What is the primary recommendation for managing a patient requiring an artificial airway?

Management of Artificial Airways

The primary recommendation for managing a patient requiring an artificial airway is to use videolaryngoscopy for intubation with meticulous pre-oxygenation, rapid sequence induction with full neuromuscular blockade, and proper tube positioning with cuff pressure maintained at 20-30 cmH2O, followed by low tidal volume ventilation and vigilant monitoring for complications. 1, 2

Pre-Intubation Preparation

Oxygenation and Positioning

• Perform meticulous pre-oxygenation with a well-fitting mask for 3-5 minutes using a closed circuit (anaesthetic circle breathing circuit preferred over bag-mask which expels virus-containing exhaled gas). 1
• Place a heat and moisture exchange (HME) filter between the catheter mount and circuit. 1
• Optimize patient positioning with ramping in obese patients and reverse Trendelenburg positioning to maximize safe apnoea time. 1, 2

Pharmacologic Approach

• Use rapid sequence induction (RSI) approach for emergency intubation. 1, 2
• For patients with cardiovascular instability risk, use ketamine 1-2 mg/kg for induction rather than propofol which can cause significant hypotension. 1, 2
• Administer rocuronium 1.2 mg/kg for neuromuscular blockade as early as practical to minimize apnoea time and prevent coughing (or suxamethonium 1.5 mg/kg if used). 1
• Ensure full neuromuscular blockade before attempting intubation - wait 1 minute or use peripheral nerve stimulator. 1
• Have vasopressor immediately available for bolus or infusion to manage hypotension. 1, 2

Intubation Technique

Device Selection and Approach

• Videolaryngoscopy is the preferred device for most trained airway managers as it improves first-pass success and allows the operator to stay further from the airway. 1, 2
• When using videolaryngoscope with Macintosh blade, a bougie may be used. 1
• When using videolaryngoscope with hyperangulated blade, a stylet is required. 1
• If videolaryngoscope unavailable, use standard Macintosh blade with bougie (pre-loaded or immediately available). 1

Tube Sizing and Placement

• Use tracheal tube size 7.0-8.0 mm internal diameter in women or 8.0-9.0 mm in men. 1
• Use tracheal tube with subglottic suction port where possible. 1
• Pass the cuff 1-2 cm below the cords without losing sight of the tube on screen to avoid bronchial intubation. 1

Rescue Oxygenation if Needed

• After loss of consciousness, gentle CPAP may be applied if seal is good to minimize need for mask ventilation. 1
• If bag-mask ventilation needed, use 2-handed, 2-person technique with VE-grip (not C-grip) particularly in obese patients, with minimal oxygen flows and airway pressures. 1
• Alternatively, second-generation supraglottic airway may be inserted after loss of consciousness to replace bag-mask ventilation if difficult. 1

Post-Intubation Management

Immediate Verification and Securing

• Verify proper tube depth with bilateral chest wall expansion - auscultation alone is unreliable in critically ill patients. 3
• Maintain endotracheal tube cuff pressure at 20-30 cmH2O to prevent air leak around cuff and aspiration while avoiding mucosal damage. 3, 4, 5
• Obtain immediate chest x-ray to confirm position and rule out pneumothorax or pneumomediastinum. 3

Ventilation Strategy

• Use low tidal volume ventilation (6-8 mL/kg ideal body weight) as the cornerstone of respiratory management to prevent ventilator-induced lung injury. 2, 4
• Perform recruitment maneuvers before PEEP selection. 2
• Apply appropriate PEEP (6-15 cmH2O initially) to prevent atelectasis, individualized based on gas exchange, hemodynamics, lung recruitability, and driving pressure. 2, 4
• Target PaO2 70-90 mmHg or SaO2 92-97%. 2

Ongoing Airway Care

• Suction only as-needed based on indicators (breath sounds, visual secretions in airway, sawtooth pattern on ventilator waveform, acute increase in airway resistance) rather than on a schedule. 6
• Apply suction for maximum 15 seconds per procedure. 6
• Use suction catheters that occlude <50% of endotracheal tube lumen in adults with suction pressure below -200 mmHg. 6
• Perform preoxygenation before suctioning. 6
• Use sterile technique during open suctioning. 6
• Avoid routine normal saline instillation during suctioning. 6
• Provide adequate humidification to prevent secretion accumulation. 5, 7

Management of Complications

Deterioration Assessment

• Check for "DOPE" causes of acute deterioration: Displacement of tube, Obstruction of tube, Pneumothorax, Equipment failure. 4
• Use lung ultrasound if doubt exists about bilateral lung ventilation - superior to auscultation for detecting pneumothorax. 3

Specific Interventions

• If subcutaneous emphysema develops, reduce peak inspiratory pressures and minimize PEEP while maintaining acceptable oxygenation. 3
• Avoid repeated intubation attempts in suspected tracheal injury as this increases trauma and worsens perforation. 3
• For severe respiratory failure (PaO2/FiO2 <150 mmHg), consider prone positioning 12-16 hours daily and neuromuscular blocking agents. 2
• Consider ECMO as rescue therapy for patients failing conventional mechanical ventilation. 2, 4

Sedation and Weaning

• Avoid abrupt discontinuation of sedation - this causes rapid awakening with anxiety, agitation, and resistance to mechanical ventilation. 8
• Reduce sedation and use partial ventilator support when gas exchange, respiratory mechanics, and hemodynamics improve. 2
• Consider weaning when PaO2/FiO2 >200 mmHg and PEEP <10 cmH2O. 2

Critical Pitfalls to Avoid

• Never ventilate multiple patients with a single ventilator - this cannot be done safely with current equipment. 2
• Avoid high-flow nasal oxygen and non-invasive ventilation in high-risk situations where intubation is likely needed. 1
• Do not delay intubation when NIV fails - delayed intubation is associated with worse outcomes. 2
• Avoid insufflation of oxygen through airway exchange catheters except in extremis due to risk of catastrophic barotrauma. 3
• Remove cricoid pressure promptly if it contributes to intubation difficulty. 1