Airway

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Chapter 2 — Airway Management in Critically Ill Adult

Core airway assessment

  1. Airway adequacy should be assessed in 4 domains: {{c1::patency, protective reflexes, inspired oxygen concentration, and respiratory drive}}.
  2. The most common cause of upper airway obstruction in an obtunded supine patient is {{c1::posterior displacement of the tongue against the posterior pharyngeal wall}}.
  3. Signs of upper airway obstruction in a spontaneously breathing patient include {{c1::stridor, poor expired airflow, intercostal retractions, respiratory distress, and paradoxical thoracoabdominal movement}}.
  4. Complete airway obstruction may have {{c1::no breath sounds at all}} because there is {{c2::no airflow through the larynx}}.
  5. Patients with decreased level of consciousness should be assumed to have {{c1::inadequate protective airway reflexes}}.
  6. Normal speech makes absence of airway protective reflexes {{c1::unlikely}}.
  7. A cuffed endotracheal tube connected to oxygen is a {{c1::sealed system}}, so delivered oxygen concentration approximates {{c2::inspired oxygen concentration}}.
  8. A face mask does not guarantee high FiO₂ because the patient’s inspiratory flow often exceeds the mask oxygen flow, causing {{c1::room-air entrainment}}.
  9. Critically ill patients desaturate quickly during airway procedures because they have {{c1::high oxygen demand, low reserve, and often impaired gas exchange}}.
  10. Objective assessment of ventilation requires {{c1::PaCO₂ on ABG or end-tidal CO₂ monitoring}}, not just chest movement.

Oxygen delivery and preoxygenation

  1. Nasal cannula generally does not reliably deliver more than {{c1::30–40% oxygen}}.
  2. Nasal cannula flow above {{c1::4–6 L/min}} often causes discomfort and nasal mucosal irritation.
  3. To maximize FiO₂ with a face mask, use {{c1::reservoir bag, tight seal, high oxygen flow, and 100% oxygen if needed}}.
  4. A non-rebreather/reservoir mask should usually be run at {{c1::15 L/min}} for preoxygenation.
  5. Preoxygenation before intubation should be with {{c1::100% oxygen for 3–5 minutes if possible}}.
  6. Teaching point: preoxygenation is not “putting on oxygen”; it is {{c1::denitrogenating the lungs and creating an oxygen reservoir before apnea}}.
  7. Major mistake: starting induction before optimal preoxygenation in a hypoxemic ICU patient risks {{c1::rapid desaturation and peri-intubation arrest}}.
  8. During difficult airway management, actively pursue oxygenation throughout the process because {{c1::oxygenation buys time}}.

Basic airway maneuvers

  1. The first lifesaving airway intervention in an obtunded patient may be a {{c1::simple airway maneuver}}, not intubation.
  2. The triple airway maneuver includes {{c1::head tilt, chin lift, and jaw thrust}}.
  3. In suspected cervical spine injury, avoid {{c1::head tilt}} and use {{c2::jaw thrust with manual in-line stabilization}}.
  4. An oropharyngeal airway prevents the {{c1::tongue from obstructing the posterior pharynx}}.
  5. Major mistake with OPA: placing it in a patient with intact gag reflex can cause {{c1::gagging, vomiting, aspiration, or laryngospasm}}.
  6. A nasopharyngeal airway may be better tolerated in a semi-conscious patient because it is {{c1::less stimulating than an OPA}}.
  7. Major mistake with NPA: avoid/think carefully in {{c1::basilar skull fracture or severe midface trauma}}.

Intubation planning as a fellow

  1. The airway plan should be verbalized before drugs are given: {{c1::Plan A, Plan B, oxygenation rescue, and surgical airway plan}}.
  2. As the fellow, your teaching script before ICU intubation should include: {{c1::role assignment, predicted difficulty, preoxygenation method, induction/paralytic doses, backup device, and cricothyrotomy trigger}}.
  3. The most dangerous airway plan is “I’ll just try again” without {{c1::changing something between attempts}}.
  4. Between failed attempts, change at least one variable: {{c1::position, blade/device, operator, bougie/stylet, suction, external laryngeal manipulation, or oxygenation strategy}}.
  5. Repeated laryngoscopy attempts cause {{c1::airway trauma, edema, bleeding, hypoxemia, and worsening visualization}}.
  6. A difficult airway may be {{c1::unanticipated despite expert preassessment}}.
  7. ICU airway difficulty is common because patients may have {{c1::hypoxemia, shock, aspiration risk, edema, secretions, limited positioning, and physiologic instability}}.
  8. The first attempt matters because each additional attempt increases {{c1::hypoxemia, aspiration, hemodynamic collapse, and airway trauma}}.
  9. Major fellow mistake: focusing only on anatomy and ignoring {{c1::physiologic difficulty}}, such as shock, severe hypoxemia, acidosis, or RV failure.
  10. “Can intubate” is less important than “can {{c1::oxygenate and ventilate}}.”

