ICU Airway Management

Perhaps because most of our Intensivists are part time Anaesthetists the UK  discussion of critical care airway management is eclipsed by the vociferous new world considerations of this topic, with many examples of what we/I would consider extreme such as the routine preparation for “emergency cric’s” in emergency patients.

On that note, this month’s questions:

1. What drugs should we be using for critical care intubation and why?

2. Does anyone or has anyone tried avoiding relaxant as has been suggested by, amongst others, Rob MacSweeney?

3. Should all ICU patients be intubated with a McGrath?

This month’s paper:  Do you use BMV whilst you intubate critically ill patients?  https://www.ncbi.nlm.nih.gov/pubmed?term=30779528

 

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A –

Happy to kick off !!

1. My preference for sick patients is diazemules 10 mg plus / minus fentanyl and choice of relaxants ( atracurium or Roc)  Picked this up years ago from Andy C and has been my goto mix since. Adequately obtunds conscious level and avoids  propofol  – and better Cvs stability in sick patients than midazolam.  Only down side can take a few minutes to get hold of it outside ICU.

2. Often do Avoid relaxants in severely obtunded patients with reduce reflexes  but not routinely.

3.No.

B –

Can I add in a fourth question, viz. should we have ODP assistance when intubating a patient on the ICU?

C – 

1. Diazemuls or midazolam, whatever can be found most quickly, roc
2. I don’t see much benefit in risking less-than-perfect intubation conditions, and I always use relaxant
3. I suspect/predict that all intubations across the hospital will be with a video laryngoscope in the next decade. This might result in fewer difficult and failed intubations overall, in a cohort that has the highest incidence of airway issues. I will continue to use a mackintosh blade until someone prizes it from my cold, dead hands.

D – 

Personally I think yes to ODP….. in the context of NAP4 recognised issues on icu and eg increasingly obese pts in saggy icu beds (which is always a much more suboptimal position) than a theatre situation + an increasingly high turnover/ less experienced icu nursing workforce … I think where possible extra help from a skilled  ODP workforce must be a good thing….

E – 

My thoughts.

Patients are usually hypoxic to start with so time limited and potentially stressful situation.

I think you need two experienced clinicians – one to do drugs and blood pressure, the other to concentrate on airway.

Experienced ODP would be ideal as they deal with intubations frequently and know what equipment to have to hand.

In terms of induction agents and relaxants I think how they are used is more important than what is used (within reason!)  – you could argue a case for all the recipes out there.

Video scopes are surely a good thing and ought to be available everywhere in this day and age.

F –

​I agree with E!

My only caveat is that I get nervous when I see trainees drawing up the 20ml of propofol…..

G – 

I’m in agreement with the comments below  – optimal pre-peri oxygenation (I do variably use BVM in a patient-dependent manner and think James’ attached article supports it), use of muscle relaxant, best available airway device and trained assistance. 

 

Would be nice to have all the ICU nurses empowered and able to act as trained airway assistants, but sadly the skill-mix sometimes dictates that I do get an ODP – especially if expected to be particularly tricky for whatever reason.

DOI: In response to the multi-faculty endorsed Guidelines for the Management of Tracheal Intubation in Critically Ill Adults published in the BJA last year 

https://bjanaesthesia.org/article/S0007-0912(17)54060-X/fulltext (the PDF is 3Mb but can circulate if anyone wants it)

and changing face of the junior ICM workforce (fewer anaesthetists by trade), a few of us have been working on updating the current Trust trauma intubation guideline to enable its use across all intubations of critically ill adults regardless of location – an obviously very heterogeneous group – both of patients and clinicians!. It incorporates the predominant recommendations from the above, combined with aspects from existing checklists including from the earlier version from the ICS and pre-hospital sources. I know checklists are a bit marmite, but the evidence for their use to prevent disaster is growing and they are more valued by the less “expert” amongst us – I obviously include myself in that bracket! 

 

I’ve attached the most recent version, and there is also a standardised intubation “kit mat” for use at the bedside/with outreach to speed-up and standardise the available kit (and empower the newer nursing staff to know what things are when we ask for them and not have to ask about every item on the list!). The image file is bit large to circulate here.

 

Also interestingly, and in response to E’s comment, in the guidelines the concept of the “airway team’ is emphasised – I’ve attached the pictures of the suggested make-up of said team. It involves significantly more people than the solo trainee doing both drugs and airway with an ICU nurse passing stuff and doing cricoid!

H – 

I don’t work in ICU, but love these QOTM threads.

Normally reluctant to contribute, as most topics go way over my head.

Dr Sira has though encouraged me to “wade in”, if I’m preaching to the choir, I apologise!

