Airway Management in Critically Ill Patients

Basic Airway Management

• Inadequate oxygenated blood delivery to the brain and vital organs is the primary cause of critical illness.
• Airway and ventilation management is the first priority in critical care.

Airway Assessment

• The most vital initial assessment is to stimulate a verbal response from the patient.
• A clear, appropriate verbal response indicates a patent airway, adequate ventilation, and sufficient brain perfusion.
• Assess for both a patent and protected airway, as patients with altered mental status are at high risk of airway compromise.

Recognition of Airway Obstruction

• Individuals who are unconscious or whose airway patency is questionable require a "look-listen-feel" approach.

Look For:

• Vomitus or secretions
• Facial bone fractures
• Facial burns
• Neck injuries or hematomas
• Abnormal chest and abdominal movements
• Increasing work of breathing (using accessory muscles)

Listen To:

• Snoring
• Gurgling
• Stridor
• Hoarseness of voice

Feel For:

• Airflow at the mouth and nose (use your cheeks to detect airflow). If there's a risk of airborne infection, avoid close contact.

Basic Techniques for Opening Airway

• Head tilt chin lift: This involves tilting the head back and lifting the chin.
• Jaw thrust maneuver: This involves pushing the jaw forward to stabilize it.
• Trauma situations (polytraumatized patients) - Avoid head tilting; use chin lift or jaw thrust alone.

Basic Adjuncts for Opening Airway

• Oropharyngeal airway: A tube inserted into the mouth to keep the airway open. Contraindicated in conscious patients with a gag reflex because it can induce vomiting and aspiration. Often followed by endotracheal intubation.
• Nasopharyngeal airway: A tube inserted through the nose to keep the airway open. Better tolerated in conscious patients but contraindicated in patients with suspected skull base fracture (potential cribriform plate fracture).

Supraglottic Airway Devices

• Laryngeal mask airway: A mask placed over the larynx.
• i-gel supraglottic airway: A supraglottic device.
• Generally easier to insert than endotracheal tubes.
• Considered life-saving alternatives in cases of difficult, failed, or skill-deficient endotracheal intubation.

Definitive Airway

• Definition: A tube inserted into the trachea with an inflated cuff below the vocal cords.
• Types:
  • Orotracheal tube
  • Nasotracheal tube
  • Surgical cricothyroidotomy
  • Tracheostomy

Endotracheal Tube

• The definitive airway device.
• Enters the larynx, passing through the vocal cords.
• Most tubes include an inflatable cuff that creates a seal between the tube and the trachea.
• This provides enhanced protection against aspiration.
• Only properly trained personnel should perform intubation.

Complications of Endotracheal Tube Insertion

• Failure to intubate
• Esophageal intubation
• Right main bronchus intubation
• Dental trauma
• Laryngeal injury
• Tracheal injury

Management of Ventilation

• Definition: Movement of air between the environment and the lungs via inspiration and expiration.

• Importance: Ensuring a patent airway is critical for oxygen delivery; however, ventilation must also be adequate.

• Causes of inadequate ventilation:

  • Airway obstruction
  • Central nervous system depression
  • Chest trauma (especially rib fractures)
  • Cervical spinal cord injury
  • Underlying chronic pulmonary diseases

• Objective signs of inadequate ventilation:

  • Altered mental status (lethargy)
  • Shallow, rapid breathing
  • Use of accessory muscles
  • Diminished chest expansion
  • Diminished breath sounds
  • Low oxygen saturation

• Improving ventilation recognition:

  • Monitor respiratory rate and work of breathing
  • Obtain arterial or venous blood gas samples
  • Utilize capnography (if available)

• Methods for managing inadequate ventilation:

  • Intubating the trachea and connecting to mechanical ventilation.
  • Ventilatory assistance using the Bag-Valve-Mask technique (prior to intubation).

• Bag-Valve-Mask device: A device used for manual ventilation. Methods include:

  • Single-person technique.
  • Two-person technique.