What is the recommended approach for airway management in critically ill patients?

Airway Management in Critically Ill Patients

The optimal approach for airway management in critically ill patients involves a structured algorithm prioritizing oxygenation while minimizing the number of airway interventions, with early preparation of the team and environment, modified airway assessment, effective pre-oxygenation, and prompt transition to rescue techniques when initial attempts fail. 1

Pre-Procedure Preparation

Team Preparation

• Designate clear roles before starting: intubator, assistant, medication administrator, and team leader 1
• Identify who will perform second/third attempts or front of neck airway (FONA) if needed 1
• Use pre-briefs and checklists to improve reliability and enable team members to voice concerns 1

Equipment Preparation

• Bring standardized airway trolley to bedside 1
• Ensure immediate availability of:
  • Primary and backup laryngoscopes (including videolaryngoscope)
  • Endotracheal tubes of various sizes
  • Bougie/stylet
  • Second-generation supraglottic airway device (SGA)
  • FONA equipment (scalpel-bougie-tube) 1

Patient Assessment

• Use MACOCHA score to predict difficult intubation 1:
  • Mallampati class III or IV (5 points)
  • Obstructive sleep apnea (2 points)
  • Cervical spine mobility reduction (1 point)
  • Mouth opening <3 cm (1 point)
  • Coma (1 point)
  • Severe hypoxemia (SpO₂ <80%) (1 point)
  • Non-anesthetist operator (1 point)
• Consider anatomical and physiological factors that increase difficulty 1
• If cricothyroid membrane is impalpable (especially in obese patients), identify using ultrasound before induction 1

Pre-Oxygenation

• Position patient head-up (ramped position) to maximize airway patency 1, 2
• Use tight-fitting facemask with circuit capable of delivering CPAP (5-10 cmH₂O) 1
• Apply nasal oxygen throughout the procedure:
  • Standard nasal cannula: 5 L/min while awake, increased to 15 L/min when unconscious 1
  • Or high-flow nasal oxygen (HFNO) at 30-70 L/min if available 1, 3
• For agitated patients, consider delayed sequence induction with small doses of ketamine to enable effective pre-oxygenation 1

Intubation Procedure

Induction and Laryngoscopy

• Use modified rapid sequence induction (RSI) with appropriate sedative and neuromuscular blocking agent 1
• Perform facemask ventilation with CPAP before attempting intubation to improve oxygenation 1
• Use videolaryngoscopy for first attempt when available and operator is skilled 1
• Limit to maximum of three attempts at laryngoscopy, with changes in approach between attempts 1
• Consider bougie use during direct laryngoscopy, especially with manual in-line stabilization 1

Between Attempts

• Maintain oxygenation with facemask ventilation between attempts 1
• If facemask ventilation is difficult, reduce or remove cricoid pressure 1
• Consider two-person technique for facemask ventilation (one person holds mask with two hands, second person squeezes bag) 1

Rescue Strategies (Plan B/C)

If Intubation Fails

• Declare failure to the team after unsuccessful attempts 1
• Insert second-generation supraglottic airway device (SGA) 1
• Confirm ventilation with waveform capnography 1

If SGA Successful

Three options to consider 1:

1. Wake the patient if clinical situation allows
2. Wait for expert help if oxygenation maintained and expert available promptly
3. Proceed to FONA if oxygenation marginal, aspiration risk, or difficult ventilation

If SGA Fails

• Attempt facemask ventilation (maximum three attempts with changes in technique) 1
• If facemask ventilation also fails, proceed immediately to FONA 1

Front of Neck Airway (FONA)

• Do not wait for life-threatening hypoxemia before transitioning to FONA 1
• Use scalpel-bougie-tube technique with vertical incision through cricothyroid membrane 1
• Avoid cannula techniques in COVID-19 patients due to risk of aerosolization 1

Special Circumstances

Obesity

• Higher risk of complications including difficult intubation (16%), severe hypoxemia (39%), cardiovascular collapse (22%), cardiac arrest (11%) 1
• Use ramped position to increase intubation success rates 1
• If intubation fails, expect rapid refractory hypoxemia and transition promptly to FONA 1
• Consider awake intubation with fiberoptic or video-laryngoscopy techniques 1

Cervical Spine Injury

• Perform RSI with manual in-line stabilization 1
• Remove anterior part of cervical collar to facilitate mouth opening 1
• Use videolaryngoscopy by skilled operators to minimize cervical movement 1
• Record neurological status prior to airway management 1

Burns and Thermal Injury

• Watch for signs of airway compromise: hoarseness, dysphagia, drooling, wheeze, carbonaceous sputum 1
• Obtain specialist advice early from burns center 1
• Consider early intubation if signs of deterioration present 1
• Use modified RSI with uncut endotracheal tube to allow for facial swelling 1
• Insert nasogastric tube after securing airway 1

Post-Intubation Care

• Confirm tracheal intubation with continuous waveform capnography 1
• Inflate cuff to pressure of 20-30 cmH₂O immediately after intubation 1
• Start mechanical ventilation only after cuff inflation and ensuring no leak 1
• Verify tube position by watching for equal bilateral chest wall expansion 1
• Record depth of tube insertion prominently 1
• Document any airway difficulties encountered for future reference 1

Common Pitfalls to Avoid

• Delaying call for expert help - call after first failed attempt 1
• Multiple attempts at laryngoscopy - limit to maximum of three attempts 1
• Failure to recognize unsuccessful ventilation - use waveform capnography 1
• Delayed transition to FONA - don't wait for profound hypoxemia 1
• Inadequate pre-oxygenation - use CPAP and nasal oxygen 1
• Task fixation during failed attempts - follow structured algorithm 1