Raj Joshi

The Physiologically Difficult Airway.

Airway management in critically ill patients involves the identification and management of the potentially difficult airway in order to avoid untoward complications. This focus on difficult airway management has traditionally referred to identifying anatomic characteristics of the patient that make either visualizing the glottic opening or placement of the tracheal tube through the vocal cords difficult. This paper will describe the physiologically difficult airway, in which physiologic derangements of the patient increase the risk of cardiovascular collapse from airway management. The four physiologically difficult airways described include hypoxemia, hypotension, severe metabolic acidosis, and right ventricular failure. The emergency physician should account for these physiologic derangements with airway management in critically ill patients regardless of the predicted anatomic difficulty of the intubation.

Video Laryngoscopy Improves Odds of First-Attempt Success at Intubation in the Intensive Care Unit. A Propensity-matched Analysis

RATIONALE Urgent tracheal intubation is performed frequently in intensive care units and incurs higher risk than when intubation is performed under more controlled circumstances. Video laryngoscopy may improve the chances of successful tracheal intubation on the first attempt; however, existing comparative data on outcomes are limited. OBJECTIVES To compare first-attempt success and complication rates during intubation when using video laryngoscopy compared with traditional direct laryngoscopy in a tertiary academic medical intensive care unit. METHODS We prospectively collected and analyzed data from a continuous quality improvement database of all intubations in one medical intensive care unit between January 1, 2012, and December 31, 2014. Propensity matching and multivariable logistic regression were used to reduce the risk of bias and control for confounding. MEASUREMENTS AND MAIN RESULTS A total of 809 intubations took place over the study period. Of these, 673 (83.2%) were performed using video laryngoscopy and 136 (16.8%) using direct laryngoscopy. First-attempt success with video laryngoscopy was 80.4% (95% confidence interval [CI], 77.2-83.3%) compared with 65.4% (95% CI, 56.8-73.4%) for intubations performed with direct laryngoscopy (P < 0.001). In a propensity-matched analysis, the odds ratio for first-attempt success with video laryngoscopy versus direct laryngoscopy was 2.81 (95% CI, 2.27-3.59). The rate of arterial oxygen desaturation events during the first intubation attempt was significantly lower for video laryngoscopy than for direct laryngoscopy (18.3% vs. 25.9%; P = 0.04). The rate of esophageal intubation during any attempt was also significantly lower for video laryngoscopy (2.1% vs. 6.6%; P = 0.008). CONCLUSIONS Video laryngoscopy was associated with significantly improved odds of first-attempt success at tracheal intubation by nonanesthesiologists in a medical intensive care unit. Esophageal intubation and oxygen desaturation occurred less frequently with the use of video laryngoscopy. Randomized clinical trials are needed to confirm these findings.

The Impact of a Comprehensive Airway Management Training Program for Pulmonary and Critical Care Medicine Fellows. A Three-Year Experience

RATIONALE Airway management in the intensive care unit (ICU) is challenging, as many patients have limited physiologic reserve and are at risk for clinical deterioration if the airway is not quickly secured. In academic medical centers, ICU intubations are often performed by trainees, making airway management education paramount for pulmonary and critical care trainees. OBJECTIVES To improve airway management education for our trainees, we developed a comprehensive training program including an 11-month simulation-based curriculum. The curriculum emphasizes recognition of and preparation for potentially difficult intubations and procedural skills to maximize patient safety and increase the likelihood of first-attempt success. METHODS Training is provided in small group sessions twice monthly using a high-fidelity simulation program under the guidance of a core group of two to three advanced providers. The curriculum is designed with progressively more difficult scenarios requiring critical planning and execution of airway management by the trainees. Trainees consider patient position, preoxygenation, optimization of hemodynamics, choice of induction agents, selection of appropriate devices for the scenario, anticipation of difficulties, back-up plans, and immediate postintubation management. Clinical performance is monitored through a continuous quality improvement program. MEASUREMENTS AND MAIN RESULTS Sixteen fellows have completed the program since July 1, 2013. In the 18 months since the start of the curriculum (July 1, 2013-December 31, 2014), first-attempt success has improved from 74% (358/487) to 82% (305/374) compared with the 18 months before implementation (P = 0.006). During that time there were no serious complications related to airway management. Desaturation rates decreased from 26 to 17% (P = 0.002). Other complication rates are low, including aspiration (2.1%), esophageal intubation (2.7%), dental trauma (0.8%), and hypotension (8.3%). First-attempt success in a 6-month period after implementation (July 1, 2014-December 31, 2014) was significantly higher (82.1 compared with 70.9%, P = 0.03) than during a similar 6-month period before implementation (July 1, 2012-December 31, 2012). CONCLUSIONS This comprehensive airway curriculum is associated with improved first-attempt success rate for intensive care unit intubations. Such a curriculum holds the potential to improve patient care.

