Preface

Shifting the performance of an invasive procedure from operating room or interventional lab to the ICU has advantages for both the patient and the doctor performing the procedure. *Bedside Procedures* is a guide to interventions that are commonly performed in the intensive care unit, without the need of an operating room. The increased availability of ultrasound guidance increases the success rate of these procedures and decreases the complication rate.

In the following chapters, the authors show that procedures like endotracheal intubation, videolaryngoscopy, pericardial puncture, lumbar puncture, and percutaneous cholecystos‐ tomy can be safely performed outside the operating room, at the bed of the patient. Intraabdominal pressure monitoring should also be used at the bed of the patient to confirm intra-abdominal hypertension and compartment syndrome in patients with pancreatitis, peritonitis, or blunt abdominal trauma.

The first chapter is the Introductory chapter.

The second chapter "Videolaryngoscopy in the Intensive Care Unit" by Eugenio Martínez Hurtado and his team from Madrid demonstrates that videolaryngoscopy becomes and is effective in reducing difficult intubation in ICU patients and remains a basic pillar in surviv‐ al, evolution, and prognosis in critically ill patients. Compared with direct laryngoscopy, videolaryngoscopy reduces the risk of difficult intubation, decreases the number of Cor‐ mack grade 3 or grade 4 views, decreases esophageal intubation, and increases first-attempt success. This chapter of the book ends with illustrations demonstrating the correct airway management and ways to avoid life-threatening complications.

The third chapter "Endotracheal Intubation in Children: Practice Recommendations, In‐ sights, and Future Directions" proposed by the team of professor Maribel Ibara Sarlat from Mexico City demonstrates that endotracheal intubation can be safely performed at the bed of the patient in critically ill children. The chapter describes the rapid sequence intubation procedure, explains how doctors should identify a patient with difficult airway, and illus‐ trates the devices and techniques for the management of difficult airway. Tips and tricks for preparation of intubation equipment, premedication in neonates, ET size selection for neo‐ nates, glottic structure identification, and management of deterioration after intubation are described in attractive tables. Pertinent images present the devices used for the management of a child that needs endotracheal intubation.

The fourth chapter "Emergency Pericardiocentesis in Children," written by professor Cecilia Lazea from Cluj-Napoca, describes the technique of echography-guided pericardiocentesis in cardiac tamponade. Images with materials used for emergency techniques emphasize the step-by-step approach to pericardiocentesis. Complications are presented at the end of the chapter, but they are not higher when pericardiocentesis is used as a bedside procedure than in the cath lab or in the operating room.

The fifth chapter "Lumbar Puncture of the Newborn" written by professor Selim Oncel from Izmit, Turkey, starts with a beautiful description of the history of lumbar puncture from an‐ cient Egypt to Heinrich Quincke. The author then presents the indications and contraindica‐ tions of the technique along with the possible complications and how to interpret the cerebrospinal fluid findings. The substantial part of the chapter consists in the procedure itself, with preparation of the materials, positioning of the newborn, how to take landmarks for the puncture, and how to successfully introduce the needle and aspirate cerebrospinal fluid. The artwork of professor Oncel speaks louder than words, and the reader of this chap‐ ter will discover a real artist in medical painting.

The sixth chapter "Percutaneous Cholecystostomy" by Michelle Maneevese and her team from Houston, United States, also starts with a historical perspective and then continues with the indications and contraindications of the technique. Percutaneous cholecystostomy quickly decompresses the gallbladder to prevent gallbladder rupture and resultant peritoni‐ tis. When performed at the bed of the patient, it can be guided by echography. Both the transhepatic and transperitoneal approaches are described as well as the Seldinger techni‐ que and the trocar technique for catheter placement inside the bladder. Fluoroscopic, ultra‐ sonographic, and tomographic images accompany the specific details of the technique.

The seventh chapter "Intra-abdominal Pressure Monitoring" by doctor Zsolt Bodnar from Letterkenny, Ireland, describes the advantages and disadvantages of the different techni‐ ques for monitoring of the intra-abdominal pressure. It is the only possible way of establish‐ ing the diagnosis of abdominal compartment syndrome and is based on the measurement of the intra-abdominal pressure through the bladder. The author proposes the continuous in‐ tra-abdominal pressure monitoring, describes the method and compares it with the intermit‐ tent method, and validates it as a new monitoring technique.

All the chapters of the book are clinically orientated providing explanations and illustrations for invasive procedures. The information is accessible with a minimal theoretical back‐ ground, but some bedside procedures may require additional training and experience. Therefore, practical recommendations are given in the book, with figures on the techniques performed in critically ill patients.

It will serve the experienced doctor who has not performed a procedure for a long time as well as the young doctors needing a practical assistance when facing a new patient.

**Cismaru Gabriel, MD, PhD**

**Chapter 1**

**Provisional chapter**

**Introductory Chapter: Bedside Procedures in Critical**

The number of procedures performed in an operating room (OR) or interventional radiology (IR) is high; therefore, the performance of bedside procedures may decongest those services and be more rapidly performed by the team that is closest to the patient. It was also demonstrated that it can prevent serious adverse effects related to the transportation of patients to OR or IR. The price for radiology performed procedures is also higher compared to those performed at the bed of the patient as there are specific charges for special radiological equip-

Some of the procedures performed at the bed of the patient may need ultrasound guidance. Ultrasound should be available in the ICU department and portable devices can guide paracentesis, thoracocentesis, pericardial puncture, abscess drainage, insertion of venous central line, or insertion of an arterial line. In the new years, hand-held ultrasound machines made the procedures even more easy to perform as it can be used for the guidance of vascular access or fluid removal from the pericardium, pleura, abdomen, cystostomy, etc. The placement of inferior vena cava filters is performed in patients with deep vein thrombosis and contraindication to anticoagulants or recurrent thromboembolism after correct anticoagulation. Filters can be implanted at the bed of the patient using intravascular echography, available as rotational or sectorial ultrasound. Transesophageal echocardiography can also be used at the bed of the patient to guide implantation of chemotherapy chambers or chambers for continuous high doses

**Introductory Chapter: Bedside Procedures in Critical** 

DOI: 10.5772/intechopen.73068

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Many procedures utilize special available kits for central venous catheter placement, arterial line placement, pericardiocentesis (**Figure 1**), pulmonary artery catheterization, percutaneous tracheostomy, temporary pacemaker insertion (**Figure 2**), port-a-cath (**Figure 3**) lumbar puncture or suprapubic cystostomy. These kits include drapes, gloves, caps, gowns and masks for

**Care Unit**

**Care Unit**

Cismaru Gabriel

**1. Introduction**

of diuretics [2].

Cismaru Gabriel

Additional information is available at the end of the chapter

ment, radiologist's time and procedural space [1].

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.73068

5th Department of Internal Medicine, Cardiology Rehabilitation, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania

**Provisional chapter**

## **Introductory Chapter: Bedside Procedures in Critical Care Unit Care Unit**

**Introductory Chapter: Bedside Procedures in Critical** 

DOI: 10.5772/intechopen.73068

#### Cismaru Gabriel Additional information is available at the end of the chapter

Cismaru Gabriel

chapter, but they are not higher when pericardiocentesis is used as a bedside procedure than

The fifth chapter "Lumbar Puncture of the Newborn" written by professor Selim Oncel from Izmit, Turkey, starts with a beautiful description of the history of lumbar puncture from an‐ cient Egypt to Heinrich Quincke. The author then presents the indications and contraindica‐ tions of the technique along with the possible complications and how to interpret the cerebrospinal fluid findings. The substantial part of the chapter consists in the procedure itself, with preparation of the materials, positioning of the newborn, how to take landmarks for the puncture, and how to successfully introduce the needle and aspirate cerebrospinal fluid. The artwork of professor Oncel speaks louder than words, and the reader of this chap‐

The sixth chapter "Percutaneous Cholecystostomy" by Michelle Maneevese and her team from Houston, United States, also starts with a historical perspective and then continues with the indications and contraindications of the technique. Percutaneous cholecystostomy quickly decompresses the gallbladder to prevent gallbladder rupture and resultant peritoni‐ tis. When performed at the bed of the patient, it can be guided by echography. Both the transhepatic and transperitoneal approaches are described as well as the Seldinger techni‐ que and the trocar technique for catheter placement inside the bladder. Fluoroscopic, ultra‐ sonographic, and tomographic images accompany the specific details of the technique.

The seventh chapter "Intra-abdominal Pressure Monitoring" by doctor Zsolt Bodnar from Letterkenny, Ireland, describes the advantages and disadvantages of the different techni‐ ques for monitoring of the intra-abdominal pressure. It is the only possible way of establish‐ ing the diagnosis of abdominal compartment syndrome and is based on the measurement of the intra-abdominal pressure through the bladder. The author proposes the continuous in‐ tra-abdominal pressure monitoring, describes the method and compares it with the intermit‐

All the chapters of the book are clinically orientated providing explanations and illustrations for invasive procedures. The information is accessible with a minimal theoretical back‐ ground, but some bedside procedures may require additional training and experience. Therefore, practical recommendations are given in the book, with figures on the techniques

It will serve the experienced doctor who has not performed a procedure for a long time as

5th Department of Internal Medicine, Cardiology Rehabilitation, "Iuliu Hatieganu" University of Medicine and Pharmacy,

**Cismaru Gabriel, MD, PhD**

Cluj-Napoca, Romania

well as the young doctors needing a practical assistance when facing a new patient.

in the cath lab or in the operating room.

VIII Preface

ter will discover a real artist in medical painting.

tent method, and validates it as a new monitoring technique.

performed in critically ill patients.

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.73068

**1. Introduction**

The number of procedures performed in an operating room (OR) or interventional radiology (IR) is high; therefore, the performance of bedside procedures may decongest those services and be more rapidly performed by the team that is closest to the patient. It was also demonstrated that it can prevent serious adverse effects related to the transportation of patients to OR or IR. The price for radiology performed procedures is also higher compared to those performed at the bed of the patient as there are specific charges for special radiological equipment, radiologist's time and procedural space [1].

Some of the procedures performed at the bed of the patient may need ultrasound guidance. Ultrasound should be available in the ICU department and portable devices can guide paracentesis, thoracocentesis, pericardial puncture, abscess drainage, insertion of venous central line, or insertion of an arterial line. In the new years, hand-held ultrasound machines made the procedures even more easy to perform as it can be used for the guidance of vascular access or fluid removal from the pericardium, pleura, abdomen, cystostomy, etc. The placement of inferior vena cava filters is performed in patients with deep vein thrombosis and contraindication to anticoagulants or recurrent thromboembolism after correct anticoagulation. Filters can be implanted at the bed of the patient using intravascular echography, available as rotational or sectorial ultrasound. Transesophageal echocardiography can also be used at the bed of the patient to guide implantation of chemotherapy chambers or chambers for continuous high doses of diuretics [2].

Many procedures utilize special available kits for central venous catheter placement, arterial line placement, pericardiocentesis (**Figure 1**), pulmonary artery catheterization, percutaneous tracheostomy, temporary pacemaker insertion (**Figure 2**), port-a-cath (**Figure 3**) lumbar puncture or suprapubic cystostomy. These kits include drapes, gloves, caps, gowns and masks for

Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons

**Figure 1.** Pericardiocentesis kit: (A) atraumatic metallic guidewire that enters inside the pericardium after the puncture with the needle; (B) dilator—is stiff, made of plastic and dilates the orifice made by the needle; it permits the introduction of the aspiration catheter; (C) aspiration catheter; and (D) needle.

> the doctor, betadine, needles, catheters, blades, syringes, drainage catheters, bags, tubes, lidocaine with and without adrenaline, for the procedure itself. The kit provides maximal barrier

> **Figure 3.** Port a cath Implantable Venous Access System kit. It can be used for chemotherapy administration, high doses of diuretics in terminal heart failure patients, parenteral nutrition, and blood sampling. (A) Syringe, (B) atraumatic metallic catheter that will be introduced through the cephalic, jugular or subclavian vein, (C) the chamber for therapy injection, (D) dilator used to access the central vein, (E) needle for venous puncture, (F) polyethylene catheter tubing that will be inserted at the junction between the right atrium and superior vena cava, and (G) 90-degree winged infusion set.

Introductory Chapter: Bedside Procedures in Critical Care Unit

http://dx.doi.org/10.5772/intechopen.73068

3

Before deciding to perform a procedure at the bedside of the patient in ICU, we should limit visitors to enter in the immediate surrounding of the patient or even in the entire unit during the performance of the procedure. This ensures a sterile field and also provides measures of privacy. On the other hand, we should separate the procedure and the patient from the rest of the ICU to minimize distractions and disruptions. This can be done by curtains or temporary partitions or by changing the room of the performance. Nurses should be present during the procedure, and they should be familiar with the technique of the procedure. Most of the time adequate sedation is necessary with midazolam, propofol and pethidine. Doses for analgesia and sedation should be prescribed by the doctor, but the volume of the vial and dilution should be known by the nurse. Prior to assisting in a new procedure, nurses, residents, students and other staff members should receive adequate training with a prior period of obser-

precautions and also lowers the rate of iatrogenic infection.

**2. How to perform bedside procedures?**

vation when there is no anterior experience [3].

**Figure 2.** Temporary pacemaker insertion kit: it contains: (A) an atraumatic guidewire that will be introduced in a central vein: femoral, jugular or subclavian, (B) a plastic introducer that will remain inside the vein during the temporary stimulation of the heart, (C) a transvenous lead that will be fixed at the level of atrial or ventricular myocardium and will be used to stimulate the heart, and (D) an external pacemaker that will deliver the stimulation to the heart through the transvenous lead.

**Figure 3.** Port a cath Implantable Venous Access System kit. It can be used for chemotherapy administration, high doses of diuretics in terminal heart failure patients, parenteral nutrition, and blood sampling. (A) Syringe, (B) atraumatic metallic catheter that will be introduced through the cephalic, jugular or subclavian vein, (C) the chamber for therapy injection, (D) dilator used to access the central vein, (E) needle for venous puncture, (F) polyethylene catheter tubing that will be inserted at the junction between the right atrium and superior vena cava, and (G) 90-degree winged infusion set.

the doctor, betadine, needles, catheters, blades, syringes, drainage catheters, bags, tubes, lidocaine with and without adrenaline, for the procedure itself. The kit provides maximal barrier precautions and also lowers the rate of iatrogenic infection.

## **2. How to perform bedside procedures?**

**Figure 2.** Temporary pacemaker insertion kit: it contains: (A) an atraumatic guidewire that will be introduced in a central vein: femoral, jugular or subclavian, (B) a plastic introducer that will remain inside the vein during the temporary stimulation of the heart, (C) a transvenous lead that will be fixed at the level of atrial or ventricular myocardium and will be used to stimulate the heart, and (D) an external pacemaker that will deliver the stimulation to the heart through the transvenous lead.

