Skip to main content
SpringerLink
Log in

Airway Management in the Intensive Care Unit

  • Chapter
Surgical Intensive Care Medicine

Abstract

Airway management in the critically ill patient is challenging. The incidence of complications when performing intubations in the ICU is much higher than in the operating room. This chapter will discuss how to perform an adequate airway evaluation, various intubating tools and techniques, and complications of intubations. The approach to managing a difficult airway and extubating a patient will be addressed. Methods to increase the safety of airway management in the ICU such as the use of experienced personnel, availability of equipment for the difficult airway, and the importance of protocols for emergency intubations will be outlined.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 129.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 219.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 249.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Simpson GD, Ross MJ, McKeown DW, Ray DC. Tracheal intubation in the critically ill: a multi-centre national study of practice and complications. Br J Anaesth. 2012;108:792–9.

    Article  CAS  PubMed  Google Scholar 

  2. Mort TC. Emergency tracheal intubation: complications associated with repeated laryngoscopic attempts. Anesth Analg. 2004;99:607–13.

    Article  PubMed  Google Scholar 

  3. Rice MJ, Mancuso A, Morey TE, Gravenstein N, Deitte L. The anatomy of the cricoid pressure unit. Surg Radiol Anat. 2010;32:419.

    Article  PubMed  Google Scholar 

  4. Chung KW, Chung HM. Gross anatomy. 7th ed. Philadelphia: Walter Kluwer/Lippincott Williams & Wilkins; 2011.

    Google Scholar 

  5. Morgan GE, Mikhail MS, Murray MJ. Clinical anesthesiology. 4th ed. New York: Lange Medical Books/McGraw-Hill Medical; 2006.

    Google Scholar 

  6. Finucane BT, Tsui BC, Santora AH. Principles of airway management. New York: Springer Science + Business Media, LLC; 2011.

    Book  Google Scholar 

  7. Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103:429–37.

    Article  PubMed  Google Scholar 

  8. De Jong A, Molinari N, Terzi N, Mongardon N, Arnal JM, Guitton C, et al. Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study. Am J Respir Crit Care Med. 2013;187:832–9.

    Article  PubMed  Google Scholar 

  9. Hastings RH, Hon ED, Nghiem C, Wahrenbrock EA. Force and torque vary between laryngoscopists and laryngoscope blades. Anesth Analg. 1996;82:462–8.

    CAS  PubMed  Google Scholar 

  10. Walz JM, Kaur S, Heard SO. Airway management and endotracheal intubation. In: Irwin RS, Rippe JM, Lisbon A, Heard SO, editors. Irwin and Rippe’s procedures, techniques and minimally invasive monitoring in intensive care medicine. Philadelphia: Wolters Kluwer/Lippincot Williams and Wilkins; 2012. p. 1–16.

    Google Scholar 

  11. Vinclair M, Broux C, Faure P, Brun J, Genty C, Jacquot C, et al. Duration of adrenal inhibition following a single dose of etomidate in critically ill patients. Intensive Care Med. 2008;34:714–9.

    Article  PubMed  Google Scholar 

  12. Chan CM, Mitchell AL, Shorr AF. Etomidate is associated with mortality and adrenal insufficiency in sepsis: a meta-analysis. Crit Care Med. 2012;40:2945–53.

    Article  CAS  PubMed  Google Scholar 

  13. McPhee LC, Badawi O, Fraser GL, Lerwick PA, Riker RR, Zuckerman IH, et al. Single-dose etomidate is not associated with increased mortality in ICU patients with sepsis: analysis of a large electronic ICU database. Crit Care Med. 2013;41:774–83.

    Article  CAS  PubMed  Google Scholar 

  14. Payen JF, Dupuis C, Trouve-Buisson T, Vinclair M, Broux C, Bouzat P, et al. Corticosteroid after etomidate in critically ill patients: a randomized controlled trial. Crit Care Med. 2012;40:29–35.