With regards emergency airway management though there’s a few papers that might be worth flagging, all relating to pre-oxygenation technique.

The first has changed my practice and is basically “poor mans thrive”.

https://www.ncbi.nlm.nih.gov/m/pubmed/25536868/

Above link is related to emergency RSI prehospitally, which probably has some parallels to ICU. (Sick patients needing intubation in a hurry)

Sticking a set of nasal cannula up your patients nose, and turning the flow meter up to “max” seems to help prevent desaturation as you intubate. Apneic oxygenation concept and doing it this way only costs a few pence.

I do it in theatres on anyone that I think might be difficult to oxygenate, or who might desaturate quickly.

On a similar thread, those clever Germans have done an RCT into formal HFNO via proper systems akin to those used in the THRIVE trial whilst performing Intubations on ICU.

https://www.ncbi.nlm.nih.gov/m/pubmed/30666367/

It’s hot off the press, and probably pertinent to this discussion.

Final thought is that pre-oxygenation should be done with a system that can deliver positive pressure (e.g a waters circuit) not a self inflating ambu bag type device or a non-rebreathe mask.

Lots of evidence that a small amount of “PEEP” during preoxygenation, increases the time from induction to desaturation. This is one example of its effects albeit not in ICU patients.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2044.2004.03615.x

My humble two penneth worth.

I – 

It is great to hear the views from the motherland.

As our ICU workforce is different here in OZ( most of us are ICM specialist only). For those cases with difficult airway, we usually call the consultant anaesthetist to help with the intubation and the ICM consultant deals with drugs etc. Unless the ICM specialist is anaesthetist which is less than 10% of us then we get the trainee to help with the drugs. I am not a big fan of propofol induction in those sick patients, I use Andy Cohen’s recipe.

Unfortunately we do not call the anaesthetic nurses, but we have a senior ICU airway nurse on each shift.

Video laryngoscopes are the first choice device here, however I still like my Macintosh blade and boogie

THRIVE is a good option with the mapleson C as preoxygenation device and we use it routinely

J – 

This is a great QOTW and I am learning loads. I especially love the idea of “poor man’s thrive” as a way of delivering some persistent oxygenation during the period I have removed the face mask.
I agree with E’s view that it is not the exact drug but the way you use it that is important, and with C’s view that muscle relaxants simply ensure optimal intubating conditions. I would add a peripheral vasopressor to my induction choice though (metaraminol), as I think it is an essential component not a desirable one.
I agree with G’s modification of B and D’s approach to ODPs. I think the labelling of a requirement for an ODP possibly narrows the field a little. I think they are essential for intubations outside the ICU (EM, ward) but on the ICU the requirement should be a skilled anaesthetic assistant rather than specifically an ODP. I hate the idea of moving towards prepping for an emergency cric on everyone but I fully agree with an attempt to standardise the intubation process and optimise the safety during it. The “4 man” intubation technique on G’s slide would best fit with how I would advocate most ITU intubations should be done. I think moving towards this model would allow the training up of the ICU nurses to allow more people to become familiar with the process, ultimately improving safety and reducing the need for an ODP in all situations.
However, I think this also brings us on to a related topic. I strongly feel that there is a difference between an urgent ICU intubation (tube change, need for intubation soon) and emergency airway management. The former can be done by assembling a team and following the process (+/- checklist) that G suggests. The latter should have intubation only as a last resort and can be delivered by anyone on ICU. Therefore, I think we should also be focusing our education on basic airway skills. I think everyone should be trained on airway manoeuvres, bag and mask and supraglottic airways, and should be retrained on this regularly.  This would hopefully demystify some of the airway techniques, improve outcomes in emergencies and help us come to terms with the changes to staffing on ICUs currently and in the future.
Many of you will have heard me bang on about this but I feel we should more away from “airway trained” being considered to mean “able to intubate” and move towards it meaning “able to deliver safe, emergency airway support whilst an intubation team is assembled”. GPICS2 states “All staff that contribute to the resident rota must have basic airway skills. All critical care units must have immediate 24/7 on-site access to a doctor or ACCP with advanced airway skills”.
I highlight that this states “on-site ACCESS” not “residence”.
Or have I gone completely off the reservation?

K – 

My drug choice varies between physiological parameters, but I’m a fan of midazolam, ketamine, roc in unstable patients.

I don’t usually use cricoid (but have done twice this week), and I bag-mask ventilate, but with low pressures.

The college mandates a ‘trained assistant’ rather than an ODP.  I can be fairly confident that I can find one of those on the unit, but less so in ED.

