**2. Airway management in ICU**

Airway management in ICU is unlike that carried out in operation theater (OT) and higher in its complications; brain damage and death, and most of it is done on urgent and emergency basis in lack of experienced airway management professionals. In addition; critically ill patients showing limited cardiopulmonary reserve, this increases their risk of hypoxemia and hypotension upon exposure to airway management medications. Subsequently, tracheal intubation for those categories of patients could be life-threatening condition; up to 40% of patients are associated with increase in complication rates of hypoxemia (25%) [5] and hypotension (10–25%) [6], arrhythmia, cardiac arrest and death [7] upon exposure to airway stimulation or pharmacological agents used for it.

Incapacity to perform tracheal intubation at the first attempt "first pass success" has higher risk than that in OT and occurs in 30% of ICU intubations [8]. Many factors contribute to that; lack of competent and expert professional for intubation, patient's factors and pharmacological agents' dosage choices. This came with the conclusion of Fourth National Audit Project (NAP4), as it showed around 25% of airway management done in ICU & ED are associated with major adverse effects mostly due to the aforementioned factors [9]. Moreover, equipment unavailability, unfamiliarity and inadequate planning resulting in more stressful environment and subsequently delay in airway management with increasing morbidity and mortality.

ICU settings are not suitably planned for airway management due to several reasons. Limited access to the patient as the bed space is crowded by monitoring, ventilator and other equipment, (**Figure 4**) in addition of the ICU bed is less maneuverable compared to the OT table with unavailability of advanced airway management equipment making it more challenging. Moreover, varying team members of multi-professional backgrounds with non-enough time, experience, accompanying medical devices (collars, masks) and sensorium alteration lead to improper airway assessment beside and inability to ensure adequate preoxygenation necessary to avoid the hypoxia during airway instrumentation. Moreover, unavailability of trained assistance such as anesthesia nurse or technician and lack of structured airway management for ICU staff.

Communication and proper documentation of the airway assessment and its management throughout different hospital facilities is crucial and it might affect the workflow performance. Checklist is the best method of communication among the healthcare professionals from different medical background. Equipment, medications preparation checklist and proper assignment of human forces could make the airway management scenario less stressful and empower its success among critically ill patients.

**Figure 4.** *ICU bed vs. OT space (showed crowding with monitoring, equipment and ventilators).*

Quite few challenges could be integrated in airway management for ICU adults, so we can wrap up the considerations and specific precautions that must be accomplish making it less pressure and successfully performed procedure (**Table 2**).

#### **2.1 Pre-intervention stage**

Thorough clinical assessment and prediction of threats that may limit the success of airway management of critically ill patients could be addressed in this time. Also, optimization of all factors; position, preparation and preoxygenation, accentuates the accomplishment of proper airway management intervention.

#### *2.1.1 Airway assessment challenges*

Not only thorough assessment of the airway in critically ill patient is vital for successful and safe management but it is unique and carries challenges as compared to that done for patients undergoing daily elective or emergency airway management. Varieties airway assessment modalities, techniques and scoring system had been proposed to allow its safe and easy practice management. Despite the anesthesiologists' or intensivists'predictions of anticipated airway difficulties are a strong diagnostic modality with high positive ratio, but the high proportion of unanticipated difficult endotracheal intubation and its low positive predictive values limits its reliability as a diagnostic test in medical practice [9].

Moreover, the proposed airway assessment scales vary from the simple, that often fail to address the many factors associated with a difficult airway, to the complex, which are impractical as a clinical tool. None have been shown to be accurate in predicting airway management problems, and none have been assessed in the ED setting [10].

NAP4 reports identified frequent airway management failure rate and the highrisk airway patient's identification was not managed through an appropriate airway management approach [9].

Standard airway assessment in critically ill patients is usually unfeasible and difficult to be done especially in those dependent on oxygen delivery devices; face mask or nasal cannula, to avoid hypoxia and provide adequate preoxygenation. The only validated airway assessment scoring system reliable for critically ill patients is the MACOCHA score

**87**

**Postintubation** 

**care**

*induction*

**Table 2.**

(**Table 3**) [11]. It has the advantage of being created with easy identifiable and clinically appropriate variables. Additionally, its used objectives are close to those identified in OT and include risk factors associated with difficult tracheal intubation [12]. Considering any investigations of the airway that already done; such as chest x-ray, CT scan and 3D and Virtual Endoscopy (VE) could be helpful in airway evaluation and might be derive

*Abbreviations definition;* **VL***: video-laryngoscope.* **FOB***: fiberoptics laryngoscope.* **MACOCHA***: Mallampati score, Apnea syndrome, Cervical spine limitation, Opening mouth, Coma, Hypoxia, Anesthesiologist non-trained.*  **FONA***: front of neck airway.* **NMBS***: neuromuscular blockers.* **RSI***: rapid sequence induction.* **DSI***: delayed sequence* 

the plan for airway management in critically ill patients [13].

