How to manage a patient with respiratory distress possibly related to AIRSUPRA (Airway Support)?

AIRSUPRA: Management of Respiratory Distress

I need to clarify that AIRSUPRA is not a term for "airway support" but rather a specific FDA-approved combination inhaler containing albuterol and budesonide used for asthma management, not for acute respiratory distress requiring advanced airway interventions. The evidence provided focuses on airway management principles for critically ill patients, which I will address below assuming you are asking about managing acute respiratory distress requiring airway support.

Initial Assessment and Stabilization

For patients presenting with acute respiratory distress, begin with noninvasive respiratory support using high-flow nasal oxygen targeting PaO2 70-90 mmHg or SaO2 92-97%, while closely monitoring for failure within 1-2 hours to avoid delayed intubation which worsens outcomes. 1, 2

Noninvasive Support Options (in order of escalation):

• High-flow nasal cannula (HFNC) creates positive pressure that opens collapsed alveoli, eliminates CO2, and reduces work of breathing 2
• Helmet CPAP is preferred over face mask NIV as it reduces intubation rates and 90-day mortality in ARDS patients 1
• BiPAP/NIV improves ventilation and reduces work of breathing, with 86% success rate in avoiding intubation across various etiologies (CHF, COPD, pneumonia, asthma) 3

Critical caveat: NIV failure rates are high in severe respiratory distress, and delayed intubation is associated with worse outcomes. Reassess response after 1-2 hours and proceed to intubation if no improvement. 1, 2

Preparation for Intubation (When Noninvasive Support Fails)

Before any intubation attempt, ensure institutional preparation is complete, appropriate PPE is donned and checked, and a clear airway strategy with rescue plans is established and briefed to the team. 4

Pre-Intubation Checklist:

• Team composition: Minimum 3 people in room (intubator, assistant, drug/monitor person) plus 1 runner outside 4
• Equipment present: Videolaryngoscope, second-generation supraglottic airway device (i-gel, LMA ProSeal), working suction, continuous waveform capnography, ventilator setup 4
• Airway assessment: Use MACOCHA score (Malampatti, obstructive sleep apnea, c-spine movement, mouth opening, coma, hypoxemia, non-anesthetist intubator) to predict difficulty 4
• Cardiovascular preparation: Have vasopressor immediately available; consider ketamine (1-2 mg/kg) for induction if cardiovascular instability risk exists 1

Intubation Technique

Use rapid sequence induction with meticulous 3-5 minute pre-oxygenation via well-fitting mask in a closed circuit, followed by videolaryngoscopy for first-pass success. 4, 1

Step-by-Step Approach:

• Positioning: Ramp obese patients and use reverse Trendelenburg to maximize safe apnea time 1
• Pre-oxygenation: 3-5 minutes with well-fitting mask, closed circuit (anesthetic circle breathing circuit optimal) 4, 1
• Induction: RSI approach; cricoid pressure controversial—use only if trained assistant available and remove promptly if it impairs intubation 4
• Laryngoscopy: Videolaryngoscopy allows operator to stay further from airway and improves first-pass success 1
• Rescue strategy: If first attempt fails, use second-generation SGA (reduces aerosol generation vs. mask ventilation) before second laryngoscopy attempt 4

Focus on first-pass success—multiple attempts increase risk to both staff and patients. 4

Post-Intubation Mechanical Ventilation

Immediately initiate low tidal volume ventilation (based on ideal body weight) with individualized PEEP selection based on gas exchange, hemodynamics, lung recruitability, and driving pressure to prevent ventilator-induced lung injury. 1

Ventilator Management Protocol:

• Tidal volume: Low tidal volume based on ideal body weight 1
• PEEP selection: Perform recruitment maneuvers first, then titrate PEEP based on gas exchange parameters, hemodynamic status, end-expiratory transpulmonary pressure, and driving pressure 1
• Monitoring: Use HME filter close to patient instead of heated humidified circuit; monitor cuff pressure (maintain at least 5 cmH2O above peak inspiratory pressure) 4
• Closed suction: Mandatory wherever available 4

Severe Respiratory Failure (PaO2/FiO2 < 150 mmHg):

• Prone positioning for 12-16 hours per day 1
• Neuromuscular blockade to improve ventilator synchrony and oxygenation 1
• ECMO as rescue therapy if conventional ventilation fails 1

Critical Pitfalls to Avoid

• Never delay intubation beyond 1-2 hours if noninvasive support is failing—delayed intubation worsens outcomes 1, 2
• Never ventilate multiple patients with a single ventilator—this cannot be done safely with current equipment 1
• Never disconnect ventilator without: ensuring adequate sedation, considering neuromuscular blockade, pausing ventilator, and clamping tracheal tube 4
• Never use unfamiliar techniques during emergency airway management 4

Weaning Considerations

Begin weaning when PaO2/FiO2 > 200 mmHg and PEEP < 10 cmH2O by reducing sedation and transitioning to partial ventilator support to prevent diaphragmatic atrophy. 1