    Article  CAS  PubMed  Google Scholar 

  15. Jabre P, Combes X, Lapostolle F, Dhaouadi M, Ricard-Hibon A, Vivien B, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009;374:293–300.

    Article  CAS  PubMed  Google Scholar 

  16. Schmidt A, Oye I, Akeson J. Racemic, S(+)- and R(−)-ketamine do not increase elevated intracranial pressure. Acta Anaesthesiol Scand. 2008;52:1124–30.

    Article  CAS  PubMed  Google Scholar 

  17. Plumb JO, Miller RM. Not using neuromuscular blocking agents in emergent intubation should be a rarity. Crit Care Med. 2012;40:3112–3.

    Article  PubMed  Google Scholar 

  18. Wilcox SR, Bittner EA, Elmer J, Seigel TA, Nguyen NT, Dhillon A, et al. Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications. Crit Care Med. 2012;40:1808–13.

    Article  CAS  PubMed  Google Scholar 

  19. Martyn JA, Richtsfeld M. Succinylcholine-induced hyperkalemia in acquired pathologic states: etiologic factors and molecular mechanisms. Anesthesiology. 2006;104:158–69.

    Article  CAS  PubMed  Google Scholar 

  20. Blanie A, Ract C, Leblanc PE, Cheisson G, Huet O, Laplace C, et al. The limits of succinylcholine for critically ill patients. Anesth Analg. 2012;115:873–9.

    Article  CAS  PubMed  Google Scholar 

  21. Larijani GE, Cypel D, Gratz I, Mroz L, Mandel R, Afshar M, et al. The efficacy and safety of EMLA cream for awake fiberoptic endotracheal intubation. Anesth Analg. 2000;91:1024–6.

    Article  CAS  PubMed  Google Scholar 

  22. Sutherland L, Misita D. Regional and topical anesthesia for endotracheal intubation. 2007 (cited May 21, 2014). In: NYSORA textbook of regional anesthesia and acute pain management (Internet). New York: McGraw-Hill (cited May 21, 2014). Available from: http://www.accessanesthesiology.com/content/3500549.

  23. Aslani A, Ng SC, Hurley M, McCarthy KF, McNicholas M, McCaul CL. Accuracy of identification of the cricothyroid membrane in female subjects using palpation: an observational study. Anesth Analg. 2012;114:987–92.

    Article  PubMed  Google Scholar 

  24. Mort TC. Preoxygenation in critically ill patients requiring emergency tracheal intubation. Crit Care Med. 2005;33:2672–5.

    Article  PubMed  Google Scholar 

  25. Mort TC, Waberski BH, Clive J. Extending the preoxygenation period from 4 to 8 min in critically ill patients undergoing emergency intubation. Crit Care Med. 2009;37:68–71.

    Article  PubMed  Google Scholar 

  26. Baillard C, Fosse JP, Sebbane M, Chanques G, Vincent F, Courouble P, et al. Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med. 2006;174:171–7.

    Article  PubMed  Google Scholar 

  27. Collins JS, Lemmens HJ, Brodsky JB, Brock-Utne JG, Levitan RM. Laryngoscopy and morbid obesity: a comparison of the “sniff” and “ramped” positions. Obes Surg. 2004;14:1171–5.

    Article  PubMed  Google Scholar 

  28. Jaber S, Jung B, Corne P, Sebbane M, Muller L, Chanques G, et al. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med. 2010;36:248–55.

    Article  PubMed  Google Scholar 

  29. Cormack RS, Lehane J. Difficult tracheal intubation in obstetrics. Anaesthesia. 1984;39:1105–11.

    Article  CAS  PubMed  Google Scholar 

  30. Sellick BA. Cricoid pressure to control regurgitation of stomach contents during induction of anesthesia. Lancet. 1961;2:404.

    Article  CAS  PubMed  Google Scholar 

  31. Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PT. Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging. Anesthesiology. 2003;99:60–4.

    Article  PubMed  Google Scholar 

  32. Rice MJ, Mancuso AA, Gibbs C, Morey TE, Gravenstein N, Deitte LA. Cricoid pressure results in compression of the postcricoid hypopharynx: the esophageal position is irrelevant. Anesth Analg. 2009;109:1546–52.

