Guidelines for the management of tracheal intubation in critically ill adults

Abstract

These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4 National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel-bougie-tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.

Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults

“…When ATI is performed outside of the theatre environment (e.g. in the critical care unit or the emergency department), the same standards of care should apply (Grade D) .…”

“…Workspace ergonomics have an impact on performance and safety , and should be considered before starting the procedure (Grade D; Fig. ; Supporting Information, Appendix S2) . This includes optimising the position of patient, operator and assistants, as well as location of equipment and monitors, which should be in the direct line of sight of the operator.…”

“…Immediate actions should include a call for help, ensuring 100% oxygen is applied and stopping (if necessary, reversing) any sedative drugs (Grade D). Operators should ‘stop and think’ to determine subsequent airway management, while also ‘priming’ for emergency FONA (Grade D). The default action in the event of unsuccessful ATI should be to postpone the procedure (Grade D).…”

Visual aids for pediatric airway management

“…A modification of the universal algorithm striving to cover all possible airway problems in one page may be represented by the set of visual aids developed by the Difficult Airway Society (DAS). The DAS guidelines, along with a set of specific algorithms, may be found on the Society's Web site (http://www.das.uk.com) and in a series of publications . They are also accompanied by an extensive background text and an intelligent discussion of difficult airway management.…”

“…A pragmatic set of visual aids for various situations are provided: first a Difficult Intubation Overview, in which the basic principles are presented, with the left column presenting the tentative airway management plans A‐D, the central column with various airway options, and a right column with possible outcomes and the ever‐important reminder to STOP AND THINK (supplemental digital content, Figure S2). This general scheme is subsequently modified for specific situations, with algorithms for the unexpected difficult intubation, difficult mask ventilation, a subset of four algorithms for obstetric airway management, and an algorithm for intubation of critically ill adults included in the most recently published ICU difficult airway guideline . And last but not least, difficult airway guidelines modified for pediatrics, available at the DAS and the APAGBI Web sites (http://www.apagbi.org.uk/guidelines).…”