Difficult airway predictors and preparation

  1. Predictors of difficult mask ventilation include {{c1::age >55, BMI >26, beard, lack of teeth, and history of snoring}}.
  2. Upper airway lesions above the vocal cords commonly present with {{c1::stridor}}.
  3. If noisy breathing is accompanied by labored breathing or nighttime difficulty, airway narrowing may be {{c1::>50%}}.
  4. For anticipated difficult intubation, strongly consider {{c1::awake intubation with spontaneous ventilation preserved}}.
  5. Fiberoptic intubation is indicated for {{c1::anticipated difficult intubation, direct laryngeal trauma, high dental injury risk, or other need for awake intubation}}.
  6. For anticipated difficult intubation under general anesthesia, prepare {{c1::multiple laryngoscopes, video laryngoscope, lubricated tubes, bougie/stylet, supraglottic airway, fiberoptic equipment, surgical airway equipment, suction, and capnography}}.
  7. Endotracheal tube sizes to have ready: women {{c1::7.0–7.5 mm internal diameter}}; men {{c2::7.5–9.0 mm internal diameter}}.
  8. BURP means {{c1::backward, upward, and rightward pressure}}.
  9. Bimanual laryngoscopy means the operator uses their own hand to optimize the laryngeal view, then {{c1::an assistant maintains that external laryngeal pressure}}.
  10. Major mistake: assuming a supraglottic airway alone is definitive in a known difficult airway patient.

Drug doses from Chapter 2 table

  1. Propofol induction dose listed for tracheal intubation: {{c1::1–2.5 mg/kg IV}}.
  2. Fentanyl dose listed: {{c1::1.0–1.5 mcg/kg IV}}.
  3. Morphine dose listed: {{c1::0.15 mg/kg IV}}.
  4. Atracurium dose listed: {{c1::0.4–0.5 mg/kg IV}}.
  5. Vecuronium dose listed: {{c1::0.1 mg/kg IV}}.
  6. Rocuronium dose listed: {{c1::0.45–0.6 mg/kg IV}}.
  7. Succinylcholine dose listed: {{c1::1.0–1.5 mg/kg IV}}.
  8. Major ICU teaching point: medication dosing must be individualized for {{c1::shock, age, frailty, severe hypoxemia, and hemodynamic instability}}.
  9. Major mistake: giving full-dose propofol to a crashing patient without anticipating {{c1::hypotension or cardiovascular collapse}}.
  10. Major mistake: paralyzing before confirming ability to {{c1::oxygenate, ventilate, and rescue the airway}} in a predicted difficult airway.

Tube confirmation

  1. Visualizing the tube pass through the cords is helpful but must be confirmed with {{c1::exhaled CO₂/capnography}}.
  2. In a difficult airway, failure to use or correctly interpret capnography is a predictor of {{c1::poor airway outcome}}.
  3. Correct tube placement should be checked by {{c1::capnography, chest rise, auscultation, oxygen saturation, ventilator mechanics, and depth marking}}.
  4. The most important confirmation of tracheal intubation is {{c1::sustained exhaled CO₂ waveform}}, especially after several breaths.
  5. Major mistake: accepting “I saw it go through” without {{c1::objective confirmation of ventilation and CO₂}}.
  6. Esophageal intubation is not immediately lethal if recognized quickly; it becomes lethal when {{c1::unrecognized}}.

Cannot intubate / cannot ventilate

  1. In failed intubation with adequate ventilation, the priority is {{c1::oxygenation and calling for help}}, not repeated traumatic attempts.
  2. In failed intubation with inadequate ventilation, the emergency pathway is {{c1::rescue oxygenation and invasive airway access}}.
  3. In a cannot-intubate/cannot-ventilate scenario, call for {{c1::help, surgical airway equipment, and experienced airway/surgical support}}.
  4. Rescue oxygenation steps include {{c1::oral/nasal airway, two-hand mask seal, 100% oxygen, supraglottic airway, and surgical airway if failing}}.
  5. A gum elastic bougie is useful when {{c1::the glottic view is limited but epiglottis or arytenoids can be identified}}.
  6. Major mistake: allowing the room to become chaotic; the airway leader should {{c1::speak calmly, assign roles, and maintain situational awareness}}.

