Strategies to prevent airway complications: a survey of adult intensive care units in Australia and New Zealand

Airway misadventures in adult critical care: a concise narrative review of managing lost or compromised artificial airways

PURPOSE OF REVIEW

Loss or compromise of artificial airways in critically ill adults can lead to serious adverse events, including death. In contrast to primary emergency airway management, the optimal management of such scenarios may not be well defined or appreciated.

RECENT FINDINGS

Endotracheal tube cuff leaks may compromise both oxygenation and ventilation, and supraglottic cuff position must first be recognized and distinguished from other reasons for gas leakage during positive pressure ventilation. Although definitive management involves tube exchange, if direct visualization is possible temporizing measures can often be considered. Unplanned extubation confers variable and context-specific risks depending on patient anatomy and physiological status. Because risk factors for unplanned extubation are well established, bundled interventions can be employed for mitigation. Tracheostomy tube dislodgement accounts for a substantial proportion of death and disability related to airway management in critical care settings. Consensus guidelines and algorithmic management of such scenarios are key elements of risk mitigation.

SUMMARY

Management of lost or otherwise compromised artificial airways is a key skill set for adult critical care clinicians alongside primary emergency airway management.

Neuromuscular blockade management in the critically Ill patient

Neuromuscular blocking agents (NMBAs) can be an effective modality to address challenges that arise daily in the intensive care unit (ICU). These medications are often used to optimize mechanical ventilation, facilitate endotracheal intubation, stop overt shivering during therapeutic hypothermia following cardiac arrest, and may have a role in the management of life-threatening conditions such as elevated intracranial pressure and status asthmaticus (when deep sedation fails or is not tolerated). However, current NMBA use has decreased during the last decade due to concerns of potential adverse effects such as venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, and even residual paralysis following cessation of NMBA use.

It is therefore essential for clinicians to be familiar with evidence-based practices regarding appropriate NMBA use in order to select appropriate indications for their use and avoid complications. We believe that selecting the right NMBA, administering concomitant sedation and analgesic therapy, and using appropriate monitoring techniques mitigate these risks for critically ill patients. Therefore, we review the indications of NMBA use in the critical care setting and discuss the most appropriate use of NMBAs in the intensive care setting based on their structure, mechanism of action, side effects, and recognized clinical indications. Lastly, we highlight the available pharmacologic antagonists, strategies for sedation, newer neuromuscular monitoring techniques, and potential complications related to the use of NMBAs in the ICU setting.

A novel scale for predicting delayed intubation in patients with inhalation injury

BACKGROUND

Strategies to predict delayed airway obstruction in patients with inhalation injury have not been extensively studied. This study aimed to develop a novel scale, predicting the need for Delayed Intubation after inhalation injury (PDI) score.

METHODS

We retrospectively identified patients with inhalation injury at four tertiary care centers in Japan between 2012 and 2018. We included patients aged 15 or older and excluded those intubated within 30 min after hospital arrival. Predictors for delayed intubation were identified with univariate analyses and scored on the basis of odds ratios. The PDI score was evaluated with the area under the receiver operating characteristic (AUROC) curve and compared with other scaling systems for burn injuries.

RESULTS

Data from 158 patients were analyzed; of these patients, 18 (11.4%) were intubated during the delayed phase. Signs of respiratory distress, facial burn, and pharyngolaryngeal swelling observed on laryngoscopy, were identified as predictors for delayed intubation. The discriminatory power of the PDI (AUROC curve = 0.90; 95% confidence interval, 0.83 to 0.97; p < 0.01) was higher than that of the other scaling systems.

CONCLUSIONS

We developed a novel scale for predicting delayed intubation in inhalation injury. The score should be further validated with other population.

National survey on airway and difficult airway management in intensive care units

OBJECTIVE

To know organization, management and training in airway (AW) in Spanish Intensive Care Units (ICUs), with special interest in difficult airway (DAW).

DESIGN

Descriptive cross-sectional study and χ² subanalysis, conducted through a national survey from november 1th to december 15th, 2016. With the SEMICYUC's support, an online questionnaire of 27 items was sent to 179 ICUs.

SETTING

ICUs of public, private centers, and consortia.

RESULTS

In total, 101 units responded (56.4%), corresponding to 1,827 beds and almost 95,000 incomes/year. The 85.1% are public hospitals, and 83.2% had residents. Of the responders, 22.8% don't use routinely AW assessment scales, being the most frequently used the Cormack-Mallampati association (35.6%). There's not intubation (IOT) protocol in 77.2%, nor DAW protocol in 75.2%. An 82.2% have a DAW cart. The 48.5% have training in IOT, and in VAD 53.5%. Having a DAW expert is significantly associated with greater training in IOT (60% vs. 39.3%; P=.03), DAW (64.4% vs. 44.6%; P=.04), and more AW protocols (73.4% vs. 37.5%; P=.000). Having an specific guideline for DAW management in UCI is considered necessary in 99%.