**Figure 1.** Pericardiocentesis kit: (A) atraumatic metallic guidewire that enters inside the pericardium after the puncture with the needle; (B) dilator—is stiff, made of plastic and dilates the orifice made by the needle; it permits the introduction

of the aspiration catheter; (C) aspiration catheter; and (D) needle.

2 Bedside Procedures

Before deciding to perform a procedure at the bedside of the patient in ICU, we should limit visitors to enter in the immediate surrounding of the patient or even in the entire unit during the performance of the procedure. This ensures a sterile field and also provides measures of privacy. On the other hand, we should separate the procedure and the patient from the rest of the ICU to minimize distractions and disruptions. This can be done by curtains or temporary partitions or by changing the room of the performance. Nurses should be present during the procedure, and they should be familiar with the technique of the procedure. Most of the time adequate sedation is necessary with midazolam, propofol and pethidine. Doses for analgesia and sedation should be prescribed by the doctor, but the volume of the vial and dilution should be known by the nurse. Prior to assisting in a new procedure, nurses, residents, students and other staff members should receive adequate training with a prior period of observation when there is no anterior experience [3].

For the safety of the procedure, adequate preparation is mandatory, with prior sedation, intravenous access, initial preparation of the kit and suitable monitoring. Specific sites for venous access are preferred in the function of the bedside procedure being performed. Advanced airway equipment should be available, especially when the bedside procedure is performed in an unstable patient. Whenever possible, informed consent should be obtained from the patient before the beginning of the procedure, and in case of unstable patients, consent should be obtained from a family member or tutor of the patient. All the staff members should be aware of the nosocomial infection risk. This risk can be reduced by proper hand hygiene, the use of antiseptic skin agents, selecting a good puncture site, and the use of sterile drapes for an aseptic technique [4].

**Chapter 2**

**Provisional chapter**

**Videolaryngoscopy in the Intensive Care Unit: We**

**Videolaryngoscopy in the Intensive Care Unit: We** 

DOI: 10.5772/intechopen.72658

Tracheal intubation is one of the most common and dangerous procedures in the intensive care units (ICU), and is usually done in more difficult conditions than in the operating room. Intubation failure can occur unexpectedly, and is the second most common event reflected in the ICU in the NAP4. Complications associated with airways were more likely to occur in ICU than in the operating room (severe hypoxemia, arrhythmia, hypotension, cardiovascular collapse, etc.), and generates more frequent damage to the patient. The theoretical benefits of videolaryngoscopes, as proper and correct use, offer the potential to reduce the difficulty of intubation in the ICU. In recent years, the role of videolaryngoscopes in ICU has been the subject of debate. Numerous studies have shown increased morbidity when performing multiple attempts at tracheal intubation. Videolaryngoscopes allow a view of the entrance of glottis independent of the line of sight, and have also been shown to improve glottis and intubation success rates in emergency and emergency services, in the prehospital setting, and specifically in patients with known predictors of difficult airway (DA).

**Keywords:** tracheal intubation, NAP4, complications, videolaryngoscopes, difficult airway, airway management, laryngoscopy, critical patient

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Airway management (AM) in intensive care units (ICU) is a common practice that is usually performed in more complicated conditions than in the operating room, where it is performed on a scheduled basis. The fundamental difference is that these patients are frequently in a situation of

**could Improve ICU Patients Safety**

**could Improve ICU Patients Safety**

Miriam Sánchez Merchante, Sonia Martín Ventura,

Eugenio Martínez Hurtado, Miriam Sánchez Merchante, Sonia Martín Ventura, María Luisa Mariscal Flores and

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

Eugenio Martínez Hurtado,

Javier Ripollés Melchor

**Abstract**

**1. Introduction**

Javier Ripollés Melchor

María Luisa Mariscal Flores and

http://dx.doi.org/10.5772/intechopen.72658

Proper hand hygiene, appropriate site selection, use of appropriate skin preparation agents, and an aseptic technique with a full body drape during device insertion have been shown to reduce the rate of nosocomial device-related infections.

In urban non-academic, rural and community hospitals, intensivists are more likely to perform bedside procedures as compared to their urban academic counterparts. This is likely because of a lack in interventional radiology departments and performance of the procedure at the bed of the patient may be particularly important [5].

We are of the strong belief that hospitalization costs can be reduced by doing the procedures at the bedside of the patient rather than referring them to the surgery department or interventional radiology.

## **Author details**

#### Cismaru Gabriel

Address all correspondence to: gabi\_cismaru@yahoo.com

5th Department of Internal Medicine, Cardiology Rehabilitation, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania

#### **References**


**Provisional chapter**

#### **Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety**

DOI: 10.5772/intechopen.72658

For the safety of the procedure, adequate preparation is mandatory, with prior sedation, intravenous access, initial preparation of the kit and suitable monitoring. Specific sites for venous access are preferred in the function of the bedside procedure being performed. Advanced airway equipment should be available, especially when the bedside procedure is performed in an unstable patient. Whenever possible, informed consent should be obtained from the patient before the beginning of the procedure, and in case of unstable patients, consent should be obtained from a family member or tutor of the patient. All the staff members should be aware of the nosocomial infection risk. This risk can be reduced by proper hand hygiene, the use of antiseptic skin agents,

selecting a good puncture site, and the use of sterile drapes for an aseptic technique [4].

reduce the rate of nosocomial device-related infections.

at the bed of the patient may be particularly important [5].

Address all correspondence to: gabi\_cismaru@yahoo.com

has come. Journal of Hospital Medicine. 2010;**5**:1-3

Internal Medicine. 2007;**146**:355-360

of Medicine and Pharmacy, Cluj-Napoca, Romania

tional radiology.

4 Bedside Procedures

**Author details**

Cismaru Gabriel

**References**

Proper hand hygiene, appropriate site selection, use of appropriate skin preparation agents, and an aseptic technique with a full body drape during device insertion have been shown to

In urban non-academic, rural and community hospitals, intensivists are more likely to perform bedside procedures as compared to their urban academic counterparts. This is likely because of a lack in interventional radiology departments and performance of the procedure

We are of the strong belief that hospitalization costs can be reduced by doing the procedures at the bedside of the patient rather than referring them to the surgery department or interven-

5th Department of Internal Medicine, Cardiology Rehabilitation, Iuliu Hatieganu University

[1] Barsuk JH, Cohen ER, Feinglass J, et al. Clinical outcomes after bedside and interventional radiology paracentesis procedures. The American Journal of Medicine. 2013;**126**:349-356 [2] Brown SM, Kasal J. Bedside ultrasound in the intensive care unit: Where is the evidence?

[3] Thakkar R, Wright SM, Alguire P, et al. Procedures performed by hospitalist and nonhospitalist general internists. Journal of General Internal Medicine. 2010;**25**:448-452 [4] Heisler M. Hospitalists and intensivists: Partners in caring for the critically ill—The time

[5] Wigton RS, Alguire P. The declining number and variety of procedures done by general internists: A resurvey of members of the American College of Physicians. Annals of

Seminars in Respiratory and Critical Care Medicine. 2015 Dec;**36**(6):878-889

Eugenio Martínez Hurtado, Miriam Sánchez Merchante, Sonia Martín Ventura, María Luisa Mariscal Flores and Javier Ripollés Melchor Eugenio Martínez Hurtado, Miriam Sánchez Merchante, Sonia Martín Ventura, María Luisa Mariscal Flores and Javier Ripollés Melchor Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.72658

#### **Abstract**

Tracheal intubation is one of the most common and dangerous procedures in the intensive care units (ICU), and is usually done in more difficult conditions than in the operating room. Intubation failure can occur unexpectedly, and is the second most common event reflected in the ICU in the NAP4. Complications associated with airways were more likely to occur in ICU than in the operating room (severe hypoxemia, arrhythmia, hypotension, cardiovascular collapse, etc.), and generates more frequent damage to the patient. The theoretical benefits of videolaryngoscopes, as proper and correct use, offer the potential to reduce the difficulty of intubation in the ICU. In recent years, the role of videolaryngoscopes in ICU has been the subject of debate. Numerous studies have shown increased morbidity when performing multiple attempts at tracheal intubation. Videolaryngoscopes allow a view of the entrance of glottis independent of the line of sight, and have also been shown to improve glottis and intubation success rates in emergency and emergency services, in the prehospital setting, and specifically in patients with known predictors of difficult airway (DA).

**Keywords:** tracheal intubation, NAP4, complications, videolaryngoscopes, difficult airway, airway management, laryngoscopy, critical patient

#### **1. Introduction**

Airway management (AM) in intensive care units (ICU) is a common practice that is usually performed in more complicated conditions than in the operating room, where it is performed on a scheduled basis. The fundamental difference is that these patients are frequently in a situation of

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

collapse), and more frequently caused harm to the patient. This study specifically mentioned the theoretical benefit of videolaryngoscopes (VL), since their proper and correct use would offer the

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety

http://dx.doi.org/10.5772/intechopen.72658

7

Other important conclusions drawn from the NAP4 were the scarce airway assessment performed in the critical units and did not allow us to anticipate a DA, resulting in poor planning. It was also observed that, in the context of an unexpected DA, the limited ability to modify the

The utility of videolaryngoscopy in anesthesia is widely recognized and endorsements advocating its use have been incorporated in the UK and American Difficult Airway Society guide-

The degree of difficulty with face mask ventilation (FMV) and intubation with direct laryngoscopy (DL) is very variable according to the studies and although the degree of difficulty for intubation does not have to correspond to the difficulty for ventilation with facial masks,

In general, the incidence of Cormack-Lehane grades 3/4 and 4/4 ranges from 1 to 10%, and 2–8%, respectively. These figures are up to 7.9% in pregnant women requiring general anesthesia, with 2% of cases being "*very difficult intubation*", an incidence similar to difficult orotra-

Finally, the catastrophic situation of "*can't-intubate-can't-oxygenate*" (CICO) can occur with an

All these figures vary between studies, mainly because there is no unanimity in the definitions

Facial mask ventilation (FMV) is a fundamental element of the AM that would ensure patient oxygenation between the different intubation attempts. It has been classically described an

In 2004, a scale of 4 degrees of difficulty FMV was established, assigning a score of 0–4 according to the difficulty found [13], which was later used in a study of 22,660 patients [14], Finding

incidence of 1–3 per 10,000 patients to 1 per 50,000 patients according to the authors.

Within the specific context of an ICU, the incidence of DA rises to 10–20% [7–12].

• Grade 2: easy FMV with an oral cannula or other adjuvants (21.1%).

• Grade 3: difficult FMV (inadequate, unstable or requiring two operators) (1.4%).

if they occur together in the same patient, the consequences can be catastrophic [4].

Traditionally, the difficulty for laryngoscopy vision is difficult to intubate [5, 6].

cheal intubation (OTI) in urgent non-obstetric surgical patients.

potential to reduce the difficulty of intubation in the ICU (**Figure 1**).

established plan may lead to a failure to resolve the situation.

lines [2, 3].

**2. Epidemiology**

or terms related to AM.

a degree of difficulty of:

• Grade 1: easy FMV (77.4%).

incidence of difficulty FMV of 0.08% [5].

**Figure 1.** Airtraq videolaryngoscope.

hypoxemia and cardiovascular collapse, so in many situations, the airway management in these clinical conditions is often complicated, if not emergency. Therefore, it is usually considered that these patients present, at the beginning, a possible difficult airway (DA).

Although failure to manage AM sometimes occurs unexpectedly, it is known to be the second most common event reflected in NAP4 in the ICU [1]. So, all patients admitted in the ICU should be considered at risk.

The airway approach in this environment has gained interest in recent years, especially after NAP4, in which airway complications were found to be more likely to occur in the ICU than in the operating room (severe hypoxemia, in addition to arrhythmias, hypotension, and cardiovascular collapse), and more frequently caused harm to the patient. This study specifically mentioned the theoretical benefit of videolaryngoscopes (VL), since their proper and correct use would offer the potential to reduce the difficulty of intubation in the ICU (**Figure 1**).

Other important conclusions drawn from the NAP4 were the scarce airway assessment performed in the critical units and did not allow us to anticipate a DA, resulting in poor planning. It was also observed that, in the context of an unexpected DA, the limited ability to modify the established plan may lead to a failure to resolve the situation.

The utility of videolaryngoscopy in anesthesia is widely recognized and endorsements advocating its use have been incorporated in the UK and American Difficult Airway Society guidelines [2, 3].

## **2. Epidemiology**

The degree of difficulty with face mask ventilation (FMV) and intubation with direct laryngoscopy (DL) is very variable according to the studies and although the degree of difficulty for intubation does not have to correspond to the difficulty for ventilation with facial masks, if they occur together in the same patient, the consequences can be catastrophic [4].

Traditionally, the difficulty for laryngoscopy vision is difficult to intubate [5, 6].

In general, the incidence of Cormack-Lehane grades 3/4 and 4/4 ranges from 1 to 10%, and 2–8%, respectively. These figures are up to 7.9% in pregnant women requiring general anesthesia, with 2% of cases being "*very difficult intubation*", an incidence similar to difficult orotracheal intubation (OTI) in urgent non-obstetric surgical patients.

Finally, the catastrophic situation of "*can't-intubate-can't-oxygenate*" (CICO) can occur with an incidence of 1–3 per 10,000 patients to 1 per 50,000 patients according to the authors.

All these figures vary between studies, mainly because there is no unanimity in the definitions or terms related to AM.

Within the specific context of an ICU, the incidence of DA rises to 10–20% [7–12].

Facial mask ventilation (FMV) is a fundamental element of the AM that would ensure patient oxygenation between the different intubation attempts. It has been classically described an incidence of difficulty FMV of 0.08% [5].

In 2004, a scale of 4 degrees of difficulty FMV was established, assigning a score of 0–4 according to the difficulty found [13], which was later used in a study of 22,660 patients [14], Finding a degree of difficulty of:

• Grade 1: easy FMV (77.4%).

**Figure 1.** Airtraq videolaryngoscope.

6 Bedside Procedures

should be considered at risk.

hypoxemia and cardiovascular collapse, so in many situations, the airway management in these clinical conditions is often complicated, if not emergency. Therefore, it is usually considered that

Although failure to manage AM sometimes occurs unexpectedly, it is known to be the second most common event reflected in NAP4 in the ICU [1]. So, all patients admitted in the ICU

The airway approach in this environment has gained interest in recent years, especially after NAP4, in which airway complications were found to be more likely to occur in the ICU than in the operating room (severe hypoxemia, in addition to arrhythmias, hypotension, and cardiovascular

these patients present, at the beginning, a possible difficult airway (DA).


In order to increase statistical power in some variables of the previous study, in 2009, a new study was carried out, collecting more than 50,000 patients [15]. It was recognized that the incidence of impossible FMV, defined as "*the inability to ventilate with facial masks despite the use of facilitating devices and 2-hand ventilation*", was found to be around 0.15%.