I’m a bit behind the times in adopting checklists for everything, but I’m gratefully reminded by keen trainees, who usually then find some essential bit of kit that I’ve forgotten.  Please carry on!

In response to the Head of School,  ‘Basic airway skills’ are not defined, but probably equate to ALS, which the majority of our medical, ACCP and some senior nurses hold.  I’m not sure what airway skills are taught on ILS, but I suspect most of the band 5’s could be considered to have basic airway skills, so you are right that an ‘intubation team’ can be ‘accessed’ from elsewhere.  Before getting rid of all our resident doctors with advanced airway training, we should define who, what, and where that help comes from.

L – 

Great QOTM

Agree any drug at right titrated dose can be used, though I have a penchant for Ketamine…, and palpitations at the sight of 20ml of propofol

Really like the poor mans thrive, used it several times.

Not used cricoid for a while, probably related to inexperienced people trying to do it badly prior to that and no great supporting evidence.

Relaxant – always use it

VLs have a role, but if the batteries dead/screen breaks you need to know how to do the basics so tend to have on standby rather than first choice.

ODP/Skilled assistant often time dependent, if you have time might take to theatre/unit, where I think the senior nurses are quite capable. If no time verbalising your A-D plan with whoever you can get. I’ve not needed it in Leeds yet, but often the ED reg knows what a bougie, LMA (and scaple) look like.

M – 

Hello all,

I am a trainee(ST5) and would like to add my observations.

1) Lot of these patients who reach the stage of needing intubation, go through the stages of HFNO, CPAP. So I insist on (if I can) to leave the HFNO hanging nearby and use it during intubation. I have used the poor man’s thrive a few times as well.

2) I am still not sure if the cricoid on ITU works as the staff do not use it regularly. Also, I have started small tidal volume BMV .

3) If possible, I try and call an ODP or a fellow trainee( there have been couple of instances where the ITU nurses felt a bit undermined when I called the ODP to help).

4) I have been teaching on the DATAA(Difficult AirwayTraining for Anaesthetic Assistants) course run by Mona and Olga among others which is aimed at ODPs and ITU nurses. It  has been well received. I ran the course in Huddersfield and Calderdale and it was well received there as well. We plan to restart it again in Leeds.

N – 

In response to L and J’s comments re airway skills, my recollection from my last attendance on the ils session (I maybe wrong I am getting a bit old and befuddled) is that all that is taught is ram in an I-Gel and bag. This is likely to lead eventually to nursing staff being unable to effectively BVM patients, unless this is taught in or by the units (unsure of this). This seems a shame as effective BVM use was always part of BLS!

As always interesting and useful QOTM, thanks for keeping doing this James and for everyone’s comments.

F –

​J, when you say we should be teaching everyone basic airway skills, who are you meaning? Are you meaning all of our nurses on ICU? If so, how would we achieve this? We have so many nurses and a massively changing pool in view of the huge turnover of nurses (I barely know who anyone is at the moment!), Im unsure how we would provide this. I presume that all nurses do ILS (?), but I don’t think this ever really teaches anyone basic airway skills. The only way people really get a feel for it is on real patients and from having a constant pool of novice anaesthetists, they generally take a little bit of time to master the skill (I know I did!!).

As we are about to introduce in-situ simulation to both sides of the city, there is the possibility to do some education and training for nurses using this. However given the number of nurses, I think this would potentially be a massive undertaking.

G – 

Great QOTM (as can be seen by the number of responses already)

1)Whatever drugs you like as long as they’re used judiciously and appropriately to the situation. Generally Midaz/fent/roc. Also as Phil stated, peripheral vasopressor.

2) Relaxant – why wouldn’t you give yourself the best conditions possible?

3) I rarely use the McGrath on ICU but it’s definitely something we should all be comfortable using and not reserving it’s use for the “difficult” patients. I use one regularly on my ENT list.

To add to C’s point  – Thio/direct laryngoscopy/sux – will they become vanishingly rare for routine use in the next 10 years?

4) ODP’s – Theatre/A&E/Ward. There is usually a nurse with appropriate experience on the floor in ICU. That said, for the anticipated difficult airway, I’d call an ODP.

Just a note about the DATAA course. As mentioned it had been run a couple of times in CHFT. Not long after the last course there was a need to perform FONA by a colleague on ICU, which went as smoothly as it could have. The ICU nurses stated that they felt much more confident in being part of the “team” managing the airway following the course.

O –

All great comments…..I have nothing in particular to add other than to say that whoever the person offering airway assistance is, that its vital to establish they understand the pertinent steps in managing a difficult airway, have full attention on that role and are able to work through an airway algorithm quickly. I personally think this requires a bit more than basic airway skills training.