    Article  PubMed  Google Scholar 

  33. Rice MJ, Mancuso AA, Morey TE, Gravenstein N, Deitte L. The anatomical correction of cricoid pressure. Minerva Anestesiol. 2010;76:304.

    CAS  PubMed  Google Scholar 

  34. Zeidan AM, Salem MR, Mazoit JX, Abdullah MA, Ghattas T, Crystal GJ. The effectiveness of cricoid pressure for occluding the esophageal entrance in anesthetized and paralyzed patients: an experimental and observational glidescope study. Anesth Analg. 2014;118:580–6.

    Article  CAS  PubMed  Google Scholar 

  35. De Jong A, Molinari N, Conseil M, Coisel Y, Pouzeratte Y, Belafia F, et al. Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis. Intensive Care Med. 2014;40:629–39.

    PubMed  Google Scholar 

  36. Walz JM, Zayaruzny M, Heard SO. Airway management in critical illness. Chest. 2007;131:608–20.

    Article  PubMed  Google Scholar 

  37. Niven AS, Doerschug KC. Techniques for the difficult airway. Curr Opin Crit Care. 2013;19:9–15.

    Article  PubMed  Google Scholar 

  38. Porhomayon J, El-Solh AA, Nader ND. National survey to assess the content and availability of difficult-airway carts in critical-care units in the United States. J Anesth. 2010;24:811–4.

    Article  PubMed  Google Scholar 

  39. Hagberg CA. Current concepts in the management of the difficult airway. Anesthesiol News. 2014;11:1–28.

    Google Scholar 

  40. Gercek E, Wahlen BM, Rommens PM. In vivo ultrasound real-time motion of the cervical spine during intubation under manual in-line stabilization: a comparison of intubation methods. Eur J Anaesthesiol. 2008;25:29–36.

    CAS  PubMed  Google Scholar 

  41. Miguel-Montanes R, Hajage D, Messika J, Bertrand F, Gaudry S, Rafat C, Labbé V, Dufour N, Jean-Baptiste S, Bedet A, Dreyfuss D, Ricard JD. Use of high-flow nasal cannula oxygen therapy to prevent desaturation during tracheal intubation of intensive care patients with mild-to-moderate hypoxemia. Crit Care Med. 2015;43:574–83.

    Article  CAS  PubMed  Google Scholar 

  42. Barjaktarevic I, Berlin D. Bronchoscopic intubation during continuous nasal positive pressure ventilation in the treatment of hypoxemic respiratory failure. J Intensive Care Med. 2015;30:161–6.

    Article  PubMed  Google Scholar 

  43. Yang T, Hou J, Li J, Zhang X, Zhu X, Ni W, et al. Retrograde light-guided laryngoscopy for tracheal intubation: clinical practice and comparison with conventional direct laryngoscopy. Anesthesiology. 2013;118:1059–64.

    Article  PubMed  Google Scholar 

  44. Epstein SK, Ciubotaru RL, Wong JB. Effect of failed extubation on the outcome of mechanical ventilation. Chest. 1997;112:186–92.

    Article  CAS  PubMed  Google Scholar 

  45. Rose L, Redl L. Survey of cuff management practices in intensive care units in Australia and New Zealand. Am J Crit Care. 2008;17:428–35.

    PubMed  Google Scholar 

  46. Kollef MH, Legare EJ, Damiano M. Endotracheal tube misplacement: incidence, risk factors, and impact of a quality improvement program. South Med J. 1994;87:248–54.

    Article  CAS  PubMed  Google Scholar 

  47. Jaber S, Amraoui J, Lefrant JY, Arich C, Cohendy R, Landreau L, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med. 2006;34:2355–61.

    Article  PubMed  Google Scholar 

  48. Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations. Anesthesiology. 1995;82:367–76.

    Article  CAS  PubMed  Google Scholar 

  49. Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S. 3,423 emergency tracheal intubations at a university hospital: airway outcomes and complications. Anesthesiology. 2011;114:42–8.