However, it is currently considered "*management of context-sensitive airway*", where a gaseous exchange is more valued than the tracheal intubation itself [18], which consists of four ventila-

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety

http://dx.doi.org/10.5772/intechopen.72658

9

The use of any of these methods depends not only on the devices but also on the situation facing the professional. In this management of context-sensitive MA, maintenance of the patient's gauche exchange is the priority and should not be "*device dependent*". Thus, careful evaluation of the "*context*" interpretation is essential for the safe practice of MA management.

The concept "*context-sensitive AM*" acquires special relevance in critically ill patients, and

• Pathology of the patient (hemorrhage, edema, trauma, increased secretions, etc.).

The primary indication for OTI in ICU is the acute respiratory failure. Weakness and fatigue of respiratory muscles (ventilatory failure) and disruption of gas exchange (respiratory failure) are common, and the risk of hypoxemia and cardiovascular shock during the OTI process is

Critical patient intubation presents life-threatening complications in more than one-third of cases [19]. The most common are respiratory and hemodynamic alterations [20]. The main adverse event associated with the technique is hypoxemia with a dramatic decrease in peripheral oxygen saturation (SapO2) despite adequate preoxygenation. In almost half of the cases, the indication for tracheal intubation is due to an acute respiratory failure with a previous

there are several causes that make it difficult to manage their AM:

**4. Complications of intubation in the critical patient**

SapO2 of less than 90% that supports the appearance of severe hypoxemia.

• What equipment and medication are available?

tion and oxygenation methods:

**2.** Supraglottic or extraglottic devices.

**1.** Facial mask.

**4.** Surgical AM.

**3.** Endotracheal tube.

**1.** Non-patient dependent:

• Who helps? **2.** Dependent patient:

• Who manages airway? • Where is the patient?

• Predictive tests of AD.

high, ranging from 15 to 50%.

#### **3. Particularities of airway management in the critical patient**

Critical patient intubation is often performed in ICU, but can also be performed in locations away from the operating room, where working conditions and available materials are often inadequate. The difficulty rate of orotracheal intubation in emergency situations is 3 times higher than the programmed procedure, with a reported incidence of 10–20% failure at the firstattempt [7], with a complication rate 50 times higher than those found during anesthesia [1].

The AM of the critically ill patient may be complicated by the anatomical characteristics involving the visualization of glottis opening, or the difficult passage of the tracheal tube through the vocal cords, or by the clinical situation itself, which may contribute to the cardiovascular collapse. Among these causes of physiologic DA are hypoxemia, hypotension, severe metabolic acidosis, and right ventricular failure [16]. In fact, approximately 20% of patients in the ICU will experience critical hypoxemia, which, in the worst case, leads to death. Other common complications are esophageal intubation, aspiration, and selective bronchial intubation, among others.

DA is defined as "*that clinical situation in which an experienced anesthesiologist present difficulties with ventilation with a face mask, difficulty with OTI, or both*". Likewise, difficult intubation can be defined as "*the need for 3 or more attempts for OTI, or more than 10 minutes to achieve it*" [2].

However, despite handling the DA forced to take decisions and perform actions quickly and effectively, the truth is that there is no unanimity in the definitions or terms related to AM, because "the DA not exists, in reality, but is a complex interaction between the patient, the anesthetist, the available equipment and other circumstances" [17].

Until a few years ago, the available systems of evaluation have had in little consideration factors not related to the patient. Some factors that complicate and diminish the safety of the management of the AM such as:


However, it is currently considered "*management of context-sensitive airway*", where a gaseous exchange is more valued than the tracheal intubation itself [18], which consists of four ventilation and oxygenation methods:

**1.** Facial mask.

• Grade 4: inability FMV (0.16%).

8 Bedside Procedures

tion, among others.

available equipment and other circumstances" [17].

management of the AM such as:

• Availability of suitable equipment.

• Pressure of time-urgency.

• Experience.

• Location.

• Human factors.

• Grade 3 or 4 + difficult intubation: 0.37%.

In order to increase statistical power in some variables of the previous study, in 2009, a new study was carried out, collecting more than 50,000 patients [15]. It was recognized that the incidence of impossible FMV, defined as "*the inability to ventilate with facial masks despite the use* 

Critical patient intubation is often performed in ICU, but can also be performed in locations away from the operating room, where working conditions and available materials are often inadequate. The difficulty rate of orotracheal intubation in emergency situations is 3 times higher than the programmed procedure, with a reported incidence of 10–20% failure at the firstattempt [7], with a complication rate 50 times higher than those found during anesthesia [1].

The AM of the critically ill patient may be complicated by the anatomical characteristics involving the visualization of glottis opening, or the difficult passage of the tracheal tube through the vocal cords, or by the clinical situation itself, which may contribute to the cardiovascular collapse. Among these causes of physiologic DA are hypoxemia, hypotension, severe metabolic acidosis, and right ventricular failure [16]. In fact, approximately 20% of patients in the ICU will experience critical hypoxemia, which, in the worst case, leads to death. Other common complications are esophageal intubation, aspiration, and selective bronchial intuba-

DA is defined as "*that clinical situation in which an experienced anesthesiologist present difficulties with ventilation with a face mask, difficulty with OTI, or both*". Likewise, difficult intubation can be defined as "*the need for 3 or more attempts for OTI, or more than 10 minutes to achieve it*" [2].

However, despite handling the DA forced to take decisions and perform actions quickly and effectively, the truth is that there is no unanimity in the definitions or terms related to AM, because "the DA not exists, in reality, but is a complex interaction between the patient, the anesthetist, the

Until a few years ago, the available systems of evaluation have had in little consideration factors not related to the patient. Some factors that complicate and diminish the safety of the

*of facilitating devices and 2-hand ventilation*", was found to be around 0.15%.

**3. Particularities of airway management in the critical patient**


The use of any of these methods depends not only on the devices but also on the situation facing the professional. In this management of context-sensitive MA, maintenance of the patient's gauche exchange is the priority and should not be "*device dependent*". Thus, careful evaluation of the "*context*" interpretation is essential for the safe practice of MA management.

The concept "*context-sensitive AM*" acquires special relevance in critically ill patients, and there are several causes that make it difficult to manage their AM:

	- Who manages airway?
	- Where is the patient?
	- What equipment and medication are available?
	- Who helps?
	- Predictive tests of AD.
	- Pathology of the patient (hemorrhage, edema, trauma, increased secretions, etc.).

#### **4. Complications of intubation in the critical patient**

The primary indication for OTI in ICU is the acute respiratory failure. Weakness and fatigue of respiratory muscles (ventilatory failure) and disruption of gas exchange (respiratory failure) are common, and the risk of hypoxemia and cardiovascular shock during the OTI process is high, ranging from 15 to 50%.

Critical patient intubation presents life-threatening complications in more than one-third of cases [19]. The most common are respiratory and hemodynamic alterations [20]. The main adverse event associated with the technique is hypoxemia with a dramatic decrease in peripheral oxygen saturation (SapO2) despite adequate preoxygenation. In almost half of the cases, the indication for tracheal intubation is due to an acute respiratory failure with a previous SapO2 of less than 90% that supports the appearance of severe hypoxemia.

The second complication due to its frequency is hemodynamic alteration with hypotension after intubation, associated or not with desaturation. Mort reported 60 cardiac arrests during 3035 intubations outside the operating room (incidence of 2%) [21]. About 83% of these patients experienced severe hypoxemia (SatpO2 < 70%). The choice of the drug suitable for anesthetic induction is very important to minimize hypotension in the critical.

Most patients requiring tracheal intubation and mechanical ventilation in the ICU are, in contrast to those requiring these procedures in an operating room, patients with a circulatory and/or respiratory compromise. Therefore, the intubation procedure should be non-

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety

http://dx.doi.org/10.5772/intechopen.72658

11

The cardiorespiratory instability usually presented by the seriously ill patient (with reduced functional residual capacity and safe apnea time), together with the urgent nature of the situation, the low predictability of the possible scenarios, jointly with the fact that it is often not possible ensure adequate gastric emptying, determine that the intubation of critical airway is a high-risk proce-

The results of the NAP4 audit are parallel to other studies that consider that multiple attempts at intubation in the critical patient result in a high incidence of adverse events [22]. In order to limit the number of attempts to two and to ensure success, interventions such as an adequate patient position and the existence, at the bedside, of correct material equipment and experi-

The assessment of the airway in the critical patient may be complex, but adequate planning should be part of the daily approach to the airway. This assessment must include the factors that predict a DA that we routinely use in the anesthesia consultation. The patient's position, the additional help present, and the available material must be evaluated prior to anesthetic induction. In addition, the physiological characteristics of the subject such as the full stomach and situations that favor desaturation (obesity and pulmonary shunt) should be considered. The oxygenation of patients before and during intubation is of paramount importance [23]. Premaneuver denitrogenate has been shown to be useful as oxygenation with nasal goggles during apnea. The administration of high concentrations of oxygen through high-flow nasal glasses (HFNG) seems to offer advantages over the classic preoxygenation models. It provides some degree of positive pressure even during laryngoscopy without requiring patient

Historically, direct laryngoscopy has been the most commonly used method for intubation in critically ill patients. Alternatives such as luminous stylet, supraglottic device, and flexible fibrobronchoscope are hardly used outside the surgical area. VLs have been proposed as an initial approach by some authors, but their implementation is being limited and reserved as a rescue technique. It is true that these devices improve the vision of the glottis, but in lessexperienced hands, they slow the procedure and, in critical patients with few reserves, addi-

In conventional airway management, routine OTI with traditional direct laryngoscopy (DL) is still the common practice [25, 26], with the Macintosh as standard gold DL, a device created just 10 years before the first ICU was Inaugurated by the anesthesiologist Bjorn Ibsen in Copenhagen (December 1953) [27, 28]. On the other hand, in DA cases, the technique of choice for intubation

dure. For this reason, all critical patients should be initially managed as potential AD.

aggressive and atraumatic.

enced personnel are necessary.

collaboration [24].

tional few seconds can have fatal consequences.

**6. Videolaryngoscopes in the ICU**

Other complications described in the literature are esophageal intubation and pulmonary aspiration. The former increases the risk of cardiac arrest by 15 times.

NAP4 reported that ICU, far from representing a safe place to operate the airway, were a place of potential danger. Airway-related complications were more likely to occur in the ICU than in the operating room, and more often resulted in harm to the patient. Thus, the rate of airway complications that appeared in the ICU was more than 50 times higher than those found during anesthesia, and 61% of the ICU patients reported on NAP4 suffered neurological damage or death, compared to 14% during the anesthetic procedure and 33% in the emergency department. Although most of the potentially fatal airway events in the ICU were due to especially tracheal tube displacement or tracheostomy (especially in obese patients), difficulties were also identified associated with esophageal intubation, rapid sequence intubation, and failure techniques of the rescue of the airways [1].

There are four factors that are independently associated with a serious complication during the procedure:


The presence of two clinicians reduces the risk of complications.

## **5. Approach of the airway management in the critical patient**

The aims of the AM, understood as the accomplishment of maneuvers and the use of devices that allow adequate and safe ventilation to patients who need it, is to guarantee the oxygenation in a situation of potential vital risk for that patient.

The optimal AM and ventilation of critical patients remain a basic pillar in survival, evolution, and prognosis, with OTI being the gold standard in these situations.

Most patients requiring tracheal intubation and mechanical ventilation in the ICU are, in contrast to those requiring these procedures in an operating room, patients with a circulatory and/or respiratory compromise. Therefore, the intubation procedure should be nonaggressive and atraumatic.

The cardiorespiratory instability usually presented by the seriously ill patient (with reduced functional residual capacity and safe apnea time), together with the urgent nature of the situation, the low predictability of the possible scenarios, jointly with the fact that it is often not possible ensure adequate gastric emptying, determine that the intubation of critical airway is a high-risk procedure. For this reason, all critical patients should be initially managed as potential AD.

The results of the NAP4 audit are parallel to other studies that consider that multiple attempts at intubation in the critical patient result in a high incidence of adverse events [22]. In order to limit the number of attempts to two and to ensure success, interventions such as an adequate patient position and the existence, at the bedside, of correct material equipment and experienced personnel are necessary.

The assessment of the airway in the critical patient may be complex, but adequate planning should be part of the daily approach to the airway. This assessment must include the factors that predict a DA that we routinely use in the anesthesia consultation. The patient's position, the additional help present, and the available material must be evaluated prior to anesthetic induction. In addition, the physiological characteristics of the subject such as the full stomach and situations that favor desaturation (obesity and pulmonary shunt) should be considered.

The oxygenation of patients before and during intubation is of paramount importance [23]. Premaneuver denitrogenate has been shown to be useful as oxygenation with nasal goggles during apnea. The administration of high concentrations of oxygen through high-flow nasal glasses (HFNG) seems to offer advantages over the classic preoxygenation models. It provides some degree of positive pressure even during laryngoscopy without requiring patient collaboration [24].

Historically, direct laryngoscopy has been the most commonly used method for intubation in critically ill patients. Alternatives such as luminous stylet, supraglottic device, and flexible fibrobronchoscope are hardly used outside the surgical area. VLs have been proposed as an initial approach by some authors, but their implementation is being limited and reserved as a rescue technique. It is true that these devices improve the vision of the glottis, but in lessexperienced hands, they slow the procedure and, in critical patients with few reserves, additional few seconds can have fatal consequences.

## **6. Videolaryngoscopes in the ICU**

The second complication due to its frequency is hemodynamic alteration with hypotension after intubation, associated or not with desaturation. Mort reported 60 cardiac arrests during 3035 intubations outside the operating room (incidence of 2%) [21]. About 83% of these patients experienced severe hypoxemia (SatpO2 < 70%). The choice of the drug suitable for

Other complications described in the literature are esophageal intubation and pulmonary

NAP4 reported that ICU, far from representing a safe place to operate the airway, were a place of potential danger. Airway-related complications were more likely to occur in the ICU than in the operating room, and more often resulted in harm to the patient. Thus, the rate of airway complications that appeared in the ICU was more than 50 times higher than those found during anesthesia, and 61% of the ICU patients reported on NAP4 suffered neurological damage or death, compared to 14% during the anesthetic procedure and 33% in the emergency department. Although most of the potentially fatal airway events in the ICU were due to especially tracheal tube displacement or tracheostomy (especially in obese patients), difficulties were also identified associated with esophageal intubation, rapid sequence intuba-

There are four factors that are independently associated with a serious complication during

**1.** Age is a factor that cannot be modified and is accompanied by a worse response of the

**2.** Second, there are two factors depending on the patient's previous physiological status, the presence of hypotension, and/or hypoxemia conditions an increased risk of complications. In some cases, these factors can be modified by optimizing blood pressure and oxygenation.

