*2.2.2 Plan B/C: (backup plan)*

*Special Considerations in Human Airway Management*

using Sugammadex [36].

**2.2 Intervention stage**

strictly controlled and strategic manner.

patency, proper oxygenation and/or ventilation.

attempts using direct (DL) or video-laryngoscope (VL).

indicator for successful ETI in critically ill patients [38].

tional policy and training preferences [39].

patients [37].

*2.2.1 Plan A*

NMBA improves intubating conditions, facemask ventilation, nasogastric tube insertion hence, reduction in the number of intubations attempts and optimizing chest wall compliance [35]. Succinylcholine has many side-effects including lifethreatening hyperkalemia and its short duration of action can spared for difficult intubation scenarios. Rocuronium could be the choice in the critically ill patients, providing similar intubating conditions to Succinylcholine and can be antagonized

Graded sedation intubation without use of NMBA has also been proposed and clinically considered for technique of choice of airway management in critically ill

This is the subsequent stage, that follows patient's optimization achieved through concomitant preoxygenation, positioning and preparation of staff, equipment and medications. It is a highly stressful time and must be carried out in a

Current guidelines state four main routes or plans as standard practice and should be done in sequence. From practical point, we believe that algorism might be modified or interchanged according to the given circumstances, such as in ED and prehospital critical settings, health care professionals could go for plan B/C straight away bypassing plan A because of limited facilities and unsuitable environment that mandate minimal airway manipulation with accomplishment of securing airway

Plan A stresses on maintenance of oxygenation either via continuous nasal cannula or interrupted facemask application between laryngoscopic attempts and allowing enough time for desirable effect of pharmacological agents, laryngoscopy

With a maximum of three trials, confirmed endotracheal intubation (ENI) through capnography with waveform trace and direct visualization of ETT pass beyond the vocal cords, the call for help of the appropriate help once failed first attempt is a must. Absence of wave trace capnography is a confirmation of failed ETI after exclusion of other causes such as ETT obstruction, pulmonary edema and cardiac arrest. Chest auscultation and its rise during inspiration are rarely used as

First attempt of ETI, must be done by the most trained, proficient available and must have all team support and consideration of manoeuvers or manipulations with the aim of improving laryngoscopy is recommended after failed first attempt [19]. Operator replacement and equipment change; use of a different blade, addition of others; bougie and external laryngeal manipulation might be reasonable and

Despite of fulfilling all the available recourses to achieve an optimal laryngoscopic view, with failure of the ETI attempts, either three done or not, the team leader must swiftly proceed to the next airway management plan. DL is the standard use in ETI during daily clinical practice hence its use experience is granted. On the other hand, VL should be in preparation for difficult situation; MACOCHA score > 3 [11] and ensure its availability for critically ill patient management. DL versus VL is the choice of the professionals involved in the airway management scenario and could be the device selected for first attempt according to the institu-

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helpful.

Critically ill patients' lifesaving by maintaining oxygenation during airway management is the priority and failed ETI [8] in the preceding plan A could resulted in sever hypoxemia [6, 40] that has several serious consequences. It's the responsibility of the team leader to ensure maintenance of adequate oxygenation throughout the stages of airway management. ETT considered as a standard and definitive airway securing device while alternatives used to provide oxygenation in scenarios of failed ETI such as supraglottic airway (SGA) devices and facemask ventilation device.

SGA is considered as a plan B rescue device which consist of variety of devices used for the same purpose; securing upper airway patency that does not require long experience. Facemask ventilation used as a plan C with the purpose of providing O2 till an alternative being fixed. DAS/ICS/FICM/RCoA guidelines use SGA (plan B) and facemask ventilation (plan C) alternatively to ensure oxygenation after plan A failure confirmation with maximum three turn attempts [19].

Second-generation laryngeal mask airways (LMA) not only possess a design of providing oxygenation, reduce the aspiration risk and conduit for fiberoptic intubation (FOI) [40], but also, promising successful performance in critical areas have been reported [41] so, it's the model of SGA devices to be considered in standard practice and should be available in the difficult airway management trolley. Provision of oxygenation, airway securing, avoidance of aspiration with minimal airway trauma, constantly remain the goals throughout the intervention and subsequent plan to awake patient, wait for airway expert, Fiberoptic Intubation (FOI) through LMA attempt for once or proceed to FONA remains the area of discussion among the airway management team [19].

Basically, it's not recommended to proceed for blind ETI via LMA, [42] on the other hand, FOB accessibility in ICU should be granted [14, 43]. There are alternatives to perform LMA/FOI-guided either using small ETT 6.0 mm inner diameter mounted over the FOB to be advanced through LMA or using Aintree intubation catheter (Cook Medical, Bloomington, IN, USA), that permits ETT > 7.0 mm inner diameter without interruption of oxygenation. Blind ETI with use of either gum elastic bougie or tube exchange catheter (Frova catheter; Cook Medical, Bloomington, IN, USA) is not advisable in critically ill patients as it's associated with tracheal injury, pharyngeal perforation, bronchial bleeding and accused for subsequent positive pressure ventilation-related pneumomediastinum [44].