Difficult Airway Characteristics Associated with First-Attempt Failure at Intubation Using Video Laryngoscopy in the Intensive Care Unit

Rationale: Video laryngoscopy has overcome the need to align the anatomic axes to obtain a view of the glottic opening to place a tracheal tube. However, despite this advantage, a large number of attempts are unsuccessful. There are no existing data on anatomic characteristics in critically ill patients associated with a failed first attempt at laryngoscopy when using video laryngoscopy. Objectives: To identify characteristics associated with first‐attempt failure at intubation when using video laryngoscopy in the intensive care unit (ICU). Methods: This is an observational study of 906 consecutive patients intubated in the ICU with a video laryngoscope between January 2012 and January 2016 in a single‐center academic medical ICU. After each intubation, the operator completed a data collection form, which included information on difficult airway characteristics, device used, and outcome of each attempt. Multivariable regression models were constructed to determine the difficult airway characteristics associated with a failed first attempt at intubation. Measurements and Main Results: There were no significant differences in sex, age, reason for intubation, or device used between first‐attempt failures and first‐attempt successes. First‐attempt successes more commonly reported no difficult airway characteristics were present (23.9%; 95% confidence interval [CI], 20.7‐27.0% vs. 13.3%; 95% CI, 8.0‐18.8%). In logistic regression analysis of the entire 906‐patient database, blood in the airway (odds ratio [OR], 2.63; 95% CI, 1.64‐4.20), airway edema (OR, 2.85; 95% CI, 1.48‐5.45), and obesity (OR, 1.59; 95% CI, 1.08‐2.32) were significantly associated with first‐attempt failure. Data collection on limited mouth opening and secretions began after the first 133 intubations, and we fit a second logistic model to examine cases in which these additional difficult airway characteristics were collected. In this subset (n = 773), the presence of blood (OR, 2.73; 95% CI, 1.60‐4.64), cervical immobility (OR, 3.34; 95% CI, 1.28‐8.72), and airway edema (OR, 3.10; 95% CI, 1.42‐6.70) were associated with first‐attempt failure. Conclusions: In this single‐center study, presence of blood in the airway, airway edema, cervical immobility, and obesity are associated with higher odds of first‐attempt failure, when intubation was performed with video laryngoscopy in an ICU.

Optimizing oxygen delivery in the critically ill: assessment of volume responsiveness in the septic patient.

BACKGROUND Assessing volume responsiveness, defined as an increase in cardiac index after infusion of fluids, is important when caring for critically ill patients in septic shock, as both under- and over-resuscitation can worsen outcomes. This review article describes the currently available methods of assessing volume responsiveness for critically ill patients in the emergency department, with a focus on patients in septic shock. OBJECTIVE The single-pump model of the circulation utilizing cardiac-filling pressures is reviewed in detail. Additionally, the dual-pump model evaluating cardiopulmonary interactions both invasively and noninvasively will be described. DISCUSSION Cardiac filling pressures (central venous pressure and pulmonary artery occlusion pressure) have poor performance characteristics when used to predict volume responsiveness. Cardiopulmonary interaction assessments (inferior vena cava distensibility/collapsibility, systolic pressure variation, pulse pressure variation, stroke volume variation, and aortic flow velocities) have superior test characteristics when measured either invasively or noninvasively. CONCLUSION Cardiac filling pressures may be misleading if used to determine volume responsiveness. Assessment of cardiopulmonary interactions has superior performance characteristics, and should be preferentially used for septic shock patients in the emergency department.

154: REASON FOR FAILED ATTEMPTS AT LARYNGOSCOPY DIFFERS BETWEEN VIDEO AND DIRECT LARYNGOSCOPES

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) at initiation of ECMO and PELOD score at initiation of ECMO, revealed that a state of fluid overload during the entire ECMO run increased the odds of death during ECMO therapy (OR=8.5, p = 0.04). Conclusions: A state of fluid overload during ECMO therapy increased mortality while on ECMO. Efforts should be taken to minimize a patient’s net fluid balance while receiving ECMO therapy.

174: FIRST ATTEMPT SUCCESS AT INTUBATION IS ASSOCIATED WITH A LOWER ODDS OF ADVERSE EVENTS IN THE ICU.

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) and acetaminophen were the most common offending drugs causing bradycardia (propofol 32.1% and fentanyl 12.5%) and increased aspartate transaminase (acetaminophen 5.8%). Of the probable/definite ADRs, fentanyl, insulin, and dextrose were the most common offending drugs causing hyperglycemia (fentanyl 24.6% and dextrose 4.3%) and hypokalemia (insulin 18.8%). Conclusions: ADRs in patients undergoing TH after cardiac arrest are common. Select agents should be used judiciously and monitored closely in this setting as a result of the possibility of ADRs.