**3.** The presence of secretions in the oropharyngeal cavity hinders laryngoscopic vision and

**4.** Lastly, the need for more than one attempt for intubation increases the risk of complications. A number greater than two attempts increases the risk of hypoxemia, bradycardia,

The aims of the AM, understood as the accomplishment of maneuvers and the use of devices that allow adequate and safe ventilation to patients who need it, is to guarantee the oxygen-

The optimal AM and ventilation of critical patients remain a basic pillar in survival, evolution,

has been associated with an increase in the rate of failure of tracheal intubation.

aspiration of gastric contents, and cardiac arrest exponentially [21].

**5. Approach of the airway management in the critical patient**

The presence of two clinicians reduces the risk of complications.

ation in a situation of potential vital risk for that patient.

and prognosis, with OTI being the gold standard in these situations.

anesthetic induction is very important to minimize hypotension in the critical.

aspiration. The former increases the risk of cardiac arrest by 15 times.

tion, and failure techniques of the rescue of the airways [1].

the procedure:

10 Bedside Procedures

organism to any aggression.

In conventional airway management, routine OTI with traditional direct laryngoscopy (DL) is still the common practice [25, 26], with the Macintosh as standard gold DL, a device created just 10 years before the first ICU was Inaugurated by the anesthesiologist Bjorn Ibsen in Copenhagen (December 1953) [27, 28]. On the other hand, in DA cases, the technique of choice for intubation is the use of the fiber optic bronchoscopy (FOB), although there are more and more studies in which videolaryngoscopy is used as an alternative approach in induced/sleep or awake patient, since FOB is an expensive, fragile, and requires regular maintenance, is complex to dispose of in emergency situations or in prehospital emergencies, and requires previous training.

Although these numbers are lower than those suggested by Greaves (80% of competence acquired with 30 cases, and complete with 100 cases), the video imaging technology of these new devices offers a shared vision between instructor and student [34], which can facilitate the teaching of airway anatomy, critical assessment of technique, and feedback. This may lead to skill acquisition faster than that achieved with traditional training with direct laryngoscopy [35]. This difficulty in achieving intubation despite the correct exposure of the larynx even in expert hands may be finally impossible, and success depends more on the operator's ability and patient's airway characteristics than on the own device [36]. However, in an attempt to overcome this problem, channeled videolaryngoscopes have the advantage of orienting the endotracheal tube (ETT) toward the trachea, allowing directed intubation with a little manipulation of the airway. On the other hand, the evidence suggests that the use of indirect laryngoscopy (IL) improves the overall success rate of emergency/emergency tracheal intubation, as well as reduces the incidence of esophageal intubation when compared to conventional direct laryngoscopy (LD) [36]. In addition to this, we must mention that the VL, thanks to its good image quality, allow to easily recognize the structures of the larynx to achieve an image with a field between 45° and 60°, as opposed to the distant and tubular vision of the classical laryngoscopy (about 15°).

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety

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13

This image also allows to be certain about both the success of the intubation and the depth of insertion of the ETT, and can also easily recognize and correct esophageal intubation, a serious cause of morbidity and mortality. And another added advantage is that they provide an LED light, of greater luminous intensity than the conventional one and with a spectral irradia-

The NAP4 (the 4th National Audit Project on Major Complications in Airway Management in the UK) specifically mentions the theoretical benefit of videolaryngoscopes [1], with evidence that

For these and other reasons, these optical devices were incorporated into the airway management guidelines by the ASA as valid options in both the DA as usual, including, without excluding or limiting, laryngoscopes with different sizes and types of blades, VL, facial masks or supraglottic airway devices (SAD) such as laryngeal mask (LMA) or Fastrach® (ILMA), laryngeal tube, etc., fibrobronchoscope (FBO), extraglottic device (Frova, Eischman, etc.),

The characteristics that would define an ideal intubation device are described in **Table 1**.

During the last few years, many types of rigid, semi-rigid, optical, fiber optic and videoassisted laryngoscopes have been developed, as well as stiff and flexible stylets, as well as the classic flexible fibrobronchoscope, all of them with a common goal: to solve a classic problem for anesthesiologists, the difficult airway. The clinical evidences tell us about the real usefulness of all these devices in the solution of the problem for which they were designed. Scientific evidence of its use, the advantage of one over another, and the choice of each of them in a

they can be more efficient than a Macintosh laryngoscope conventional.

tion closer to the human eye.

nasal intubation, etc. [2].

particular patient are yet to be determined.

**6.1. Features**

Failure of endotracheal intubation using Classical Direct Laryngoscopy with a Macintosh laryngoscope or other technique may occur unexpectedly. And, since the second most common event reflected in the NAP4 reports on the ICU was failed intubation, proper and correct use of videolaryngoscopes (VL) would offer the potential to reduce the difficulty of intubation in general in the ICU [1, 29].

Numerous studies have shown increased morbidity when performing multiple attempts at tracheal intubation. Videolaryngoscopes allow a view of the entrance of glottis independent of the line of sight (LI), especially those that have angled blades. The fact that the image sensor is in the distal part of the blade causes us to have a panoramic view of the glottis, without the need to "*align the axes*", thus avoiding hyperextension of the head, and in practice having a Laryngoscopy Cormack-Lehane (CL) grade 1 or 2 (CL 1/4 or 2/4) in 99% of the cases (**Figure 2**).

VL have also been shown to improve glottis and intubation success rates in emergency and emergency services, in the prehospital setting, and specifically in patients with known predictors of DA [30].

However, achieving CL grade 1 laryngoscopy (CL 1/4) in laryngoscopy with a VL does not guarantee the success of OTI, which is relatively frequent in VLs that have a curved leaf, especially during the learning stage [31, 32].

Previous studies with novice and experienced anesthetists have suggested that the learning curve with an optical device can be around 20 applications to be competent to manage [33].

**Figure 2.** Glottic view differences.

Although these numbers are lower than those suggested by Greaves (80% of competence acquired with 30 cases, and complete with 100 cases), the video imaging technology of these new devices offers a shared vision between instructor and student [34], which can facilitate the teaching of airway anatomy, critical assessment of technique, and feedback. This may lead to skill acquisition faster than that achieved with traditional training with direct laryngoscopy [35].

This difficulty in achieving intubation despite the correct exposure of the larynx even in expert hands may be finally impossible, and success depends more on the operator's ability and patient's airway characteristics than on the own device [36]. However, in an attempt to overcome this problem, channeled videolaryngoscopes have the advantage of orienting the endotracheal tube (ETT) toward the trachea, allowing directed intubation with a little manipulation of the airway.

On the other hand, the evidence suggests that the use of indirect laryngoscopy (IL) improves the overall success rate of emergency/emergency tracheal intubation, as well as reduces the incidence of esophageal intubation when compared to conventional direct laryngoscopy (LD) [36].

In addition to this, we must mention that the VL, thanks to its good image quality, allow to easily recognize the structures of the larynx to achieve an image with a field between 45° and 60°, as opposed to the distant and tubular vision of the classical laryngoscopy (about 15°).

This image also allows to be certain about both the success of the intubation and the depth of insertion of the ETT, and can also easily recognize and correct esophageal intubation, a serious cause of morbidity and mortality. And another added advantage is that they provide an LED light, of greater luminous intensity than the conventional one and with a spectral irradiation closer to the human eye.

The NAP4 (the 4th National Audit Project on Major Complications in Airway Management in the UK) specifically mentions the theoretical benefit of videolaryngoscopes [1], with evidence that they can be more efficient than a Macintosh laryngoscope conventional.

For these and other reasons, these optical devices were incorporated into the airway management guidelines by the ASA as valid options in both the DA as usual, including, without excluding or limiting, laryngoscopes with different sizes and types of blades, VL, facial masks or supraglottic airway devices (SAD) such as laryngeal mask (LMA) or Fastrach® (ILMA), laryngeal tube, etc., fibrobronchoscope (FBO), extraglottic device (Frova, Eischman, etc.), nasal intubation, etc. [2].

#### **6.1. Features**

**Figure 2.** Glottic view differences.

in general in the ICU [1, 29].

during the learning stage [31, 32].

of DA [30].

12 Bedside Procedures

is the use of the fiber optic bronchoscopy (FOB), although there are more and more studies in which videolaryngoscopy is used as an alternative approach in induced/sleep or awake patient, since FOB is an expensive, fragile, and requires regular maintenance, is complex to dispose of in

Failure of endotracheal intubation using Classical Direct Laryngoscopy with a Macintosh laryngoscope or other technique may occur unexpectedly. And, since the second most common event reflected in the NAP4 reports on the ICU was failed intubation, proper and correct use of videolaryngoscopes (VL) would offer the potential to reduce the difficulty of intubation

Numerous studies have shown increased morbidity when performing multiple attempts at tracheal intubation. Videolaryngoscopes allow a view of the entrance of glottis independent of the line of sight (LI), especially those that have angled blades. The fact that the image sensor is in the distal part of the blade causes us to have a panoramic view of the glottis, without the need to "*align the axes*", thus avoiding hyperextension of the head, and in practice having a Laryngoscopy Cormack-Lehane (CL) grade 1 or 2 (CL 1/4 or 2/4) in 99% of the cases (**Figure 2**). VL have also been shown to improve glottis and intubation success rates in emergency and emergency services, in the prehospital setting, and specifically in patients with known predictors

However, achieving CL grade 1 laryngoscopy (CL 1/4) in laryngoscopy with a VL does not guarantee the success of OTI, which is relatively frequent in VLs that have a curved leaf, especially

Previous studies with novice and experienced anesthetists have suggested that the learning curve with an optical device can be around 20 applications to be competent to manage [33].

emergency situations or in prehospital emergencies, and requires previous training.

The characteristics that would define an ideal intubation device are described in **Table 1**.

During the last few years, many types of rigid, semi-rigid, optical, fiber optic and videoassisted laryngoscopes have been developed, as well as stiff and flexible stylets, as well as the classic flexible fibrobronchoscope, all of them with a common goal: to solve a classic problem for anesthesiologists, the difficult airway. The clinical evidences tell us about the real usefulness of all these devices in the solution of the problem for which they were designed. Scientific evidence of its use, the advantage of one over another, and the choice of each of them in a particular patient are yet to be determined.


**1.** VL with "*Standard*" rigid blade, similar to the LD Macintosh such as the C-MAC (Karl Storz, Tuttligen, Germany) or McGrath MAC (Aircraft Medical, Edinburgh, UK), among others. Also used as a conventional direct laryngoscope. This reduces, at least theoretically,

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety

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15

Other advantages common to all of them are the ease of visualization of the glottic structures, which allow to use any type of endotracheal tube (ETT) and the longer duration than the

The disadvantage is that, even in most of cases CL improves, the introduction of ETT is sometimes difficult and a certain practice is required, so eventually ETT must be performed with a

**2.** VL with *Angled Rigid Blade* such as Glidescope (Verathon, Bothell, WA, USA), king vision with no channel blades (KingSystems, www.Kingsystems.com, distributed in Spain by Ambu a/S, www.ambu.es), the McGrath MAC X blade (aircraft medical, Edinburgh, UK),

All of them present advantages common to all of them: ease of visualization of glottic struc-

The disadvantage is that, although Cormack-Lehane improves in most cases, the introduction

The lack of a channel in which to put the ETT usually requires a certain practice and, often, it is necessary to preform the ETT with a catcher that provides the same the angulation that has

**3.** Videolaryngoscopes with *Channel to guide* the ETT such as Airtraq (Prodol Meditec, Vizcaya, Spain, 2005. US Patent No 6,843,769), King Vision with a channeled blade (KingSystems), and the Pentax-AWS-S100 (Pentax Corporation, Tokyo, Japan), among others. They all have a channel through which the ETT slides for intubation. As the ETT is directed by the channel, we must do any modification of movements on the device and not on the tube. The tube does not need to be preformed with a stylet and generally enhances the Cormack-

The new optical devices are recommended to improve the management of the airway, both in anesthetic care and in critical patients [41, 42, 45, 46]. In recent years, the role of videolaryngoscopes has been debated, especially its use in the ICU [29, 31, 37, 42, 47–51], where there is a lack of scientific evidence and, in general, intubation is performed in more complicated conditions than in the operating room [52]. However, this evidence is supported in the surgical setting as there are randomized controlled trials (RCTs), meta-analyses, and systematic reviews. Although the environments are different, neither the techniques for the acquisition of competencies, and in one place as in the other, there are situations of unexpected vital commitment and/or deterioration of respiratory and hemodynamic function [7, 21, 41, 53, 54]. Therefore, the results of existing studies in surgical areas can be extrapolated to the field of

or the C-MAC D blade (Karl Storz, Tuttligen, Germany), among others.

tures, allow to use any type of ETT and longer duration than the fiberscope.

the blade of the VL so as to be able to direct it to the entrance of the glottis.

the learning curve needed to use them correctly.

guarantor (contrary to which occurs with angled blades).

fiberscope, combined with the lowest cost.

of ETT is sometimes difficult.

**6.3. Current scientific evidence**

ICU for many of the above-mentioned plots.

Lehane.


**Table 1.** Characteristics of an ideal intubation device.

At the moment, all the VL present as common characteristics [37–44]:

	- (a) Camcorder whose digital image is transmitted to a screen of an external monitor.
	- (b) Beam of optical fibers.
	- (c) System of prisms, which transmit the image through a system of lenses.

#### **6.2. Classification**

Resulting the classifications proposed by Pott et al. [43], Healy et al. [38], and Niforopoulou et al. [44], although all VLs allow a view of the entrance of glottis independent of the line of sight (indirect laryngoscopy [LI]), could be classified according to the type of blade [42]:

**1.** VL with "*Standard*" rigid blade, similar to the LD Macintosh such as the C-MAC (Karl Storz, Tuttligen, Germany) or McGrath MAC (Aircraft Medical, Edinburgh, UK), among others. Also used as a conventional direct laryngoscope. This reduces, at least theoretically, the learning curve needed to use them correctly.

Other advantages common to all of them are the ease of visualization of the glottic structures, which allow to use any type of endotracheal tube (ETT) and the longer duration than the fiberscope, combined with the lowest cost.

The disadvantage is that, even in most of cases CL improves, the introduction of ETT is sometimes difficult and a certain practice is required, so eventually ETT must be performed with a guarantor (contrary to which occurs with angled blades).

**2.** VL with *Angled Rigid Blade* such as Glidescope (Verathon, Bothell, WA, USA), king vision with no channel blades (KingSystems, www.Kingsystems.com, distributed in Spain by Ambu a/S, www.ambu.es), the McGrath MAC X blade (aircraft medical, Edinburgh, UK), or the C-MAC D blade (Karl Storz, Tuttligen, Germany), among others.

All of them present advantages common to all of them: ease of visualization of glottic structures, allow to use any type of ETT and longer duration than the fiberscope.

The disadvantage is that, although Cormack-Lehane improves in most cases, the introduction of ETT is sometimes difficult.

The lack of a channel in which to put the ETT usually requires a certain practice and, often, it is necessary to preform the ETT with a catcher that provides the same the angulation that has the blade of the VL so as to be able to direct it to the entrance of the glottis.