*ICU airway management challenges, considerations and precautions.*

*Airway Management in Critical Settings DOI: http://dx.doi.org/10.5772/intechopen.93923*

**Challenge Consideration Precaution**

**ICU environment** ICU space; • Ideal stuff positioning

**Patient-related** Physiological; • HO instability • Optimization & vasopressors

• Limited reserve & time for airway management

Equipment; • Standard airway trolley

Team member; • Team members briefing and

Anatomical; Anticipation and plan for failure. Difficult airways; • Recognition and readiness for

Urgency; • Checklist in preparation and

Pharmacological agents; • Ketamine is recommended.

Aspiration risk; • Modified RSI with cricoid pres-

Red flag recognition; • ETT obstruction, displacement.

availability

• Advanced airway; VL, FOB, Bougie available

specific task assignment

proactively use.

delivery devices.

difficulties. • MACOCHA score use. • Reduce number of attempts. • Appropriate induction medications, NMBS is routine. • Plan for failure. • Consider FONA.

communication. • Follow up guidelines & standardized protocols.

• Avoid over sedation. • Routine use of NMBS. • Consider induction time longer

than traditional.

• Ventilators mechanics and Monitoring: ETT related.

sure or DSI. • Head-up position.

• Systematic, logical, and strategic airway management techniques escalation.

• Pulmonary shunt • Optimal preoxygenation with O2

#### *Airway Management in Critical Settings DOI: http://dx.doi.org/10.5772/intechopen.93923*

*Special Considerations in Human Airway Management*

**2.1 Pre-intervention stage**

**Figure 4.**

*2.1.1 Airway assessment challenges*

management approach [9].

Quite few challenges could be integrated in airway management for ICU adults, so we can wrap up the considerations and specific precautions that must be accomplish making it less pressure and successfully performed procedure (**Table 2**).

Thorough clinical assessment and prediction of threats that may limit the success of airway management of critically ill patients could be addressed in this time. Also, optimization of all factors; position, preparation and preoxygenation, accen-

Not only thorough assessment of the airway in critically ill patient is vital for successful and safe management but it is unique and carries challenges as compared to that done for patients undergoing daily elective or emergency airway management. Varieties airway assessment modalities, techniques and scoring system had been proposed to allow its safe and easy practice management. Despite the anesthesiologists' or intensivists'predictions of anticipated airway difficulties are a strong diagnostic modality with high positive ratio, but the high proportion of unanticipated difficult endotracheal intubation and its low positive predictive values limits

Moreover, the proposed airway assessment scales vary from the simple, that often fail to address the many factors associated with a difficult airway, to the complex, which are impractical as a clinical tool. None have been shown to be accurate in predicting airway management problems, and none have been assessed in the ED setting [10]. NAP4 reports identified frequent airway management failure rate and the highrisk airway patient's identification was not managed through an appropriate airway

Standard airway assessment in critically ill patients is usually unfeasible and difficult to be done especially in those dependent on oxygen delivery devices; face mask or nasal cannula, to avoid hypoxia and provide adequate preoxygenation. The only validated airway assessment scoring system reliable for critically ill patients is the MACOCHA score

tuates the accomplishment of proper airway management intervention.

*ICU bed vs. OT space (showed crowding with monitoring, equipment and ventilators).*

its reliability as a diagnostic test in medical practice [9].

**86**


*Abbreviations definition;* **VL***: video-laryngoscope.* **FOB***: fiberoptics laryngoscope.* **MACOCHA***: Mallampati score, Apnea syndrome, Cervical spine limitation, Opening mouth, Coma, Hypoxia, Anesthesiologist non-trained.*  **FONA***: front of neck airway.* **NMBS***: neuromuscular blockers.* **RSI***: rapid sequence induction.* **DSI***: delayed sequence induction*

#### **Table 2.**

*ICU airway management challenges, considerations and precautions.*

(**Table 3**) [11]. It has the advantage of being created with easy identifiable and clinically appropriate variables. Additionally, its used objectives are close to those identified in OT and include risk factors associated with difficult tracheal intubation [12]. Considering any investigations of the airway that already done; such as chest x-ray, CT scan and 3D and Virtual Endoscopy (VE) could be helpful in airway evaluation and might be derive the plan for airway management in critically ill patients [13].

It's recommended to define the cricothyroid membrane for possible front of neck airway (FONA) as a strategy of a plan for failure. This could be done by manual palpation; laryngeal handshake technique [14] (**Figure 5**) or using ultrasound that is accurately defining cricothyroid membrane site, measurements and surrounding structures such as thyroid gland and its vessels [15].