I like some others don’t have a particular preference for a ‘standard’ induction formula, the key is understanding the pharmacology and using drugs appropriately. I’m also pretty generous with vasopressors at induction.

I always use muscle relaxant for the same reason as C.

I don’t routinely use cricoid, but am pretty particular about patient positioning (if time allows!).

I’ve started using BMV more recently during apnoeic period, due to experience and the paper attached to one of the comments in this thread.

Final note…..if you are using HFNO2 for preoxygenation….its difficult to BMV once the patient is asleep so plan to take it off…..small point….but seconds often count in this vulnerable group

P –

Long-time listener, first-time caller.

Good question of the week! Here are a few of my thoughts…

1. What drugs should we be using for critical care intubation and why?=

As many have implied in previous the previous discussion, my slightly flippant answer to this question is the right ones… and that will depend on both your own personal experience and the case at hand.

Some of my own personal favourite cocktails are:

SIRS/Sepsis – Fentanyl (1-3mcg/kg) / Midazolam (0.5-1mg/kg) / Rocuronium(1mg/kg)
Polytrauma without significant bleeding – Ketamine (3mg/kg) /Fentanyl (2mcg/kg) / Rocuronium(1mg/kg)
Polytrauma with significant bleeding – Ketamine (1mg/kg) / Fentanyl (1mcg/kg) / Rocuronium (1mg/kg)
Isolated head injury – Alfentanil (20-30mcg/kg) or lidocaine (1.5mg/kg) / Thiopentone (5mg/kg) / Rocuronium(1mg/kg)
Almost all of these recipes have a robust phenylephrine chaser delivered prior to the first blood pressure reading.

2. Does anyone or has anyone tried avoiding relaxant as has been suggested by, amongst others, Rob MacSweeney?

Having advocated the above for the first question I confess I have intubated people with morphine, midazolam and lidocaine (no NMBDs) on wards when circumstances have required it working under the doctrine of you need to be pragmatic. Having said this it wouldn’t be my first choice as pragmatically you probably want the optimum intubating conditions as soon as possible.

3. Should all ICU patients be intubated with a McGrath?

I suspect this is the way of the future and it is certainly easier to direct a trainee if you can see what they can. As Andy Breen says I’m not ready to hang up my Mac just yet!

Just to further muddy the water… what is the role for awake fiberoptic intubation on the intensive care unit? I know one colleague who has employed this technique very successfully in the past.

4. Should we have ODP assistance when intubating a patient on the ICU?

I have had assistance from ODPs on critical care in the past and it was very valuable. However they are not always available in an satisfactory timeframe and I do worry about deskilling our nursing staff. I’ve talked to several of the staff on my unit and it seems to be something they worry about too! I ran a similar course to the one that was described in Scotland several years ago. I’d be happy to help if you relaunched it in Leeds.

Regarding the paper and subsequent discussion:

Yes I do bag. Especially in neuro.

Yes I think HFNO is a good idea.

Yes I always add a bit of PEEP.

I don’t believe CP really works. I do ask for some semblance of it to be applied (as I don’t think I’d perform well on the witness stand when an aggressive barrister is asking me why I deviated from what is still commonly accepted practice) but I then have an extremely low threshold to asked for it to be removed.

 

Q – 

As P has mentioned I think there is a role for awake intubation. I have done this on many occasions very successfully. The type of cases have included unstable necks in respiratory failure, patients in halos jackets on very high Fio2’s where NIV has failed, type 2 respiratory failure from neurological causes (neuromuscular weakness), severe RV dysfunction where previous transition to IPPV (+/- a bit of hypoxia/hypercarbia) has precipitated cardiac arrest. For the weak patient with good tracheal anaesthesia you can often avoid having to sedate them at all afterwards with the attendant need for vasoconstrictors. Largely a few intraoral sprays and a trans-tracheal injection of some 4% will suffice. It can be a bit awkward if they are puffing away as you frequently only get a view on expiration as the airway collapses down as they breath in, but usually do-able as their airways are almost always anatomically normal. And if it fails you haven’t lost anything, apart from a bit of egg on your face for doing something few nurses have never seen, and then failing to do it.

Regarding drugs for intubation on ICU, my only mantra is remember to have some atropine drawn up/at the bed space. Hypoxic patients, in the event of difficulty, get bradycardic which can then be made worse by the vagal stimulus of intubation. I’ve had a patient arrest (SCI, pre-intubation FiO2 >80%, cervical fixation) when a trainee didn’t remove the upper dentures and couldn’t get the angle to get a tube in despite a good view. It’s amazing how long it takes to get atropine out the cupboard.