**3.** Videolaryngoscopes with *Channel to guide* the ETT such as Airtraq (Prodol Meditec, Vizcaya, Spain, 2005. US Patent No 6,843,769), King Vision with a channeled blade (KingSystems), and the Pentax-AWS-S100 (Pentax Corporation, Tokyo, Japan), among others.

They all have a channel through which the ETT slides for intubation. As the ETT is directed by the channel, we must do any modification of movements on the device and not on the tube.

The tube does not need to be preformed with a stylet and generally enhances the Cormack-Lehane.

#### **6.3. Current scientific evidence**

At the moment, all the VL present as common characteristics [37–44]:

• Economic and one-time use. Disposable, no risk of cross contamination.

• Rapid orotracheal intubation, with minimal manipulation of the patient.

/ventilate.

• Short learning curve. Easy intubation with minimal skills.

(b) Beam of optical fibers.

• Light and portable.

14 Bedside Procedures

• Good glottal visibility.

• Allow aspiration.

• Suitable for all types of ETT. • Allow the administration of O<sup>2</sup>

• Adaptable to the anatomy.

• It does not produce hemodynamic changes.

• It can be used with the patient in any position. • Possibility of connection to monitor for teaching.

• Can be used with little mouth opening. • Do not need cervical hyperextension.

• It can be used in awake patients. • Multiple display options.

• Storage capacity and image integration.

**Table 1.** Characteristics of an ideal intubation device.

**4.** *Research*: images can be stored.

**6.2. Classification**

**1.** *Technically*: they present a wider image, high resolution, with improvement of the degree

• Presence of an anti-fogging system that ensures the visualization of the airway despite the presence of secretions.

(a) Camcorder whose digital image is transmitted to a screen of an external monitor.

**2.** *Procedure*: similar to the Macintosh or Miller laryngoscope, although on other occasions it

**3.** *Teaching*: allow to teach and show multiple visions, the assistant visualizes and can see the result of laryngeal manipulation. The procedure can be saved and remembered. It facili-

**5.** *Comfort for the user*: more comfortable posture, less contact with secretions, blood, etc.

Resulting the classifications proposed by Pott et al. [43], Healy et al. [38], and Niforopoulou et al. [44], although all VLs allow a view of the entrance of glottis independent of the line of sight (indirect laryngoscopy [LI]), could be classified according to the type of blade [42]:

of laryngoscopy. Indirect vision of the glottis can be obtained in different ways:

(c) System of prisms, which transmit the image through a system of lenses.

is inserted through the midline, or fiber optic bronchoscope (FOB).

tates the learning of alternative techniques to FBO, etc.

The new optical devices are recommended to improve the management of the airway, both in anesthetic care and in critical patients [41, 42, 45, 46]. In recent years, the role of videolaryngoscopes has been debated, especially its use in the ICU [29, 31, 37, 42, 47–51], where there is a lack of scientific evidence and, in general, intubation is performed in more complicated conditions than in the operating room [52]. However, this evidence is supported in the surgical setting as there are randomized controlled trials (RCTs), meta-analyses, and systematic reviews. Although the environments are different, neither the techniques for the acquisition of competencies, and in one place as in the other, there are situations of unexpected vital commitment and/or deterioration of respiratory and hemodynamic function [7, 21, 41, 53, 54]. Therefore, the results of existing studies in surgical areas can be extrapolated to the field of ICU for many of the above-mentioned plots.

In this sense, Healy et al. published an updated systematic review of Videolaringoscopes in 2012 with the objective of organizing the literature about the effectiveness of modern VL in the OTI and then performing a quality assessment and making recommendations for its use [38].

time it takes to visualize the glottis. In the study by Yeatts et al. was found that a shorter time was required to insert an ETT when a conventional direct laryngoscopy was performed [56]. In fact, in this study, an IL with Glidescope (Verathon Médico, Bothell, WA) was associated with prolonged intubation times in trauma patients, with a longer time of hypoxemia and a higher mortality in patients with traumatic brain injury [57]. These results coincide with those of the ICU study carried out by Griesdale et al., who found that intubation with Glidescope

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In addition, the study by De Jong et al., from the Montpellier group, evaluated McGrath MAC, a "*mixed*" VL that can be used both to obtain direct and indirect laryngoscopy vision [51]. This prospective study showed that systematic use of a "*mixed*" VL, also termed "*combo VL*" or "*combined VL*", for intubation within a process of quality improvement using an algorithm of airway management significantly reduced the incidence of difficult laryngoscopy and/or

In the multivariate analysis, the use of a standard laryngoscope was an independent risk factor for difficult laryngoscopy and/or difficult intubation, as was the Mallampati III or IV score and the status of nonexpert operator. On the other hand, in the subgroup of patients with difficult intubation predicted by the MACOCHA score (**Figure 3**), the incidence of difficult

VL resulted in lower oxygen saturations [58].

difficult intubation.

**Figure 3.** Macocha score.

The comparison of VL with LD was based on three main results: global success, first-attempt success, and successful intubation time.

The vision of the glottis was a desirable result, but since with the VL the intubation can be performed despite having a limited view of it and, on the other hand, a good view of the larynx does not always guarantee a successful intubation, it was not considered a target for the recommendation.

The final recommendations of the study could be summarized in three points:


Be that as it may, the use of VLs not only improves glottic vision, and in the ICU they also present other advantages such as positive effects on teamwork, communication and knowledge of the situation, as well as on technical skills. The use of VL on the training of residents, with an adjunct that shares their opinion as responsible for intubation seen on the screen, giving advice to help intubation, training nurses of the ICU allowing them to control the effect of the pressure on the cricoid during the sellick, adjusting it as necessary. In addition, the VL is immediately available, which means an improvement in the management of the unexpected DA [37, 55].

A major advantage of standard "*rigid*" VL, like the LD Macintosh, is that they use the same skills as LD, which reduces the need for specific training in VL, while facilitating the training of residents in the management of the airway by LD. In addition, intubation can be recorded for post-event teaching.

The study by De Jong et al., from the Montpellier group, evaluated the McGrath MAC (Aircraft Medical, Edinburgh, Scotland), a VL with a Macintosh type spade that allows intubation using conventional or indirect direct laryngoscopy. The results reported by these authors are similar to other studies, noting that it is easier to visualize the glottis using VL and that fewer attempts are required to achieve intubation. However, although De Jong et al. showed a significant reduction in the incidence of difficult laryngoscopy and/or difficult intubation with VL McGrath MAC (4 vs. 16%) in ICU patients did not provide information on whether or not actual intubation time was shorter [51].

In ICU, where patients are often under a cardiorespiratory compromise, reducing the time the patient is without adequate ventilation/oxygenation is probably more important than the time it takes to visualize the glottis. In the study by Yeatts et al. was found that a shorter time was required to insert an ETT when a conventional direct laryngoscopy was performed [56]. In fact, in this study, an IL with Glidescope (Verathon Médico, Bothell, WA) was associated with prolonged intubation times in trauma patients, with a longer time of hypoxemia and a higher mortality in patients with traumatic brain injury [57]. These results coincide with those of the ICU study carried out by Griesdale et al., who found that intubation with Glidescope VL resulted in lower oxygen saturations [58].

In addition, the study by De Jong et al., from the Montpellier group, evaluated McGrath MAC, a "*mixed*" VL that can be used both to obtain direct and indirect laryngoscopy vision [51]. This prospective study showed that systematic use of a "*mixed*" VL, also termed "*combo VL*" or "*combined VL*", for intubation within a process of quality improvement using an algorithm of airway management significantly reduced the incidence of difficult laryngoscopy and/or difficult intubation.

In the multivariate analysis, the use of a standard laryngoscope was an independent risk factor for difficult laryngoscopy and/or difficult intubation, as was the Mallampati III or IV score and the status of nonexpert operator. On the other hand, in the subgroup of patients with difficult intubation predicted by the MACOCHA score (**Figure 3**), the incidence of difficult



In this sense, Healy et al. published an updated systematic review of Videolaringoscopes in 2012 with the objective of organizing the literature about the effectiveness of modern VL in the OTI and then performing a quality assessment and making recommendations

The comparison of VL with LD was based on three main results: global success, first-attempt

The vision of the glottis was a desirable result, but since with the VL the intubation can be performed despite having a limited view of it and, on the other hand, a good view of the larynx does not always guarantee a successful intubation, it was not considered a target for

**1.** In patients at risk of difficult laryngoscopy, the use of Airtraq, C-Trach, GlideScope, Pentax

**2.** The use of the Airtraq, Bonfils, Bullard, C-Trach, GlideScope, and Pentax AWS by an operator with reasonable prior experience is recommended for successful intubation in CLD (CL ≥ 3).

**3.** There is additional evidence to support the use of Airtraq, Bonfils, C-Trach, GlideScope, McGrath, and Pentax AWS after intubation failed by direct laryngoscopy to achieve suc-

Be that as it may, the use of VLs not only improves glottic vision, and in the ICU they also present other advantages such as positive effects on teamwork, communication and knowledge of the situation, as well as on technical skills. The use of VL on the training of residents, with an adjunct that shares their opinion as responsible for intubation seen on the screen, giving advice to help intubation, training nurses of the ICU allowing them to control the effect of the pressure on the cricoid during the sellick, adjusting it as necessary. In addition, the VL is immediately available, which means an improvement in the management of the unexpected

A major advantage of standard "*rigid*" VL, like the LD Macintosh, is that they use the same skills as LD, which reduces the need for specific training in VL, while facilitating the training of residents in the management of the airway by LD. In addition, intubation can be recorded

The study by De Jong et al., from the Montpellier group, evaluated the McGrath MAC (Aircraft Medical, Edinburgh, Scotland), a VL with a Macintosh type spade that allows intubation using conventional or indirect direct laryngoscopy. The results reported by these authors are similar to other studies, noting that it is easier to visualize the glottis using VL and that fewer attempts are required to achieve intubation. However, although De Jong et al. showed a significant reduction in the incidence of difficult laryngoscopy and/or difficult intubation with VL McGrath MAC (4 vs. 16%) in ICU patients did not provide information on whether or not

In ICU, where patients are often under a cardiorespiratory compromise, reducing the time the patient is without adequate ventilation/oxygenation is probably more important than the

The final recommendations of the study could be summarized in three points:

AWS, and V-MAC is recommended for successful intubation.

for its use [38].

16 Bedside Procedures

the recommendation.

cessful intubation.

for post-event teaching.

actual intubation time was shorter [51].

DA [37, 55].

success, and successful intubation time.

intubation was much higher in the standard laryngoscope group (47%) than in the "*mixed*" VL group (0%). These results were in agreement with the previous studies [51].

meta-analysis [50], data from Silverberg et al. [61] was excluded for the analysis of time for successful intubation on the grounds of high bias risk (due to suboptimal allocation concealment and randomization strategy). The study by Silverberg demonstrated statistically and clinically significant differences in the time for successful intubation favoring videolaryngoscopy. Non-inclusion may affect the pooled data analysis by Zhao et al. [50]. Curiously, data from the same study was included for pooled analysis of the primary outcome (rate of successful intubation on the first-attempt). Two of the included studies compared the performance of the Glidescope with direct laryngoscopy, and two pooled data sets were included from studies comparing the McGrath videolaryngoscope against direct laryngoscope. Not all videolaryngoscopes are the same and the airway literature distinguishes channeled videolaryngoscopes versus the anteriorly angulated variety versus the Macintosh-like videolaryngoscopes—appreciating peculiar advantages and disadvantages of each. Combining results

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety

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In this regard, Joshi et al. [65] have tried to identify characteristics associated with firstattempt failure at intubation when using videolaryngoscopy in the ICU. They perform 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

In this single-center study, 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%;

Presence of blood in the airway (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 higher odds of first-attempt failure, when intubation was performed with videolaryngoscopy in an ICU.

In a second logistic model to examine cases in which these additional difficult airway characteristics were collected (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

There are important limitations in this study, such that when certain difficult airway characteristics such as blood, vomit, or airway edema could have been known before the intubation attempt or encountered during the attempt, it is possible that operator reporting of these difficult airway characteristics was more common when they were unexpectedly encountered. Moreover, multivariable analyses account for experience of the operator. The generalization of these study results may be limited given the exposure, airway curriculum, and experience

Nevertheless, the intensive care professional should account for these difficult airway characteristics, blood, cervical immobility, and airway edema, when preparing for endotracheal intubation with video laryngoscopy in addition to standard practices employed to optimize

from all videolaryngoscopes as an entity may have its limitations.

on difficult airway characteristics, device used, and outcome of each attempt.

95% confidence interval [CI], 20.7–27.0% vs. 13.3%, 95% CI, 8.0–18.8%).

associated with first-attempt failure [65].

of trainees at this institution compared to others.

first-attempt success.

Cameron et al. perform a study to evaluate the odds of first-attempt success with video laryngoscopy compared with direct laryngoscopy, using a propensity-matched analysis to reduce the risk of bias, for intubations performed in a medical ICU. They accomplish an analysis of prospectively collected data for 809 consecutive intubations performed between 2012 and 2014 in the ICU of an academic tertiary referral center that supports fellowship training programs in pulmonary and critical care medicine [59].

This study comparing video laryngoscopy with direct laryngoscopy as performed by nonanesthesiologist trainees in a medical ICU demonstrates improved first-attempt success associated with video laryngoscopy. Author's findings are clinically significant and consistent with other reports and meta-analyses. These results, in combination with the existing literature on the success of video laryngoscopy and the availability of video laryngoscopy in most academic medical ICUs, suggest that video laryngoscopy should be considered the primary method of laryngeal visualization for intubations performed in ICUs, where there is increased risk of intubation-related complications.

A 2014 meta-analysis found that, compared with direct laryngoscopy, videolaryngoscopy improved glottis view and first-attempt success for orotracheal intubation in ICU [10]. However, both randomized controlled trials (RCTs) and observational studies were included in that study, and evidence from RCTs was limited. In the past months, new RCTs have debated the application of videolaryngoscopy in airway management in ICU [60, 61]. Bing-Cheng Zhao et al. performs a meta-analysis of RCTs to evaluate the effects of video laryngoscopy on first-attempt success and complications related to intubation in ICU patients [50].

Four RCTs enrolling 678 patients were included [60–63], and compared with direct laryngoscopy, videolaryngoscopy did not significantly improve first-attempt success rate (RR 1.17, 95% CI 0.89–1.53). In videolaryngoscopy groups, poor glottis visualization was less common (RR 0.30, 95% CI 0.14–0.64), and incidence of esophageal intubation was lower (RR 0.31, 95% CI 0.11–0.90). However, videolaryngoscopy did not reduce the time for successful intubation and other outcomes, including severe hypoxemia, hypotension, mechanical ventilation duration, and ICU mortality.

