Endotracheal intubation in the ICU

Abstract

Endotracheal intubation in the ICU is a high-risk procedure, resulting in significant morbidity and mortality. Up to 40% of cases are associated with marked hypoxemia or hypotension. The ICU patient is physiologically very different from the usual patient who undergoes intubation in the operating room, and different intubation techniques should be considered. The common operating room practice of sedation and neuromuscular blockade to facilitate intubation may carry significant risk in the ICU patient with a marked oxygenation abnormality, particularly when performed by the non-expert. Preoxygenation is largely ineffective in these patients and oxygen desaturation occurs rapidly on induction of anesthesia, limiting the time available to secure the airway. The ICU environment is less favorable for complex airway management than the operating room, given the frequent lack of availability of additional equipment or additional expert staff. ICU intubations are frequently carried out by trainees, with a lesser degree of airway experience. Even in the presence of a non-concerning airway assessment, these patients are optimally managed as a difficult airway, utilizing an awake approach. Endotracheal intubation may be achieved by awake direct laryngoscopy in the sick ICU patient whose level of consciousness may be reduced by sepsis, hypercapnia or hypoxemia. As the patient’s spontaneous respiratory efforts are not depressed by the administration of drugs, additional time is available to obtain equipment and expertise in the event of failure to secure the airway. ICU intubation complications should be tracked as part of the ICU quality improvement process.

Airway management outside the operating room: how to better prepare

“…For example, awake intubation ± topicalization may be indicated in some situations, patient cooperation and circumstances permitting. 40 Although neuromuscular blocking agents help optimize intubating conditions, non-anesthesiologists may be uncomfortable with their use. Many practitioners are fearful of ''burning bridges'' despite evidence that paralysis improves or does not worsen the ability to maskventilate and may improve first-pass intubation success.…”

Acromio-Axillo-Suprasternal Notch Index: A New Screening Test to Predict Difficult Laryngoscopy in General Population

“…Endotracheal intubation is an essential part of general anesthesia [1] . Pre-operative prediction of difficult laryngoscopy has the main role in airway management as 85% of all inabilities to maintain airway result in permanent cerebral damage and up to 30% result in death [2,3] .…”

Airway registry and training curriculum improve intubation outcomes in the intensive care unit

“…Despite technologic advances in methods for performing intubation, recent studies continue to report frequent adverse events associated with tracheal intubation, and complications occur in up to 40% of procedures (1)(2)(3). Even in the absence of anatomic predictors of a difficult airway, critically ill patients are particularly vulnerable to desaturation, hemodynamic instability, and cardiac arrest due to poor physiologic reserve (4,5).…”

“…In recent years, there has been a greater focus on management strategies and outcomes in critically ill patients in the emergency department (ED) and ICU (3,9,10). In 2012, we initiated a comprehensive airway management quality improvement program to measure variables related to airway management in the ICU and identify targeted opportunities for intervention to improve outcomes (11).…”