor on a static position
Tip 2-improved first pass
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
Position number 2Tracheal position
CRICOID PRESSURE
BURP(backward-upward-rightward pressure)
BIMANUAL EXTERNAL LARYNGEAL MANIPULATION
LARYNGEAL VIEW DURING LARYNGOSCOPY A RANDOMIZED TRIAL COMPARING CRICOID PRESSURE BACKWARD-UPWARD-RIGHTWARD PRESSURE AND BIMANUAL LARYNGOSCOPY Levitan RM et al Ann Emerg Med 27(6)548 June 2006
Tip 3 improved first pass
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
Video larnyngoscopy
CMAC
90 first pass
97 beyond pgy1 1st
operator
GLIDESCOPE
80 First pass
97 beyond PYY1 1st
operatorDirect Laryngoscopy
83 First Pass97 1st operator
Tip 4 --maybe
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
Intubation Success Part Two
PHYSIOLOGICALLY DIFFICULT AIRWAY
25 become hypotensive
3 of hypotensive patients have full cardiac arrest
NEAR III (national emergency airway registry)
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
The Physiologically Difficult Airway
① Hypoxia pre intubation
② Hypotension
intravascularly depleted shock index gt 8
① Right ventricular failure
Right MI
① Severe metabolic acidosis
THE PHYSIOLOGICALLY DIFFICULT AIRWAY Mosier JM et al West J Emerg Med 16(7)1109 December 2015
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
medications cause hypotensionhypoxia
positive pressure ventilation decreases venous return
PEEP increases right heart out flow pressures
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
What To Do
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
STATE 1 ---------Hypoxia
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
Hypoxia
STATE 2 AND 3hellip
Hypotension Right ventricular failure Assess volume status using IVC ultra sound(controversial)
Volume reponders IV fluid bolus
Volume NON responders pre arrest Push dose pressors epinephrine 5-20 mcg iv
Take a 10 ml syringe with 9 ml of normal saline
Into this syringe draw up 1 ml of epinephrine from the car-diac amp (Cardiac amp contains Epinephrine 100 mcgml) 10 mls of Epinephrine 10 mcgml
Onset-1 minuteDuration-5-10 minutesDose-05-2 ml every 2-5 minutes (5-20 mcg) Weingart August 2017 Emcrit podcast (205) for information dosing to be checked with local pharmacy
Tip 5
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
Hypoxia
Hypotension Right ventricular failure
Assess volume status using IVC ultra sound (controversial)
Volume reponders
IV fluid bolus
Volume NON responders pre arrest
Push dose pressors epinephrine 5-20 mcg
lowest dose of induction agent
STATE 4 hellip
Metabolic acidosis delayed sequence intubation(just ventilate)
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
SummaryMake sure the patient needs to be intubated
Assume all airways are difficult and optimize 1st pass success
Optimize positioning of both physician and patientSniff position
Active head manipulation External larangeal manipulation
Consider video laryngoscopy
Optimize intubation outcome by optimizing difficult physiological states prior to or during incubation Passive apneic diffusion oxygenation Fluids
Push dose pressors
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
THE PHYSIOLOGICALLY DIFFICULT AIRWAYMosier JM et al West J Emerg Med 16(7)1109 December 2015
Radical evolution the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubationMarshall SD12 Pandit JJ3 4Anaesthesia 2016 Feb71(2)131-7 doi 101111anae13354 Epub2015 Dec 16
Pavlov I et al Apneic Oxygenation Reduces the Incidence of Hypoxemia During Emergency Intubation A systematic Review and Meta-Analysis Am J Emerg Med 2017 [Epub Ahead of Print] PMID 28647137
Binks MJ et al Apneic Oxygenation During Intubation in the Emergency Department and During Retrieval A Systematic Review and Meta-Analysis Am J Emerg Med 2017 S0735 ndash 6757 (17) 30497 PMID 28684195
Oliveira L et al Effectiveness of Apneic Oxygenation During Intubation A systematic Review and Meta-Analysis Ann Emerg Med 2017 [epub ahead of print
wwwuptodate com Approach to the difficult airway in adults outside the operating room
wwwuptodatecom Devices for difficult airway management outside the or]