Nonetheless, trial sequential analysis showed that the current evidence on the use of videolaryngoscopy is still inconclusive. The prima facie question is whether there may be a type H error due to an inadequate sample size, seeing that there already exists a trend favoring the use of videolaryngoscopy in relation to the primary outcome of successful first-attempt intubation. A previously published meta-analysis of nine studies by De Jong et al. demonstrated the superiority of videolaryngoscopy versus direct laryngoscopy with an odds ratio (OR) of 2.07 (95% CI 1.35–3.16) [10]. Significant heterogeneity exists in the forest plot (P test 73%) with appreciable differences between the operators from inexperienced medical students to critical care medicine experts [50]. Nonanaesthesiologist as operator has been validated to be a risk factor for difficulty in intubation in ICU [64]. The operator's training and experience in comparative studies is, in our opinion, a critical factor which influences reported differences among various intubation devices. Out of the four randomized trials included for the meta-analysis [50], data from Silverberg et al. [61] was excluded for the analysis of time for successful intubation on the grounds of high bias risk (due to suboptimal allocation concealment and randomization strategy). The study by Silverberg demonstrated statistically and clinically significant differences in the time for successful intubation favoring videolaryngoscopy. Non-inclusion may affect the pooled data analysis by Zhao et al. [50]. Curiously, data from the same study was included for pooled analysis of the primary outcome (rate of successful intubation on the first-attempt). Two of the included studies compared the performance of the Glidescope with direct laryngoscopy, and two pooled data sets were included from studies comparing the McGrath videolaryngoscope against direct laryngoscope. Not all videolaryngoscopes are the same and the airway literature distinguishes channeled videolaryngoscopes versus the anteriorly angulated variety versus the Macintosh-like videolaryngoscopes—appreciating peculiar advantages and disadvantages of each. Combining results from all videolaryngoscopes as an entity may have its limitations.

intubation was much higher in the standard laryngoscope group (47%) than in the "*mixed*" VL

Cameron et al. perform a study to evaluate the odds of first-attempt success with video laryngoscopy compared with direct laryngoscopy, using a propensity-matched analysis to reduce the risk of bias, for intubations performed in a medical ICU. They accomplish an analysis of prospectively collected data for 809 consecutive intubations performed between 2012 and 2014 in the ICU of an academic tertiary referral center that supports fellowship training pro-

This study comparing video laryngoscopy with direct laryngoscopy as performed by nonanesthesiologist trainees in a medical ICU demonstrates improved first-attempt success associated with video laryngoscopy. Author's findings are clinically significant and consistent with other reports and meta-analyses. These results, in combination with the existing literature on the success of video laryngoscopy and the availability of video laryngoscopy in most academic medical ICUs, suggest that video laryngoscopy should be considered the primary method of laryngeal visualization for intubations performed in ICUs, where there is increased

A 2014 meta-analysis found that, compared with direct laryngoscopy, videolaryngoscopy improved glottis view and first-attempt success for orotracheal intubation in ICU [10]. However, both randomized controlled trials (RCTs) and observational studies were included in that study, and evidence from RCTs was limited. In the past months, new RCTs have debated the application of videolaryngoscopy in airway management in ICU [60, 61]. Bing-Cheng Zhao et al. performs a meta-analysis of RCTs to evaluate the effects of video laryngoscopy on first-attempt success and complications related to intubation in ICU patients [50].

Four RCTs enrolling 678 patients were included [60–63], and compared with direct laryngoscopy, videolaryngoscopy did not significantly improve first-attempt success rate (RR 1.17, 95% CI 0.89–1.53). In videolaryngoscopy groups, poor glottis visualization was less common (RR 0.30, 95% CI 0.14–0.64), and incidence of esophageal intubation was lower (RR 0.31, 95% CI 0.11–0.90). However, videolaryngoscopy did not reduce the time for successful intubation and other outcomes, including severe hypoxemia, hypotension, mechanical ventilation duration,

Nonetheless, trial sequential analysis showed that the current evidence on the use of videolaryngoscopy is still inconclusive. The prima facie question is whether there may be a type H error due to an inadequate sample size, seeing that there already exists a trend favoring the use of videolaryngoscopy in relation to the primary outcome of successful first-attempt intubation. A previously published meta-analysis of nine studies by De Jong et al. demonstrated the superiority of videolaryngoscopy versus direct laryngoscopy with an odds ratio (OR) of 2.07 (95% CI 1.35–3.16) [10]. Significant heterogeneity exists in the forest plot (P test 73%) with appreciable differences between the operators from inexperienced medical students to critical care medicine experts [50]. Nonanaesthesiologist as operator has been validated to be a risk factor for difficulty in intubation in ICU [64]. The operator's training and experience in comparative studies is, in our opinion, a critical factor which influences reported differences among various intubation devices. Out of the four randomized trials included for the

group (0%). These results were in agreement with the previous studies [51].

grams in pulmonary and critical care medicine [59].

risk of intubation-related complications.

and ICU mortality.

18 Bedside Procedures

In this regard, Joshi et al. [65] have tried to identify characteristics associated with firstattempt failure at intubation when using videolaryngoscopy in the ICU. They perform 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.

In this single-center study, 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%).

Presence of blood in the airway (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 higher odds of first-attempt failure, when intubation was performed with videolaryngoscopy in an ICU.

In a second logistic model to examine cases in which these additional difficult airway characteristics were collected (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 [65].

There are important limitations in this study, such that when certain difficult airway characteristics such as blood, vomit, or airway edema could have been known before the intubation attempt or encountered during the attempt, it is possible that operator reporting of these difficult airway characteristics was more common when they were unexpectedly encountered. Moreover, multivariable analyses account for experience of the operator. The generalization of these study results may be limited given the exposure, airway curriculum, and experience of trainees at this institution compared to others.

Nevertheless, the intensive care professional should account for these difficult airway characteristics, blood, cervical immobility, and airway edema, when preparing for endotracheal intubation with video laryngoscopy in addition to standard practices employed to optimize first-attempt success.

Janz et al. [62] evaluates the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt in a randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy among 150 critically ill adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows in a Medical ICU in a tertiary, academic medical center.

The first intubation attempts were made by a nonexpert in 83.8% of patients. There were no difference in first-pass success between the VL (67.7%) and the ML (70.3%) groups (absolute difference, −2.5% [95% CI, −11.9% to 6.9%]; p = 0.60. These results were sustained even after

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The proportion of first-attempt intubations performed by nonexperts (primarily residents, n = 290) did not differ between the groups (84.4% with videolaryngoscopy vs. 83.2% with direct laryngoscopy; absolute difference 1.2% [95% CI, −6.3% to 8.6%]; p = 0.76). The median time to successful intubation was 3 min (range, 2–4 min) for both videolaryngoscopy and direct laryngoscopy (absolute difference, 0 [95% CI, 0 to 0]; p = 0.95). Videolaryngoscopy was not associated with life-threatening complications (24/180 [13.3%] vs. 17/179 [9.5%] for direct laryngoscopy; absolute difference, 3.8% [95% CI, −2.7% to 10.4%]; p = 0.25). In post hoc analysis, videolaryngoscopy was associated with severe life-threatening complications (17/179 [9.5%] vs. 5/179 [2.8%] for direct laryngoscopy; absolute difference, 6.7% [95% CI, 1.8% to 11.6%]; p = 0.01) but not with mild to moderate life-threatening complications (10/181 [5.4%]

The main reason for intubation failure in the ML group was inability to see the glottis, and in

The ability to see the glottis is related to the expertise with the procedure and the equipment you are using, either way, since the groups were balanced regarding the physicians' expertise, the difference found between the two groups here might be because it is easier to visualize the glottis with the VL. The failure of tracheal catheterization, 70.7% (VL) vs. 23.5% (ML), can be explain with the learning curve or because they study a non-channeled VL. Eye-hand coordination, especially when looking through a monitor, is not learned with a few training sessions. Stratified by center and "*the status of expertise or nonexpertise of the individual performing intubation*". Unfortunately, the expert defying criteria did not include any experience with VL, and a good explanation for this difference is the lack of experience with the VL device

Several studies comparing videolaryngoscopy with direct laryngoscopy have demonstrated improved rates of first-attempt success in the operating room, emergency department, trauma unit, and simulation laboratory, as well as during active cardiopulmonary resuscitation [56– 58, 71–80]. Data comparing videolaryngoscopy with direct laryngoscopy on first-attempt success in the ICU are limited to a small number of observational studies [30, 36, 81–83], a

Randomized controlled trial data comparing video laryngoscopy with direct laryngoscopy in the medical ICU are limited in number and external validity, especially for intubations per-

Videolaryngoscopes have among their disadvantages the cost, which mainly restriction access in areas outside the operating room. Devices need to be connected to the mains or batteries,

meta-analysis of those studies [10], and some randomized controlled trials [60, 61].

and those that have an external monitor connected by cable may be little "*portable*".

vs. 14/181 [7.7%]; absolute difference, −2.3% [95% CI, −7.4% to 2.8%]; p = 0.37).

adjusting for operator expertise and MACOCHA score.

the VL group was failure of tracheal catheterization.

besides the absence of channel in the blade.

formed by nonanesthesiologists.

**6.4. Limitations**

The primary outcome was the rate of intubation on first-attempt, adjusted for the operator's previous experience with the intubating device at the time of the procedure. Adjustment for the operator's previous device experience was performed by collecting the number of times the operator had previously used a VL or DL at the time of each intubation event during the trial, such that the adjustment for prior experience with a specific device was updated constantly as the trial progressed.

Videolaryngoscopy improves glottic visualization but does not appear to increase procedural success in unadjusted analyses or after adjustment for the operator's previous experience with the assigned device (OR for video laryngoscopy on intubation on first-attempt 2.02, 95% CI, 0.82–5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct laryngoscopy [62].

The results of all of these studies are in contrast with results of prior studies demonstrating improved procedural success with VL [30, 36, 61]. There are several potential explanations for this difference, as that prior study limited to noncritically ill populations [66] may not apply to the patient, operator, and procedural conditions surrounding intubation in the ICU.

A lack of accounting of the experience of the operator at the time of the procedure [30, 36, 49, 61, 67] may also confound the results all of these works.

Several studies have shown that videolaryngoscopy enhances the laryngeal view in patients with apparently normal and anticipated difficult airways [32, 33, 39, 53, 68–70]. And there are a number of possible reasons why improving glottis view with VL does not translate into procedural success. Therefore, these data may not be generalizable to operators using videolaryngoscopes other than the McGrath MAC and direct laryngoscopes with straight blades. And some authors theorize that improving glottic view with VL may only matter to less-experienced operators [62].

The MACMAN trial (McGrath Mac Videolaryngoscope Versus Macintosh Laryngoscope for Orotracheal Intubation in the Critical Care Unit) is a multicentre, open-label, randomized controlled superiority trial published in JAMA [63]. It was a multicenter, randomized, openlabel trial, which included all ICU patients that needed orotracheal intubation.

Lascarrou et al. try to determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients. They perform a randomized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between 2015 and 2016, and there was 28 days of follow-up.

The primary outcome was the proportion of patients with successful first-pass intubation. The secondary outcomes included time to successful intubation and mild to moderate and severe life-threatening complications.

The first intubation attempts were made by a nonexpert in 83.8% of patients. There were no difference in first-pass success between the VL (67.7%) and the ML (70.3%) groups (absolute difference, −2.5% [95% CI, −11.9% to 6.9%]; p = 0.60. These results were sustained even after adjusting for operator expertise and MACOCHA score.

The proportion of first-attempt intubations performed by nonexperts (primarily residents, n = 290) did not differ between the groups (84.4% with videolaryngoscopy vs. 83.2% with direct laryngoscopy; absolute difference 1.2% [95% CI, −6.3% to 8.6%]; p = 0.76). The median time to successful intubation was 3 min (range, 2–4 min) for both videolaryngoscopy and direct laryngoscopy (absolute difference, 0 [95% CI, 0 to 0]; p = 0.95). Videolaryngoscopy was not associated with life-threatening complications (24/180 [13.3%] vs. 17/179 [9.5%] for direct laryngoscopy; absolute difference, 3.8% [95% CI, −2.7% to 10.4%]; p = 0.25). In post hoc analysis, videolaryngoscopy was associated with severe life-threatening complications (17/179 [9.5%] vs. 5/179 [2.8%] for direct laryngoscopy; absolute difference, 6.7% [95% CI, 1.8% to 11.6%]; p = 0.01) but not with mild to moderate life-threatening complications (10/181 [5.4%] vs. 14/181 [7.7%]; absolute difference, −2.3% [95% CI, −7.4% to 2.8%]; p = 0.37).

The main reason for intubation failure in the ML group was inability to see the glottis, and in the VL group was failure of tracheal catheterization.

The ability to see the glottis is related to the expertise with the procedure and the equipment you are using, either way, since the groups were balanced regarding the physicians' expertise, the difference found between the two groups here might be because it is easier to visualize the glottis with the VL. The failure of tracheal catheterization, 70.7% (VL) vs. 23.5% (ML), can be explain with the learning curve or because they study a non-channeled VL. Eye-hand coordination, especially when looking through a monitor, is not learned with a few training sessions. Stratified by center and "*the status of expertise or nonexpertise of the individual performing intubation*". Unfortunately, the expert defying criteria did not include any experience with VL, and a good explanation for this difference is the lack of experience with the VL device besides the absence of channel in the blade.

Several studies comparing videolaryngoscopy with direct laryngoscopy have demonstrated improved rates of first-attempt success in the operating room, emergency department, trauma unit, and simulation laboratory, as well as during active cardiopulmonary resuscitation [56– 58, 71–80]. Data comparing videolaryngoscopy with direct laryngoscopy on first-attempt success in the ICU are limited to a small number of observational studies [30, 36, 81–83], a meta-analysis of those studies [10], and some randomized controlled trials [60, 61].

Randomized controlled trial data comparing video laryngoscopy with direct laryngoscopy in the medical ICU are limited in number and external validity, especially for intubations performed by nonanesthesiologists.

#### **6.4. Limitations**

Janz et al. [62] evaluates the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt in a randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy among 150 critically ill adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows in a Medical ICU in a tertiary,

The primary outcome was the rate of intubation on first-attempt, adjusted for the operator's previous experience with the intubating device at the time of the procedure. Adjustment for the operator's previous device experience was performed by collecting the number of times the operator had previously used a VL or DL at the time of each intubation event during the trial, such that the adjustment for prior experience with a specific device was updated con-

Videolaryngoscopy improves glottic visualization but does not appear to increase procedural success in unadjusted analyses or after adjustment for the operator's previous experience with the assigned device (OR for video laryngoscopy on intubation on first-attempt 2.02, 95% CI, 0.82–5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct

The results of all of these studies are in contrast with results of prior studies demonstrating improved procedural success with VL [30, 36, 61]. There are several potential explanations for this difference, as that prior study limited to noncritically ill populations [66] may not apply to the patient, operator, and procedural conditions surrounding intubation in the ICU.