Cricothyrotomy and surgical airway

  1. The cricothyroid membrane lies between the {{c1::thyroid cartilage and cricoid cartilage}}.
  2. Needle cricothyrotomy is an emergency oxygenation technique but does not create a {{c1::definitive airway}}.
  3. Needle cricothyrotomy commonly uses a {{c1::14-gauge cannula}}.
  4. Surgical cricothyrotomy allows placement of a {{c1::cuffed tube}} and can provide positive-pressure ventilation.
  5. Surgical cricothyrotomy may be simpler and more useful than needle cricothyrotomy in many adult ICU emergencies because it provides {{c1::a more secure airway with ventilation and aspiration protection}}.
  6. Major mistake: waiting until profound hypoxemia before declaring {{c1::cannot intubate/cannot oxygenate}}.
  7. Teaching trigger: “If we cannot oxygenate with mask or supraglottic airway, we move to {{c1::front-of-neck access}}.”
  8. Cricothyrotomy is usually faster than tracheostomy in an emergency because it is {{c1::more superficial and anatomically simpler}}.

Tracheostomy

  1. Tracheostomy is usually created between the {{c1::second and third tracheal rings}} or one space higher.
  2. Compared with prolonged translaryngeal intubation, tracheostomy may reduce {{c1::agitation and sedation needs}}.
  3. The weaning benefit of tracheostomy is more related to {{c1::reduced sedation}} than the small reduction in dead space.
  4. Major tracheostomy complication to remember anatomically: anterior erosion can injure the {{c1::brachiocephalic artery/vein}}.
  5. Sudden bleeding from a tracheostomy site can represent {{c1::tracheo-innominate fistula until proven otherwise}}.

Extubation and tube displacement

  1. A difficult airway remains dangerous at extubation because {{c1::reintubation may be harder than the original intubation}}.
  2. Before extubating a difficult airway patient, the team must have {{c1::a credible reintubation plan}}.
  3. ICU endotracheal tube displacement is life-threatening and often {{c1::preventable}}.
  4. Tube position can change with {{c1::patient posture and head position}}.
  5. Sudden high airway pressures after intubation may suggest {{c1::tube obstruction, kinking, biting, mucus plug, bronchospasm, pneumothorax, or ventilator problem}}.
  6. In a ventilated patient with acute deterioration, immediately check {{c1::patient, tube, circuit, ventilator, breath sounds, SpO₂, ETCO₂, and hemodynamics}}.
  7. Major mistake: troubleshooting the ventilator while forgetting to assess {{c1::the patient and the airway first}}.
  8. For suspected tube obstruction, pass a {{c1::suction catheter}}; inability to pass suggests {{c2::kink, obstruction, or biting}}.
  9. If an intubated patient acutely desaturates and you cannot ventilate, disconnect from ventilator and use {{c1::bag-valve ventilation with 100% oxygen}}.
  10. Major mistake: assuming the tube is still in place after patient movement without checking {{c1::tube depth, capnography, chest rise, and breath sounds}}.

Human factors and teaching procedure

  1. Human factors in airway crises include {{c1::teamwork, equipment, workspace, culture, authority gradient, situational awareness, and cognitive overload}}.
  2. A successful airway procedure depends not only on skill but also on {{c1::team communication and role clarity}}.
  3. The airway leader should explicitly assign: {{c1::operator, medication nurse, airway assistant, suction, monitor/recorder, backup airway, and runner}}.
  4. Before intubation, the fellow should say: “Our oxygenation plan is {{c1::preoxygenation, apneic oxygenation if used, BVM rescue, supraglottic rescue, and cricothyrotomy if cannot oxygenate}}.”
  5. Before intubation, the fellow should say: “Our hemodynamic plan is {{c1::pressors ready/running, fluids/blood if appropriate, and post-intubation sedation plan}}.”
  6. Before intubation, the fellow should say: “Our failure point is {{c1::after failed oxygenation or limited attempts, we stop and move to rescue}}.”
  7. Good procedural teaching uses the sequence: {{c1::indication → contraindications → anatomy → equipment → steps → confirmation → complications → rescue plan}}.
  8. The fellow should teach airway anatomy by identifying {{c1::mouth/nose, pharynx, epiglottis, vocal cords/glottis, cricoid cartilage, trachea, and carina}}.
  9. The fellow should teach that airway management is not the same as intubation; airway management means {{c1::oxygenation, ventilation, protection from aspiration, and securing the airway when needed}}.
  10. The key mindset of ICU airway management is {{c1::oxygenation first, first-pass success, backup plan ready, and early rescue when failing}}.

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