Airway management can significantly affect outcomes for hospitalized critically ill patients. Failure to deliver adequate oxygen may cause irreversible brain damage or preclude successful resuscitation. Options for management may range from assisted ventilation with a bag-valve-mask (BVM) to noninvasive ventilation (NIV) support to endotracheal intubation (Table 121-1). A successful outcome in any intubation demands proficiency in patient assessment, knowledge of the equipment (basic and advanced), requisite technical skills, appreciation of individual limitations, and an alternative plan to deal with the difficult or failed airway.
Table 121-1Overview of Emergency Airway Management |Favorite Table|Download (.pdf) Table 121-1 Overview of Emergency Airway Management
|Technique ||Description ||Notes |
|Rapid Sequence Intubation (RSI) ||Defined by the simultaneous administration of a sedative and paralytic agent to assist in endotracheal intubation, usually via direct laryngoscopy || |
Avoids insufflation of the stomach
Minimizes risk of aspiration with assisted BVM ventilation
|Bag-Valve-Mask (BVM) Ventilation ||The ability to ventilate a patient can be an effective bridge prior to intubation and is a requirement prior to use of any paralytic agents || |
Prior to ventilating with a BVM, place an airway adjunct to maintain patent airway and to optimize ventilation:
If patient has dentures, they should be left in place during BVM ventilation and removed just prior to insertion of laryngoscope
If the operator is having problems maintaining a seal or ventilating, two-hand BVM should be attempted
|Endotracheal Intubation ||Airway control established usually through direct laryngoscopy and orotracheal intubation ||Any operator attempting intubation, particularly if using paralytic agents, should be very comfortable with the technique, equipment, rescue devices, and with other resources for assistance, have a plan to address any contingency |
A small survey published in 2010 noted that individual hospitalists (n = 175) performed, on average, only 10 endotracheal intubations in the previous year with a range of 3 to 20. For those performing endotracheal intubation, it is important to maintain this essential skill, and to be aware of their own practices and skill limitations. Depending on their clinical environment and work setting, the expectations for different hospitalists in advanced airway management will vary. However, all hospitalists should be versed in initial airway management and stabilization, including effective use of oral and nasal airway and BVM devices.
Successful intubation requires not only knowledge of the basic procedural steps, but also knowledge of airway anatomy, landmarks, and locations of various airway structures relative to each other.
INDICATION FOR INTUBATION
All indications for endotracheal intubation can be classified as (1) failure to maintain a patent airway, (2) failure of oxygenation and/or ventilation, and (3) anticipation of a rapidly deteriorating clinical course (Table 121-2).
TABLE 121-2Indications for Intubation