## *2.2.3 Plan D; life-saving front of neck airway (FONA)*

Life-threatening hypoxemia development in critically ill patients is frequent [45] and might be encountered at any stage of airway intervention, hence its prevention though ETI (plan A), SGA and facemask (plan B/C) use is emphasized. Not only, plan of failure with serious hypoxemia elaboration could drive towards FONA (**Figure 8**) but also, inadequate minimal oxygenation, aspiration, difficult ventilation and failure of LMA/FOI are potential indications [46]. Forever, efforts to eliminate cannot intubate cannot oxygenate (CICO) scenario must be maintained and its causes must be corrected while preparation of FONA is being proposed. The possible reasons for CICO might be related to patient's (airway; impacted foreign body or laryngeal narrowing either from inside as laryngeal edema or from outside as high cricoid pressure), cardiovascular collapse or related to equipment failure.

Late FONA during airway management scenario is common and is responsible for its associated morbidity and mortality [43, 47]. FONA setup prior to and at declaration of CICO occurred in three steps; immediate availability of FONA set,

opening the set after one failed attempt of plan B/C and immediate FONA set use on CICO declaration [19].

FONA either scalpel cricothyroidotomy or other techniques; which need experience, specific preparations and include non-scalpel cricothyroidotomy, percutaneous tracheostomy and surgical tracheostomy. Scalpel cricothyroidotomy recommended in DAS guidelines offers the following advantages; timesaving, reliable, conducted in few steps with well-known immediately available equipment,

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

**2.3 Post-intervention stage**

with 25% leading to death [49].

date immediate management.

*2.3.2 Weaning and extubation*

benefiting from recruitment manoeuvers [38].

*2.3.1 Post-intubation care*

tomy in ICU, will be discussed in another chapter.

high success rate, fitting for most of patients and providing definitive airway device [48]. For a brief technique steps of scalpel cricothyroidotomy and tracheos-

be avoided by follow-up FONA steps in a proper way as once it encountered, nonscalpel cricothyroidotomy by experienced professional, percutaneous dilatable tracheostomy and surgical tracheostomy have to be proposed immediately without delay.

Plan D (FONA) failure means a bad scenario that carries poor prognosis and must

Not only providing airway securing device in critically ill patients is highly challenging, but post airway securing maintenance is also important to prevent airway displacement or obstruction. In addition of airway care, sedation and/or muscle relaxation are typically administered. They are not only having high-risk during intubation but also afterwards in rates of 82%; airway displacement and blockage,

Furthermore; postintubation hypoxia occurred from multiple attempts, interruption of oxygenation, alveolar de-recruitment and collapse, and changes in the alveolar gas exchange may indicate an increase in initial lung volumes settings and

Attention payed towards recognition of red flag in intubated patients such as absent air entry on auscultation, abnormal EtCO2, increasing peak airway pressure (PAP), unattained inhaled tidal volume and abnormal chest x-ray findings, man-

Airway securing device in critically ill patients might be temporary for bridging a reversible and treatable medical disorder or permanent for irreversible and long-term pathology that demanding it. The former, long-term medical conditions, alternative tracheostomy have to be considered with a debate of its timing, On the other hand in reversible and corrected medical conditions; weaning and extubation must be considered in due time to avoid complications of prolonged ETT. Critically

Tracheostomy might be an alternative of ETT as a definitive airway in critically ill patients in incidence of 7–19% [50] while extubation is the plan once the circumstances permit. Extubation is an elective procedure and mandates careful evaluation, preparation with the target of maintenance of oxygenation and stand-

DAS incorporated extubation guidelines in anesthesia practice and could derive

i.Considering the reasons for intubation in addition of the complications of prolonged dependence on ETT and its anatomical and physiological

ii. "At-risk" extubation is a term used to describe the possible hazards associated with extubation process and must be considered in the plan step,

ill patients' intubation is challenging and extubation does too.

by intubation plan if extubation failure takes place.

that in ICU and summarized in four steps; [51].

especially the pre-existing factors.

**Step 1: Plan for extubation:**

consequences.

#### **Figure 8.**

*Plan D protocol in DAS/ICS/FICM/RCoA guidelines.*

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

high success rate, fitting for most of patients and providing definitive airway device [48]. For a brief technique steps of scalpel cricothyroidotomy and tracheostomy in ICU, will be discussed in another chapter.

Plan D (FONA) failure means a bad scenario that carries poor prognosis and must be avoided by follow-up FONA steps in a proper way as once it encountered, nonscalpel cricothyroidotomy by experienced professional, percutaneous dilatable tracheostomy and surgical tracheostomy have to be proposed immediately without delay.

#### **2.3 Post-intervention stage**