    Article  PubMed  Google Scholar 

  50. Mayo PH, Hegde A, Eisen LA, Kory P, Doelken P. A program to improve the quality of emergency endotracheal intubation. J Intensive Care Med. 2011;26:50–6.

    Article  PubMed  Google Scholar 

  51. Khemani RG, Randolph A, Markovitz B. Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children and adults. Cochrane Database Syst Rev. 2009;8(3): CD001000.

    Google Scholar 

  52. Khemani RG, Randolph A, Markovitz B. Steroids for post extubation stridor: pediatric evidence is still inconclusive. Intensive Care Med. 2010;36:1276–7.

    Article  PubMed  Google Scholar 

  53. MacIntyre N. Discontinuing mechanical ventilatory support. Chest. 2007;132:1049–56.

    Article  PubMed  Google Scholar 

  54. Seely AJ, Bravi A, Herry C, Green G, Longtin A, Ramsay T, et al. Do heart and respiratory rate variability improve prediction of extubation outcomes in critically ill patients? Crit Care. 2014;18:R65.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Jaber S, Chanques G, Matecki S, Ramonatxo M, Vergne C, Souche B, et al. Post-extubation stridor in intensive care unit patients. Risk factors evaluation and importance of the cuff-leak test. Intensive Care Med. 2003;29:69–74.

    Article  PubMed  Google Scholar 

  56. Faris K, Zayaruzny M, Spanakis S. Extubation of the difficult airway. J Intensive Care Med. 2011;26:261–6.

    Article  PubMed  Google Scholar 

  57. Miller RD, editor. Anesthesia. 4th ed. New York: Churchill Livingstone; 1994. p. 1413.

    Google Scholar 

  58. Roberts PR, Todd SR, editors. Comprehensive critical care: adult. Mount Prospect, IL: Society of Critical Care Medicine; 2012. p. 283.

    Google Scholar 

  59. Standring S (Editor-in-Chief). Gray’s anatomy. 40th ed. Madrid: Churchill Livingstone/Elsevier; 2008

    Google Scholar 

  60. Huang H-H, Lee M-S, Shih Y-L, Chu H-C, Huang T-Y, Hsieh T-Y. Modified Mallampati classification as a clinical predictor of peroral esophagogastroduodenoscopy tolerance. BMC Gastroenterol. 2011;11:1.

    Article  CAS  Google Scholar 

  61. Barash PG, Cullen BF, Stoelting RK. Clinical anesthesia. 3rd ed. Philadelphia: JB Lippincott; 1997. p. 585.

    Google Scholar 

  62. Civetta JM, Taylor RW, Kirby RR. Critical care. 3rd ed. Philadelphia, PA: Lippincott-Raven; 1997. p. 765.

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anesthesiology, UMass Memorial Medical Center, 55 Lake Avenue North, Worcester, MA, 01655, USA

    Catherine Kuza MD, Elifçe O. Cosar MD & Stephen O. Heard MD

Authors
  1. Catherine Kuza MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Elifçe O. Cosar MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Stephen O. Heard MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Stephen O. Heard MD .

Editor information

Editors and Affiliations

  1. Department of Surgical Critical Care; Lahey Hospital and Medical Center, Division of Surgery, Burlington, Massachusetts, USA

    John M. O'Donnell

  2. Surgical Critical Care Medicine, Pr�-Card�o Hospital, Critical Care Medicine, University Hospital, Federal University of Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil

    Flávio E. Nácul

Rights and permissions

Reprints and permissions

Copyright information

© 2016 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Kuza, C., Cosar, E.O., Heard, S.O. (2016). Airway Management in the Intensive Care Unit. In: O'Donnell, J., Nácul, F. (eds) Surgical Intensive Care Medicine. Springer, Cham. https://doi.org/10.1007/978-3-319-19668-8_2

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-19668-8_2

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-19667-1

  • Online ISBN: 978-3-319-19668-8

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation