1. AIRWAY MANAGEMENT IN THE ICU Rachel Garvin, MD Assistant Professor, Neurosurgery Neurocritical Care October 5, 2012

2. Goals of this Lecture To give you some comfort level with airways and tips to help your patient

3. Topics to be covered Why airway is so important Why patients with neurologic injury have airway issues Airway Anatomy Causes of compromised airway Airway Evaluation Airway Adjuncts Drugs

4. Why is airway management so important in the NeuroICU? Hypoxemia contributes to secondary brain injury Brain injured patients have numerous reasons to have airway compromise You should have an understanding of basic airway management to aid in your patient’s care

5. Study by Rincon et al looked at ARDS/ALI in TBI Prevalence of 22% with mortality of 28% Significant increase in prevalence over the past 20 years More common in young white males

6. Neural control Corticobulbar tract Lower CN’s Nucleus ambiguus Several respiratory centers Dorsal medulla Ventral medulla Dorsal rostral pons C-spine/Upper T-spine

7. Why do neuro patients have respiratory failure? As a result of their primary injury Due to secondary injury Other injuries Development of respiratory infection Development of ARDS

8. Corral et al looked at non-neurologic complications in severe TBI patients Respiratory infections in 68% of severe TBI patients Mortality not increased but hospital LOS, time on mechanical ventilation increased

9. Why is it important to understand airway anatomy? Airway Obstruction – where is it? Will my rescue devices work? What is happening in laryngospasm? What if I need to crich someone?

10. Concerning Airway

11. Airway Anatomy

13. Conditions that can compromise airway Degree of wakefulness Aspiration Body habitus Concurrent injuries Medications Co-morbidities

14. Airway Evaluation

18. Facial Features Beard, no teeth, buck teeth, dentures, recessed jaw Neck Short neck, landmarks unclear Limited Mobility C-collar, arthritis

19. Airway Evaluation

20. 3-3-2 Rule

21. Quick Assessment: Mouth: how much can they open it? Tongue: how much can they protrude it? Jaw: mobility Neck: mobility

22. Airway Adjuncts – what you can do before calling anesthesia Positioning Plastic in orifices Preoxygenate Jaw Thrust Check sedation

23. Positioning

25. Plastic

26. Placing a nasal trumpet Placed with bevel towards turbinates Left sided goes in angled down Right sided goes in facing upward and then turned

27. Placing an Oral Airway Pick the appropriate size 3-4 for small adult, 4-5 medium, 5-6 large Insert facing upward and then rotate down Do not use in an awake patient

28. Preoxygenate

29. Oxygen Delivery: High vs Low Flow Nasal Cannula Simple Face Mask Nonrebreather Face Mask Venti Mask Flow does NOT = FiO2

30. LMA

31. BVM Technique

33. If all else fails…..

34. What drugs do you want? Sedatives Paralytics

35. Sedatives Etomidate Propofol Ketamine

36. Etomidate GABA like effects Minimal effect on BP; can lower ICP Can reduce plasma cortisol levels Hepatic metabolism; renally excreted Dose 0.3mg/kg

37. Propofol Anesthetic agent Respiratory and CV depressant  can drop BP by as much as 30% Vasodilation and negative inotropic effect Dose is 1-1.5mg/kg

38. Ketamine Anesthetic and dissociative agent Hepatic metabolism Can cause laryngeal spasm, hypertension Emergence reaction  give benzo with it 1-2mg/kg

39. Paralytics Succinylcholine Vecuronium Rocuronium Cisatricurium If you don’t think you can BVM someone, don’t paralyze them!!

40. Succinylcholine Only depolarizing NMB Avoid in hyperkalemia, 24 hour post major burn, neuromuscular disease, patients with several days of ICU critical illness Onset in 60 seconds and lasts around 5 minutes 1-1.5mg/kg

41. Rocuronium Nondepolarizing Onset about 90 seconds and last 30-40 minutes Lasts longer in those with hepatic impairment Dose is 0.6-1mg/kg Effect is dose dependent

42. Vecuronium Similar to rocuronium Slower onset time (up to 4 minutes) Lasts 40-60 minutes 0.08-0.1mg-kg

43. Conclusion Appropriate airway management is crucial in patients with brain injury Remember your airway anatomy and assessment in patient evaluation Use your adjuncts to help you Be vigilant in the drugs being given to your patients if intubation is required

44. Questions?

45. References Corral L, Casimiro JF, Ventura JL, Marcos P, Herrero JI, Manez R. Impact of non-neurologic complications in severe traumatic brain injury outcome. Critical Care 2012; 16:R44. Karanjia N, Nordquist D, Stevens R, Nyquist P. A Clinical Descriuption of Extubation Failure in Patients with Primary Brain Injury. Neurocritical Care 2011; 15:4-12. Rincon F, Ghosh S, Dey S, Maltenfort M, Vibbert M, Urtecho J, McBride W, Moussouttas M, Bell R, Ratliff J, Jallo J. Impact of Acute Lung Injury and Acute Respiratory Distress Syndrome After Traumatic Brain Injury in the United States. Neurosurgery 2012; 71:795-803. Wong E, Yih-Yng Ng. The Difficult Airway in the Emergency Department. Int J Emerg Med, 2008: 1:107-111.