*2.1.2 Preparation and preoxygenation challenges*

Formerly it's mentioned that; checklist, proper communication, documentation and team briefing with specific task assignment is a key for successful airway management in critical settings. Standard pre-intubation checklist has been developed via Difficult Airway Society (DAS), Intensive Care Society (ICS), Faculty of Intensive Care Medicine (FICM) and Royal College of Anesthetists (RCoA), United Kingdom solving this high-pressure situation (**Figure 6**).

Efficient preoxygenation with end-tidal oxygen concentration of more than 85% is the target [16] must be done in parallel to assessment and preparation. Traditional techniques are somewhat doing this task [17] and the choice of oxygen delivery device depends on the patient's comfort, device availability and the indication for intervention. Although use FIO2 of 100% with high flow rate; 10–15 L/min


*Abbreviations definition: MACOCHA= Mallampati score III or IV, Apnea syndrome, Cervical spine limitation, Opening mouth <3cm, Coma, Hypoxia, Anesthesiologist non-trained. Score: 0-12 =easy; 12=difficult.*

**Table 3.** *MACOCHA score [11].*

**89**

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

volume ventilation (MVV) [20].

*Pre-management preparation; patient, equipment, team assignment.*

**Figure 6.**

training [19] (**Figure 7**).

concentration (EtO2) monitoring; if available.

in a tight-sealed facemask for 3 minutes could be enough in intact spontaneously breathing derive [18] but the use of simple face mask even with reservoir bag is not recommended [19]. Moreover, non-invasive positive pressure ventilation (NIPPV) and continuous positive pressure ventilation (CPAP) could be alternatives for preoxygenation in seriously hypoxic patients resulting in improved oxygenation and prevention of atelectasis associated with FIO2 of 100% via supporting the minute

High flow nasal oxygenation (HFNO) between 30 and 70 L/min is a suitable method for preoxygenation that showed safety to extend the safe apnea time during airway instrumentation and effectiveness when combined with NIPPV use [21]. Not only, continuous positive airway pressure (CPAP) delivery with a tight-sealed facemask of 5–10 cm H2O is recommended for preoxygenation, but also, the use of nasal oxygen with a flow of 5 L/min throughout airway management [19] and might be achieved by NIPPV especially in patients with respiratory failure [20]. Plan for failure must be the strategy of airway management planning, allowing logical and prepared expectations for different scenarios that might occur during the procedure. The guidelines resulted from collaborations of DAS/ICS/FICM/ RCoA in United Kingdom with the aim of providing structured, standard and systematic approach of airway management in critically ill patients with the concern of not being a replacement of clinical judgment but rather an organizational and individual framework for clinical practice preparation and health care professionals

Providing the patient's comfort, upper airway patency, optimizing functional residual capacity and decreasing aspiration risk; sniffing position is desirable as an initial position for airway management in critical settings, [22] while titration of bed head-up if cervical spine injury was suspected or confirmed [22, 23] and with prevalence of obesity among population, ramping position could be an alternative [24]. All airway management in critical settings must be carried out in presence of standard ASA monitoring; electrocardiogram (ECG)/heart rate (HR), non-invasive blood pressure (NIBP), pulse oximetry with oxygen saturation (SPO2), end-tidal carbon dioxide (EtCO2) [25]. Invasive blood pressure (IBP) is desirable either vasopressors in-use or HD instability is most likely expected and end-tidal oxygen

**Figure 5.** *Laryngeal handshake technique.*

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

#### **Figure 6.**

*Special Considerations in Human Airway Management*

structures such as thyroid gland and its vessels [15].

Kingdom solving this high-pressure situation (**Figure 6**).

**Factors related to patient** Mallampati score III or IV

**Factors related to pathology** Coma

*Opening mouth <3cm, Coma, Hypoxia, Anesthesiologist non-trained.*

*Score: 0-12 =easy; 12=difficult.*

*MACOCHA score [11].*

**Table 3.**

*2.1.2 Preparation and preoxygenation challenges*

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

Formerly it's mentioned that; checklist, proper communication, documentation and team briefing with specific task assignment is a key for successful airway management in critical settings. Standard pre-intubation checklist has been developed via Difficult Airway Society (DAS), Intensive Care Society (ICS), Faculty of Intensive Care Medicine (FICM) and Royal College of Anesthetists (RCoA), United

Efficient preoxygenation with end-tidal oxygen concentration of more than 85% is the target [16] must be done in parallel to assessment and preparation. Traditional techniques are somewhat doing this task [17] and the choice of oxygen delivery device depends on the patient's comfort, device availability and the indication for intervention. Although use FIO2 of 100% with high flow rate; 10–15 L/min

**Factors Points**

**Factors related to operator** 1 **Total: 12** *Abbreviations definition: MACOCHA= Mallampati score III or IV, Apnea syndrome, Cervical spine limitation,* 

Obstructive sleep apnea syndrome (OSA) Reduced mobility of cervical spine. Limited mouth opening <3cm.

Sever hypoxemia (<80%)

1 1

**88**

**Figure 5.**

*Laryngeal handshake technique.*

*Pre-management preparation; patient, equipment, team assignment.*

in a tight-sealed facemask for 3 minutes could be enough in intact spontaneously breathing derive [18] but the use of simple face mask even with reservoir bag is not recommended [19]. Moreover, non-invasive positive pressure ventilation (NIPPV) and continuous positive pressure ventilation (CPAP) could be alternatives for preoxygenation in seriously hypoxic patients resulting in improved oxygenation and prevention of atelectasis associated with FIO2 of 100% via supporting the minute volume ventilation (MVV) [20].

High flow nasal oxygenation (HFNO) between 30 and 70 L/min is a suitable method for preoxygenation that showed safety to extend the safe apnea time during airway instrumentation and effectiveness when combined with NIPPV use [21]. Not only, continuous positive airway pressure (CPAP) delivery with a tight-sealed facemask of 5–10 cm H2O is recommended for preoxygenation, but also, the use of nasal oxygen with a flow of 5 L/min throughout airway management [19] and might be achieved by NIPPV especially in patients with respiratory failure [20].

Plan for failure must be the strategy of airway management planning, allowing logical and prepared expectations for different scenarios that might occur during the procedure. The guidelines resulted from collaborations of DAS/ICS/FICM/ RCoA in United Kingdom with the aim of providing structured, standard and systematic approach of airway management in critically ill patients with the concern of not being a replacement of clinical judgment but rather an organizational and individual framework for clinical practice preparation and health care professionals training [19] (**Figure 7**).

Providing the patient's comfort, upper airway patency, optimizing functional residual capacity and decreasing aspiration risk; sniffing position is desirable as an initial position for airway management in critical settings, [22] while titration of bed head-up if cervical spine injury was suspected or confirmed [22, 23] and with prevalence of obesity among population, ramping position could be an alternative [24].

All airway management in critical settings must be carried out in presence of standard ASA monitoring; electrocardiogram (ECG)/heart rate (HR), non-invasive blood pressure (NIBP), pulse oximetry with oxygen saturation (SPO2), end-tidal carbon dioxide (EtCO2) [25]. Invasive blood pressure (IBP) is desirable either vasopressors in-use or HD instability is most likely expected and end-tidal oxygen concentration (EtO2) monitoring; if available.

#### **Figure 7.**

*DAS/ICS/FICM/RCoA guidelines for ETI in critically ill patients.*
