Airway Safety in the Neurocritical Care Unit

Abstract

Adverse events related to the airway are, unfortunately, not uncommon in the neuroICU. Most airway-related adverse events are likely preventable. A strong understanding of safety issues related to airway management is essential for the neurocritical care provider. Recognizing the need to establish an airway is likely the first and most important safety consideration. An inappropriate delay in intubation may result in aspiration, cardiac arrest, or the need for prolonged mechanical ventilation. Prior to intubating the neurocritical care patient, the provider must assess the likelihood of a difficult airway and difficult bag-mask ventilation. Neurocritical care providers should be familiar with the difficult airway algorithm. In the patient at risk for cerebral herniation, the use of rapid sequence intubation along with lidocaine and/or fentanyl may help blunt airway reflexes associated with increased intracranial pressure (ICP). Attention must be paid to the pupillary exam and adequacy of cerebral perfusion during intubation. The availability of airway teams may improve patient survival and decrease the need for surgical airways. Adverse events associated with extubation include post-extubation stridor (PES) and inability to protect the airway. The use of glucocorticoids in patients with an insufficient cuff leak can decrease the risk of post-extubation stridor. Preventable adverse events in the intubated patient include airway occlusion and unplanned extubation. The use of humidifiers and adequate suctioning can greatly decrease or eliminate the risk of airway occlusion.