CONCLUSIONS

There is room for improvement in AW management. It's necessary to identify an expert in DAW in each Unit, and the development of an specific guideline for DAW management in critical care.

Adherence to Evidence-Base Endotracheal Intubation Practice Patterns by Intensivists and Emergency Department Physicians

BACKGROUND

Endotracheal intubation outside the operating room (OR) is mainly performed by intensive care (IC) physicians and emergency department (ED) physicians. We hypothesized that difference in practice patterns exists between these two groups of physicians.

METHODS

A retrospective chart review was performed on all endotracheal intubations that were performed out of OR over a fi ve year period at our health care facility. Practice patterns of IC and ED physicians were compared regarding use of (a) video laryngoscopy, (b) paralytic agents, (c) waveform capnography, and (d) use of larger size of endotracheal tube (internal diameter ≥ 8 mm).

RESULTS

A total of 201 patients underwent out of OR intubations over a 5 year period. IC physicians used more often than ED physicians video laryngoscopy (67% vs. 49%; p = 0.008), waveform capnography (99% vs. 86%; p = 0.001) and larger size endotracheal tubes (95% vs. 60%; p < 0.001). Conversely, paralytic agents were used less frequently by IC than ED physicians (12% vs. 51%; p < 0.001). The success of fi rst intubation attempt was higher by IC than ED physicians (82% vs. 67%; p = 0.018).

CONCLUSIONS

IC physicians more often adhered to currently considered preferable practices for endotracheal intubation than ED physicians in this single center retrospective study. Although larger scale studies are needed to unveil the effects of different practice patterns on short and long term outcomes, the present study identifi es opportunity to bridge practice gaps that could lead to improved outcomes.

Critical Care Junior Doctors' Profile in a Lower Middle-income Country: A National Cross-sectional Survey

Background and Aims:

Retention of junior doctors in specialties such as critical care is difficult, especially in resource-limited settings. This study describes the profile of junior doctors in adult state intensive care units in Sri Lanka, a lower middle-income country.

Materials and Methods:

This was a national cross-sectional survey using an anonymous self-administered electronic questionnaire.

Results:

Five hundred and thirty-nine doctors in 93 Intensive Care Units (ICUs) were contacted, generating 207 responses. Just under half of the respondents (93, 47%) work exclusively in ICUs. Most junior doctors (150, 75.8%) had no previous exposure to anesthesia and 134 (67.7%) had no previous ICU experience while 116 (60.7%) ICU doctors wished to specialize in critical care. However, only a few (12, 6.3%) doctors had completed a critical care diploma course. There was a statistically significant difference (P < 0.05) between the self-assessed confidence of anesthetic background junior doctors and non-anesthetists. The overall median competency for doctors improves with the length of ICU experience and is statistically significant (P < 0.05). ICU postings were less happy and more stressful compared to the last non-ICU posting (P < 0.05 for both). The vast majority, i.e., 173 (88.2%) of doctors felt the care provided for patients in their ICUs was good, very good, or excellent while 71 doctors (36.2%) would be happy to recommend the ICU where they work to a relative with the highest possible score of 10.

Conclusion:

Measures to improve training opportunities for these doctors and strategies to improve their retention in ICUs need to be addressed.

Tracheal extubation of the adult intensive care patient with a predicted difficult airway - a narrative review

Management of the difficult airway is an important, but as yet poorly-studied, component of intensive care management. Although there has been a strong emphasis on prediction and intubation of the difficult airway, safe extubation of the patient with a potentially difficult airway has not received the same attention. Extubation is a particularly vulnerable time for the critically ill patient and, because of the risks involved and the consequences of failure, it warrants specific consideration. The Royal College of Anaesthetists 4th National Audit Project highlighted differences in the incidence and consequences of major complications during airway management between the operating room and the critical care environment. The findings in the section on Intensive Care and Emergency Medicine reinforce the importance of good airway management in the critical care environment and, in particular, the need for appropriate guidelines to improve patient safety. This narrative review focuses on strategies for safe extubation of the trachea for patients with potentially difficult upper airway problems in the intensive care unit.

Resuscitation Prior to Emergency Endotracheal Intubation: Results of a National Survey

Introduction

Respiratory failure is a common problem in emergency medicine (EM) and critical care medicine (CCM). However, little is known about the resuscitation of critically ill patients prior to emergency endotracheal intubation (EETI). Our aim was to describe the resuscitation practices of EM and CCM physicians prior to EETI.

Methods

A cross-sectional survey was developed and tested for content validity and retest reliability by members of the Canadian Critical Care Trials Group. The questionnaire was distributed to all EM and CCM physician members of three national organizations. Using three clinical scenarios (trauma, pneumonia, congestive heart failure), we assessed physician preferences for use and types of fluid and vasopressor medication in pre-EETI resuscitation of critically ill patients.

Results

In total, 1,758 physicians were surveyed (response rate 50.2%, 882/1,758). Overall, physicians would perform pre-EETI resuscitation using either fluids or vasopressors in 54% (1,193/2,203) of cases. Most physicians would “always/often” administer intravenous fluid pre-EETI in the three clinical scenarios (81%, 1,484/1,830). Crystalloids were the most common fluid physicians would “always/often” administer in congestive heart failure (EM 43%; CCM 44%), pneumonia (EM 97%; CCM 95%) and trauma (EM 96%; CCM 96%). Pre-EETI resuscitation using vasopressors was uncommon (4.9%). Training in CCM was associated with performing pre-EETI resuscitation (odds ratio, 2.20; 95% CI, [1.44–3.36], p<0.001).

Conclusion

Pre-EETI resuscitation is common among Canadian EM and CCM physicians. Most physicians use crystalloids pre-EETI as a resuscitation fluid, while few would give vasopressors. Physicians with CCM training were more likely to perform pre-EETI resuscitation.

Transcutaneous PTCCO2 measurement in combination with arterial blood gas analysis provides superior accuracy and reliability in ICU patients

Hyper or hypoventilation may have serious clinical consequences in critically ill patients and should be generally avoided, especially in neurosurgical patients. Therefore, monitoring of carbon dioxide partial pressure by intermittent arterial blood gas analysis (PaCO₂) has become standard in intensive care units (ICUs). However, several additional methods are available to determine PCO₂ including end-tidal (PETCO₂) and transcutaneous (PTCCO₂) measurements. The aim of this study was to compare the accuracy and reliability of different methods to determine PCO₂ in mechanically ventilated patients on ICU. After approval of the local ethics committee PCO₂ was determined in n = 32 ICU consecutive patients requiring mechanical ventilation: (1) arterial PaCO₂ blood gas analysis with Radiometer ABL 625 (ABL; gold standard), (2) arterial PaCO₂ analysis with Immediate Response Mobile Analyzer (IRMA), (3) end-tidal PETCO₂ by a Propaq 106 EL monitor and (4) transcutaneous PTCCO₂ determination by a Tina TCM4. Bland-Altman method was used for statistical analysis; p < 0.05 was considered statistically significant. Statistical analysis revealed good correlation between PaCO₂ by IRMA and ABL (R² = 0.766; p < 0.01) as well as between PTCCO₂ and ABL (R² = 0.619; p < 0.01), whereas correlation between PETCO₂ and ABL was weaker (R² = 0.405; p < 0.01). Bland-Altman analysis revealed a bias and precision of 2.0 ± 3.7 mmHg for the IRMA, 2.2 ± 5.7 mmHg for transcutaneous, and -5.5 ± 5.6 mmHg for end-tidal measurement. Arterial CO₂ partial pressure by IRMA (PaCO₂) and PTCCO₂ provided greater accuracy compared to the reference measurement (ABL) than the end-tidal CO₂ measurements in critically ill in mechanically ventilated patients patients.

[Dissection of the wired endotracheal tube's lumen during general anesthesia: a case report]

OBJECTIVE

The aim of this study is to report a case of a clinically significant obstruction during mechanical ventilation caused by the dissection of the wired endotracheal tube's lumen during general anesthesia in a pediatric patient.

CASE REPORT

A12-years old patient undergoing general anesthesia for open appendectomy was intubated with a wired endotracheal tube and difficult removal of the guide. After starting the mechanical ventilation, there was increased expiratory fraction of CO₂ and need for increased inspiratory pressure. Chance of complications with higher incidences were raised and treated unsuccessfully. Finally, during patient reintubation, the dissection of the endotracheal tube lumen was observed, and ventilation was restored to normal.

CONCLUSION

Anesthesia involves numerous possible complications. Suspicion and constant vigilance are essential for early diagnosis and treatment of any threat to the individual integrity. This case is relevant for emphasizing a possible very rare complication related to airway, which can quickly cause hypoxia and irreversible damage. Thus, this case contributes to the detection of this complication more frequently.

Raising the Alarm: A Cross-Sectional Study Exploring the Factors Affecting Patients' Willingness to Escalate Care on Surgical Wards

BACKGROUND

Delays in escalation of care for patients may contribute to poor outcome. The factors that influence surgical patients' willingness to call for help on wards are currently unknown. This study explored the factors that affect patients' willingness to call for help on surgical wards; how patients call for help and to whom; how to encourage patients to call for help, and the barriers to patients calling for help.

METHODS

A cross-sectional study was conducted in three London hospitals using a questionnaire designed through expert opinion and the published literature. A total of 155 surgical patients (83% response rate) participated.

RESULTS

Patients were more willing to call for help using the bedside buzzer or by calling a nurse compared to a doctor (p < 0.001). The prompts to calling for help patients were most likely to act on were bleeding and pain. Patients were more willing to call for help if encouraged by a healthcare professional than a relative or fellow patient (p < 0.01). Patients were more likely to worry about taking up too much time when calling for help than being perceived as difficult (p < 0.001). For some prompts, male patients were more willing to call for help (p < 0.05).

CONCLUSIONS

This is the first study to identify factors affecting patients' willingness to call for help on surgical wards. Interventions that take these factors into account can be developed to encourage patients to call for help and may avoid delays in treatment.

[French national survey on difficult intubation in intensive care units]

OBJECTIVES

Assessing the theoretical knowledge, practical experience of French intensivists, and their compliance with French Anesthesiology and Critical Care Society's difficult airway algorithms of the expert's SFAR conference of 2006.

STUDY DESIGN

Prospective and descriptive national survey.

MATERIAL AND METHODS

An anonymous questionnaire with 40 questions was emailed to physicians working in intensive care units in France.

RESULTS

Five hundred and eight intensivists answered the survey. Ninety-seven percent of physicians reported having a portable storage unit for difficult intubation. As for practical experience, 421 physicians (83 %) have set up less than 10 laryngeal mask airway, 257 (51 %) have performed less than 10 intubations under fibroscopy and 269 (53 %) have never performed a cricothyroidotomy on mannequin, and 331 (65 %) on a patient. In case of emergency intubation, 29 % of them do not use a rapid sequence induction. Three hundred physicians (59 %) use capnography as monitoring of the endotracheal position. Two hundred and nine (42 %) consider they have not been trained to difficult intubation and 443 (87 %) would like to participate in high fidelity simulations mannequin.

CONCLUSIONS

National airway management algorithm was insufficiently followed. Alternative techniques do not seem to be mastered by all physicians. French intensivists expect more training on difficult intubation, including high fidelity simulation.

Virtual airway simulation to improve dexterity among novices performing fibreoptic intubation

We developed a virtual reality software application (iLarynx) using built-in accelerometer properties of the iPhone(®) or iPad(®) (Apple Inc., Cupertino, CA, USA) that mimics hand movements for the performance of fibreoptic skills. Twenty novice medical students were randomly assigned to virtual airway training with the iLarynx software or no additional training. Eight out of the 10 subjects in the standard training group had at least one failed (> 120 s) attempt compared with two out of the 10 participants in the iLarynx group (p = 0.01). There were a total of 24 failed attempts in the standard training group and four in the iLarynx group (p < 0.005). Cusum analysis demonstrated continued group improvement in the iLarynx, but not in the standard training group. Virtual airway simulation using freely available software on a smartphone/tablet device improves dexterity among novices performing upper airway endoscopy.

Techniques for the difficult airway

PURPOSE OF REVIEW

Management of the difficult airway is associated with significant morbidity and mortality in critically ill patients. An increasing array of advanced airway tools are available, but appropriate selection and application in the ICU remains poorly defined.

RECENT FINDINGS

Difficult airway incidence during emergent intubation is 10%, but complications of ICU airway management remain common. Training and equipment in many ICUs remain variable despite data that demonstrate that an 'intubation management bundle' and a systematic approach to teamwork and training can reduce life-threatening airway complications. A protocol employing an extraglottic airway (EGA) early in cases of inadequate ventilation has been associated with no episodes of prolonged hypoxemia in 12 225 consecutive intubations. Direct laryngoscopy with gum elastic bougie is the most commonly employed method to manage emergent difficult airways, and videolaryngoscopes also provide greater glottic visualization and a high rate of intubation success in patients with difficult airway risk factors or a failed airway.

SUMMARY

A systematic approach to intubation that emphasizes planning and teamwork can reduce intubation complications. Early use of an EGA or cricothyroidotomy may reduce complications when oxygenation is inadequate. Use of a gum elastic bougie or indirect optical device is also associated with a high rate of intubation success when oxygenation permits.