A lack of accounting of the experience of the operator at the time of the procedure [30, 36, 49,

Several studies have shown that videolaryngoscopy enhances the laryngeal view in patients with apparently normal and anticipated difficult airways [32, 33, 39, 53, 68–70]. And there are a number of possible reasons why improving glottis view with VL does not translate into procedural success. Therefore, these data may not be generalizable to operators using videolaryngoscopes other than the McGrath MAC and direct laryngoscopes with straight blades. And some authors theorize that improving glottic view with VL may only matter to

The MACMAN trial (McGrath Mac Videolaryngoscope Versus Macintosh Laryngoscope for Orotracheal Intubation in the Critical Care Unit) is a multicentre, open-label, randomized controlled superiority trial published in JAMA [63]. It was a multicenter, randomized, open-

Lascarrou et al. try to determine whether video laryngoscopy increases the frequency of successful first-pass orotracheal intubation compared with direct laryngoscopy in ICU patients. They perform a randomized clinical trial of 371 adults requiring intubation while being treated at 7 ICUs in France between 2015 and 2016, and there was 28 days of follow-up.

The primary outcome was the proportion of patients with successful first-pass intubation. The secondary outcomes included time to successful intubation and mild to moderate and severe

label trial, which included all ICU patients that needed orotracheal intubation.

61, 67] may also confound the results all of these works.

academic medical center.

20 Bedside Procedures

stantly as the trial progressed.

less-experienced operators [62].

life-threatening complications.

laryngoscopy [62].

Videolaryngoscopes have among their disadvantages the cost, which mainly restriction access in areas outside the operating room. Devices need to be connected to the mains or batteries, and those that have an external monitor connected by cable may be little "*portable*".

Because they provide an indirect image, the blood, secretions, and fogging of the lens obscure the image.

The fogging can be prevented by pre-aspirating the pharynx, or by preheating or applying specific solutions to the distal lens if the device does not have a concrete anti-fogging system (such as GlideScope, Airtraq, King Vision, etc.).

Like any other device, VLs require a learning curve. Those who have a shovel similar to that of the Macintosh (without a canal) need a transglottic device (guarantor, Frova, Eschman, etc.), inserted through a technique that must be learned since they can generate traumatisms on the soft palate during its introduction. On the other hand, if the operator cannot properly position the device-channel blade, the tube can be guided into the esophagus. When this occurs, while maintaining a good vision of the glottis and the patient remains stable and well oxygenated, we can try to solve the problem by a light movement of the device (**Figure 4**) or the ETT (**Figure 5**), which will help guide the ETT and achieve successful intubation.

#### **6.5. Complications**

All of these devices allow an optimal visualization of the glottic anatomy, but sometimes the maneuvers required for intubation involve greater complexity because of the difficulty in orienting the ETT.

For this reason, specific guides and catheters have been designed for intubation.

Nevertheless, in parallel with the clinical use of these devices, complications have been described.

Thus, lacerations of the glottic mucosa, vocal cord lesions, subluxations of arytenoids, and supracarinal tears are some of the complications encountered with the use of these new devices.

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety

http://dx.doi.org/10.5772/intechopen.72658

23

If we decide to use any device in our patients we think about practical approach of this device and not only in theoretical applications. In the case of videolaryngoscopes, we can raise

When we will perform the intubation, we must take into account that videolaryngoscope intubation is quite different than traditional direct laryngoscopy. The videolaryngoscope blade must be inserted into the middle of the mouth and rotated around the tongue in order

Always insert the videolaryngoscope midline into the mouth looking at the patient until its

Once the blade has turned the corner into the pharynx, look at the monitor while glancing at

doubts about how is the procedure different of direct videolaryngoscopy?

**6.6. Practical approach to videolaryngoscopy**

**Figure 5.** Technique for orienting the endotracheal tube (ETT).

to line up the camera lens with the larynx.

your patient to optimally position the blade.

tip has passed the palate.

**Figure 4.** Technique to guide endotracheal tube (ETT).

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety http://dx.doi.org/10.5772/intechopen.72658 23

**Figure 5.** Technique for orienting the endotracheal tube (ETT).

Thus, lacerations of the glottic mucosa, vocal cord lesions, subluxations of arytenoids, and supracarinal tears are some of the complications encountered with the use of these new devices.

#### **6.6. Practical approach to videolaryngoscopy**

**Figure 4.** Technique to guide endotracheal tube (ETT).

the image.

22 Bedside Procedures

successful intubation.

**6.5. Complications**

orienting the ETT.

(such as GlideScope, Airtraq, King Vision, etc.).

Because they provide an indirect image, the blood, secretions, and fogging of the lens obscure

The fogging can be prevented by pre-aspirating the pharynx, or by preheating or applying specific solutions to the distal lens if the device does not have a concrete anti-fogging system

Like any other device, VLs require a learning curve. Those who have a shovel similar to that of the Macintosh (without a canal) need a transglottic device (guarantor, Frova, Eschman, etc.), inserted through a technique that must be learned since they can generate traumatisms on the soft palate during its introduction. On the other hand, if the operator cannot properly position the device-channel blade, the tube can be guided into the esophagus. When this occurs, while maintaining a good vision of the glottis and the patient remains stable and well oxygenated, we can try to solve the problem by a light movement of the device (**Figure 4**) or the ETT (**Figure 5**), which will help guide the ETT and achieve

All of these devices allow an optimal visualization of the glottic anatomy, but sometimes the maneuvers required for intubation involve greater complexity because of the difficulty in

Nevertheless, in parallel with the clinical use of these devices, complications have been described.

For this reason, specific guides and catheters have been designed for intubation.

If we decide to use any device in our patients we think about practical approach of this device and not only in theoretical applications. In the case of videolaryngoscopes, we can raise doubts about how is the procedure different of direct videolaryngoscopy?

When we will perform the intubation, we must take into account that videolaryngoscope intubation is quite different than traditional direct laryngoscopy. The videolaryngoscope blade must be inserted into the middle of the mouth and rotated around the tongue in order to line up the camera lens with the larynx.

Always insert the videolaryngoscope midline into the mouth looking at the patient until its tip has passed the palate.

Once the blade has turned the corner into the pharynx, look at the monitor while glancing at your patient to optimally position the blade.

There are three types of blade. The non-channeled blades can be equal to the traditional direct laryngoscope blade or can be angled. This angle used to be 60° or similar, and make impossible direct visualization of the glottis.

Because a standard disposable stylet is so malleable, occasionally it will straighten during insertion, especially if the oral space is tight. This leads to the scenario of being able to see the larynx and not being able to "get there". There are specific stylets, some of them nondisposable, which are preconfigured to the correct curve of their videolaryngoscope. Some of them are very stiff and can potentially damage pharyngeal structures, so that they must pull back

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety

http://dx.doi.org/10.5772/intechopen.72658

25

Regardless of which stylet you are using, insert the endotracheal tube with the curve aimed

If the mouth is small, it can be helpful to insert the ETT into the mouth first, slide it far to the right side of the mouth, and then insert the videolaryngoscope non-channeled blade midline. To avoid lesions, it is mandatory to look at the patient during insertion of the ETT as described above until its tip has passed out of view beyond the tonsillar pillars. Only after the tip of the ETT has turned the corner into the pharynx should you look at the monitor, otherwise you can injure teeth, lips, tongue, and pharyngeal structures. Manipulate the tip of the tube through the glottis, and then pause to withdraw the stylet 2–3 cm. to effectively soften the tip

Channeled videolaryngoscopes have the advantage of orienting the ETT toward the trachea,

After successful intubation, remove the videolaryngoscope looking at the patient, not the monitor. And, finally, we must think about regurgitation. Cricoid pressure, also named Sellick maneuver, is a standard anesthetic maneuver used to reduce the risk of aspiration of gastric contents during the induction of general anesthesia, applied after induction, in the period between loss of consciousness and placement of a cuffed tracheal tube. This is also a standard component of a rapid sequence induction technique. Cricoid pressure has been shown to prevent gastric

A correct Sellick maneuver should be applied with a force of 10 N when the patient is awake, increasing to 30 N as consciousness is lost. These pressures occlude the esophagus and prevent aspiration during intubation, but often resulting in worsened glottis view and complicate

If initial attempts at videolaryngoscopy are difficult during rapid sequence induction, cricoid pressure should be released. This should be done under vision and suction available and, if

In most cases, there is sufficient time to improve the intubation conditions, to perform an initial assessment and to evaluate the risk of intubation, to verify the availability of material,

toward the right side of the mouth, under direct vision until to see it on the monitor. At this point rotate the tube back toward the midline, and aim it at the glottic opening.

of the ETT. Advance the ETT into the trachea looking at the monitor.

allowing directed intubation with a little manipulation of the airway.

we see regurgitation, cricoid pressure should be immediately reapplied.

distension during mask ventilation too.

**7. Optimization of processes**

inductive agents and to plan alternatives.

intubation.

slightly before fully inserting the ETT into the trachea.

The third type is the channeled blades that have a channel to lead the ETT toward to the glottis.

We have to be very clear that videolaryngoscopes allow a view of the entrance of glottis independent of the line of sight, especially those that have angled blades, but if we use a nonchanneled and non-angled blade, it will be equal to the traditional direct laryngoscope blade, and we have a similar glottic view if we perform a direct laryngoscopy.

Other important question is about patient head position regard. One of the most important features of these devices, particularly angled blades, is that the head and neck should be in extreme sniffing position or in a neutral position during all the intubation intent. We can see indirectly glottis, independent of the line of sight, because the image sensor is in the distal part of the blade. This give us a panoramic view of the glottis, without the need to "align the axes", thus avoiding hyperextension of the head.

But, if we do not need to move head's patient, do we still lift the jaw upward like in direct videolaryngoscopy? In clinical practice, Cormack-Lehane grade obtained with videolaryngoscopes use to be one or two at last in 99% of the cases. But, this view not guarantees the success of intubation, which is relatively frequent in videolaryngoscopes that have a curved leaf, especially during the learning stage. This difficulty in achieving intubation despite the correct exposure of the larynx even in expert hands may be finally impossible.

So, in practice, sometimes perform the traditional maneuvers as lift the jaw upward, BURP maneuver, wear the epiglottis or move carefully the videolaryngoscope can facilitate the intubation.

As stated above, usually all patients had grade 1 or 2 Cormack-Lehane views (grade 1: full glottic view; grade 2: partial glottic view; grade 3: epiglottis visible but no glottic view; and grade 4: epiglottis not visible) with videolaryngopscopes. However, achieving CL grade 1 laryngoscopy in videolaryngoscopy does not guarantee the success of OTI, which is relatively frequent in VLs that have a curved leaf.

There have been a number of maneuvers suggested to increase the success of passing the endotracheal tube when glottic visualization is excellent and the tube is not easily passed using usual methods.

With non-channeled blades, once the blade is positioned with the larynx in view (as we explain in the previous point), we insert the ETT along the right side of the blade. Even though the magnificent view of the larynx on the monitor at this point, we must remember that the larynx is not in the direct line of sight.

Therefore, a properly curved stylet must be used to guide the endotracheal tube into the larynx. Unlike the typical "hockey-stick" shape used during direct laryngscopy and in the standard videolaryngoscope blades, the stylet should match the curve on the angled blades.

If it is being used a standard stylet, it must be placed into the ETT and then mold it against the blade so that the curves match. The ETT can leave into the sleeve to keep it clean.

Because a standard disposable stylet is so malleable, occasionally it will straighten during insertion, especially if the oral space is tight. This leads to the scenario of being able to see the larynx and not being able to "get there". There are specific stylets, some of them nondisposable, which are preconfigured to the correct curve of their videolaryngoscope. Some of them are very stiff and can potentially damage pharyngeal structures, so that they must pull back slightly before fully inserting the ETT into the trachea.

Regardless of which stylet you are using, insert the endotracheal tube with the curve aimed toward the right side of the mouth, under direct vision until to see it on the monitor.

At this point rotate the tube back toward the midline, and aim it at the glottic opening.

If the mouth is small, it can be helpful to insert the ETT into the mouth first, slide it far to the right side of the mouth, and then insert the videolaryngoscope non-channeled blade midline.

To avoid lesions, it is mandatory to look at the patient during insertion of the ETT as described above until its tip has passed out of view beyond the tonsillar pillars. Only after the tip of the ETT has turned the corner into the pharynx should you look at the monitor, otherwise you can injure teeth, lips, tongue, and pharyngeal structures. Manipulate the tip of the tube through the glottis, and then pause to withdraw the stylet 2–3 cm. to effectively soften the tip of the ETT. Advance the ETT into the trachea looking at the monitor.

Channeled videolaryngoscopes have the advantage of orienting the ETT toward the trachea, allowing directed intubation with a little manipulation of the airway.

After successful intubation, remove the videolaryngoscope looking at the patient, not the monitor.

And, finally, we must think about regurgitation. Cricoid pressure, also named Sellick maneuver, is a standard anesthetic maneuver used to reduce the risk of aspiration of gastric contents during the induction of general anesthesia, applied after induction, in the period between loss of consciousness and placement of a cuffed tracheal tube. This is also a standard component of a rapid sequence induction technique. Cricoid pressure has been shown to prevent gastric distension during mask ventilation too.

A correct Sellick maneuver should be applied with a force of 10 N when the patient is awake, increasing to 30 N as consciousness is lost. These pressures occlude the esophagus and prevent aspiration during intubation, but often resulting in worsened glottis view and complicate intubation.

If initial attempts at videolaryngoscopy are difficult during rapid sequence induction, cricoid pressure should be released. This should be done under vision and suction available and, if we see regurgitation, cricoid pressure should be immediately reapplied.

## **7. Optimization of processes**

There are three types of blade. The non-channeled blades can be equal to the traditional direct laryngoscope blade or can be angled. This angle used to be 60° or similar, and make impos-

The third type is the channeled blades that have a channel to lead the ETT toward to the glottis.

We have to be very clear that videolaryngoscopes allow a view of the entrance of glottis independent of the line of sight, especially those that have angled blades, but if we use a nonchanneled and non-angled blade, it will be equal to the traditional direct laryngoscope blade,

Other important question is about patient head position regard. One of the most important features of these devices, particularly angled blades, is that the head and neck should be in extreme sniffing position or in a neutral position during all the intubation intent. We can see indirectly glottis, independent of the line of sight, because the image sensor is in the distal part of the blade. This give us a panoramic view of the glottis, without the need to "align the

But, if we do not need to move head's patient, do we still lift the jaw upward like in direct videolaryngoscopy? In clinical practice, Cormack-Lehane grade obtained with videolaryngoscopes use to be one or two at last in 99% of the cases. But, this view not guarantees the success of intubation, which is relatively frequent in videolaryngoscopes that have a curved leaf, especially during the learning stage. This difficulty in achieving intubation despite the correct

So, in practice, sometimes perform the traditional maneuvers as lift the jaw upward, BURP maneuver, wear the epiglottis or move carefully the videolaryngoscope can facilitate the intubation.

As stated above, usually all patients had grade 1 or 2 Cormack-Lehane views (grade 1: full glottic view; grade 2: partial glottic view; grade 3: epiglottis visible but no glottic view; and grade 4: epiglottis not visible) with videolaryngopscopes. However, achieving CL grade 1 laryngoscopy in videolaryngoscopy does not guarantee the success of OTI, which is relatively frequent

There have been a number of maneuvers suggested to increase the success of passing the endotracheal tube when glottic visualization is excellent and the tube is not easily passed

With non-channeled blades, once the blade is positioned with the larynx in view (as we explain in the previous point), we insert the ETT along the right side of the blade. Even though the magnificent view of the larynx on the monitor at this point, we must remember that the larynx

Therefore, a properly curved stylet must be used to guide the endotracheal tube into the larynx. Unlike the typical "hockey-stick" shape used during direct laryngscopy and in the standard videolaryngoscope blades, the stylet should match the curve on the angled blades.

If it is being used a standard stylet, it must be placed into the ETT and then mold it against the

blade so that the curves match. The ETT can leave into the sleeve to keep it clean.

and we have a similar glottic view if we perform a direct laryngoscopy.

exposure of the larynx even in expert hands may be finally impossible.

sible direct visualization of the glottis.

24 Bedside Procedures

axes", thus avoiding hyperextension of the head.

in VLs that have a curved leaf.

is not in the direct line of sight.

using usual methods.

In most cases, there is sufficient time to improve the intubation conditions, to perform an initial assessment and to evaluate the risk of intubation, to verify the availability of material, inductive agents and to plan alternatives.

Even so, on other occasions, the urgency of intubation in ICU is extreme (cardiorespiratory arrest, polytrauma, coma, etc.), and OTI should be performed in an optimal attempt of intubation with little time to optimize the patient.

Therefore, prior to anesthetic induction, at least the presence of two operators, water overload and preoxygenation with NIMV is recommended for 3 min in case of acute respiratory failure.

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety

• Ventilation: facial mask of adequate size, manual resuscitator, oropharyngeal cannula.

• Intubation: laryngoscopes, videolaryngoscopes, endotracheal tubes, extraglottic devices

• Position: the position of the patient is an important factor and limits the reduction of functional residual capacity. Several studies have shown that prior oxygenation in the semi-

In the case of expected intubation difficulty, there should be a practically immediate availability of advanced AM material with different rescue devices of ventilation and intubation

The ICU should have prepared a difficult airway trolley, similar to those that can be found in

One-third of patients had severe arterial desaturation (SatO<sup>2</sup> < 80%) during intuation manevers.

**Figure 6.** Reanimation difficult airway trolley examples. Left, Infanta Leonor University Hospital. Right, Getafe University

difficulty, as well as a Coniotomy cannula in the event of an eventual CICO situation.

Acute hypoxemic insufficiency is the main cause of intubation in the ICU.

[90, 91].

http://dx.doi.org/10.5772/intechopen.72658

27

**7.1. Patient's preparation**

• Vacuum cleaner.

**7.2. Preoxygenation**

Hospital, Madrid, Spain.

the surgical blocks [1] (**Figure 6**).

• Medication.

Before the AM should be prepared the basic material:

(such as FROVA or an introducer of Eschmann).

seated position or with the head at 25° can achieve greater PaO<sup>2</sup>

Critical patient may present, mainly, hypoxemia, severe metabolic acidosis, hypotension, and right ventricular insufficiency [9, 16, 19, 20], with a degree of hemodynamic instability resulting in a low cardiopulmonary reserve, in addition to a full stomach, etc., and the implementation of a package of measures for intubation can reduce the incidence of life-threatening complications from 32 to 17% (p = 0.01) during intubation (biblioUCI46). This package of measures should consist of 10 key points (**Table 2**).

Of these recommendations, six have individually demonstrated their benefit, both in anesthetic practice and in critical care (noninvasive mechanical ventilation [NIM], the presence of two operators, rapid sequence intubation [drugs and Sellick maneuver], capnography, and protection ventilation pulmonary).

The presence of a second operator in crisis situations has been shown to reduce the complications associated with the OTI procedure such as esophageal intubation (0.9% vs. 3.4%), traumatic intubation (1.7% vs. 6.8%), bronchoaspiration (0.9% vs. 5.8%), tooth damage (0% vs. 1.0%), and selective intubation (2.6% vs. 7.2%). The overall rate of complications also decreased significantly (6.1% vs. 21.7%, p < 0.0001) [89].

#### **Prior to intubation**

1. Presence of two operators.

2. Perform a loading of fluids (500 ml of isotonic saline or 250 ml of colloid) in the absence of cardiopulmonary edema.

3. Preparation of maintenance sedation.

4. Preoxygenation for 3 min with noninvasive mechanical ventilation (NIMV) in case of acute respiratory failure (100% FiO<sup>2</sup> , ventilatory support pressure between 5 and 15 cm H<sup>2</sup> O, to obtain an expiratory volume between 6 and 8 ml kg−1 and a PEEP of 5 cm H2 O).

#### **During intubation**

*Rapid sequence intubation* (RSI): etomidate 0.2–0.3 mg kg−1 or ketamine 1.5–3 mg kg−1, combined with succinylcholine 1–1.5 mg kg−1 in the absence of allergy, hyperkalemia, severe acidosis, acute or chronic neuromuscular disease, burn patient of more than 48 h evolution and spinal cord trauma. Rocuronium bromide (rocuronium) 0.9–1.2 mg kg−1 may be used when succinylcholine is not indicated [84–87].

5. *Sellick maneuver* [88].

#### **Post-intubation**


9. Initiate *lung protection mechanical ventilation*: tidal volume 6–8 ml kg−1. According to ideal weight, PEEP <5 cm H<sup>2</sup> O, and respiratory frequency between 10 and 20 resp./min, FiO<sup>2</sup> 100% for a plateau pressure <30 cm H<sup>2</sup> O.

**Table 2.** Package of measures for intubation in ICU.

Therefore, prior to anesthetic induction, at least the presence of two operators, water overload and preoxygenation with NIMV is recommended for 3 min in case of acute respiratory failure.

#### **7.1. Patient's preparation**

Before the AM should be prepared the basic material:


**Prior to intubation**

26 Bedside Procedures

edema.

(100% FiO<sup>2</sup>

**During intubation**

5. *Sellick maneuver* [88]. **Post-intubation**

8. Initiate long-term sedation.

1. Presence of two operators.

3. Preparation of maintenance sedation.

protection ventilation pulmonary).

8 ml kg−1 and a PEEP of 5 cm H2

2. Perform a loading of fluids (500 ml of isotonic saline or 250 ml of colloid) in the absence of cardiopulmonary

Even so, on other occasions, the urgency of intubation in ICU is extreme (cardiorespiratory arrest, polytrauma, coma, etc.), and OTI should be performed in an optimal attempt of intuba-

Critical patient may present, mainly, hypoxemia, severe metabolic acidosis, hypotension, and right ventricular insufficiency [9, 16, 19, 20], with a degree of hemodynamic instability resulting in a low cardiopulmonary reserve, in addition to a full stomach, etc., and the implementation of a package of measures for intubation can reduce the incidence of life-threatening complications from 32 to 17% (p = 0.01) during intubation (biblioUCI46). This package of

Of these recommendations, six have individually demonstrated their benefit, both in anesthetic practice and in critical care (noninvasive mechanical ventilation [NIM], the presence of two operators, rapid sequence intubation [drugs and Sellick maneuver], capnography, and

The presence of a second operator in crisis situations has been shown to reduce the complications associated with the OTI procedure such as esophageal intubation (0.9% vs. 3.4%), traumatic intubation (1.7% vs. 6.8%), bronchoaspiration (0.9% vs. 5.8%), tooth damage (0% vs. 1.0%), and selective intubation (2.6% vs. 7.2%). The overall rate of complications also

4. Preoxygenation for 3 min with noninvasive mechanical ventilation (NIMV) in case of acute respiratory failure

*Rapid sequence intubation* (RSI): etomidate 0.2–0.3 mg kg−1 or ketamine 1.5–3 mg kg−1, combined with succinylcholine 1–1.5 mg kg−1 in the absence of allergy, hyperkalemia, severe acidosis, acute or chronic neuromuscular disease, burn patient of more than 48 h evolution and spinal cord trauma. Rocuronium bromide (rocuronium) 0.9–1.2 mg kg−1 may

9. Initiate *lung protection mechanical ventilation*: tidal volume 6–8 ml kg−1. According to ideal weight, PEEP <5 cm H<sup>2</sup>

O, to obtain an expiratory volume between 6 and

100% for a plateau pressure <30 cm H<sup>2</sup>

O,

O.

, ventilatory support pressure between 5 and 15 cm H<sup>2</sup>

decreased significantly (6.1% vs. 21.7%, p < 0.0001) [89].

O).

6. Immediate confirmation of the position of the ETT by *capnography*.

be used when succinylcholine is not indicated [84–87].

tion with little time to optimize the patient.

measures should consist of 10 key points (**Table 2**).

7. Noradrenaline if diastolic BP remains <35 mmHg.

**Table 2.** Package of measures for intubation in ICU.

and respiratory frequency between 10 and 20 resp./min, FiO<sup>2</sup>

In the case of expected intubation difficulty, there should be a practically immediate availability of advanced AM material with different rescue devices of ventilation and intubation difficulty, as well as a Coniotomy cannula in the event of an eventual CICO situation.

The ICU should have prepared a difficult airway trolley, similar to those that can be found in the surgical blocks [1] (**Figure 6**).

#### **7.2. Preoxygenation**

Acute hypoxemic insufficiency is the main cause of intubation in the ICU.

One-third of patients had severe arterial desaturation (SatO<sup>2</sup> < 80%) during intuation manevers.

**Figure 6.** Reanimation difficult airway trolley examples. Left, Infanta Leonor University Hospital. Right, Getafe University Hospital, Madrid, Spain.

Hypoxemia may favor the complications observed during intubation such as arrhythmias, myocardial ischemia, cardiac arrest, and hypoxia in the brain.

after the OTI. When compared with not do, RM is associated with a higher PaO2

sponders, a perfusion of noradrenaline will be initiated [111, 112].

indicated because of its inotropic effect [16, 109, 110, 113, 114].

[103, 104].

**7.4. Hypotension**

50–200 mcg [16, 109, 110].

hyperventilation.

**7.5. Severe metabolic acidosis**

OTI cardiovascular collapse [21, 54, 105–107].

5 min (93 ± 36 vs. 236 ± 117 mmHg) and 30 min (39 ± 180 vs. 110 ± 79 mmHg) after intubation

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety

Peri-OTI hypotension is a risk factor for adverse events, including cardiorespiratory arrest related to the management of AM, and up to 30% of critically ill patients may present post-

Systolic blood pressure (SBP) <70 mmHg complicates 10% of intubations in ICU patients [9, 54, 106, 107], and when the patient has a preinduction gravity HR/SBP > 0.8, hemodynamic optimization should be performed pre-OTI and use inducing drugs with little response.

In responder patients, resuscitation with volume [108–110] can be made, while in the nonre-

If pre-OTI resuscitation is not feasible due to the critical situation of the patient, vasoactive drugs will be prepared for bolus administration in order to maintain blood pressure during OTI and subsequent resuscitation. Although there is insufficient evidence, adrenaline diluted at a concentration of 1–10 mcg mL−1, to be administered in boluses of 10–50 mcg, may be most

In patients who are not in shock but exhibit a transient drop in post-OTI blood pressure due to the vasodilatory effects of induction agents or the onset of positive pressure ventilation, diluted phenylephrine at a concentration of 100 mcg mL−1 will be administered in boluses at

When acidemia develops from respiratory acidosis, it can be corrected rapidly by increasing alveolar ventilation. However, when acidemia depends on metabolic acidosis, maintenance of acid-base homeostasis depends on compensatory respiratory alkalosis based on alveolar

In situations of severe metabolic acidosis such as diabetic ketoacidosis, poisoning salicylate, or severe lactic acidosis, the patient may not be able to make an alveolar hyperventilation that achieves buffering generated organic acids with a worsening acidosis [9, 16, 19, 20, 105, 115].

When OTI is required in these patients, even a brief apnea time can lead to a significant drop

Therefore, OTI should be avoided in patients with severe metabolic acidosis in whom adequate ventilation with the ventilator cannot be ensured, and NIV can be used to adequately

If the OTI cannot be delayed, getting the patient to maintain spontaneous ventilation becomes a critical action during intubation and mechanical ventilation, as this will allow the patient

in pH given the loss of respiratory compensation that was already insufficient.

support respiratory work until correction of underlying metabolic acidosis.

(with FiO<sup>2</sup>

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100%)

29

Preoxygenation is the administration of 100% FiO<sup>2</sup> before induction. This maneuver aims to displace the alveolar nitrogen (N2 ) by replacing it with oxygen (denitrogenation), in order to obtain an intrapulmonary O2 reserve that allows the maximum apnea time with the lowest desaturation [92–96].

Traditional preoxygenation, performed with ventilation at current volume with Mapleson circuit and well-sealed facial mask, using a fresh gas flow of 5 L/min. of 100% oxygen for 3–5 min [94], is insufficient in the critical patient [97]. And only 50% of these patients will experience an increase of their PaO2 higher than 5% compared to their baseline values after conventional preoxygenation for 4 min [98].

In all ICU patients, preoxygenation should be performed using a NIMV with PEEP 5–10 cm H2 O + PS 5–15 with FiO<sup>2</sup> 100%, a management that has been shown to prevent patient desaturation during the procedure [98].

The mean pressure on AM will lead to alveolar recruitment, with the temporary reduction of intrapulmonary shunt [99] and an improvement in oxygenation. However, when this positive pressure is removed for OTI there is a risk of alveolar dis-reclusion, which will cause rapid desaturation.

Maintenance of continuous positive pressure during intubation with the use of a nasal mask has been shown to be beneficial in the operating room to patients with hypoxemic respiratory insufficiency and may be useful in ICU [100]. This apnea (or apneic) oxygenation is based on the alveolar pressure exerted by the blood circulation in the alveoli at slightly sub-atmospheric levels, generating a negative pressure gradient.

Another option is the high-flow nasal cannula (CNAF), a system that can provide up to 100% warm and humidified FiO<sup>2</sup> at a maximum flow of 60 L/min. [101].

This system allows an increase in CO<sup>2</sup> clearance due to better pharyngeal space clearance [102], in addition to the generation of a continuous positive pressure in flow-dependent AM (CPAP) (up to 7.4 cm H<sup>2</sup> O to 60 L/min), with the reduction of respiratory resistance and maintenance of alveolar opening.

#### **7.3. Recruitment maneuver**

Idea of NIMV use during preoxygenation is to recruit lung tissue available for gas exchange: "*open the lung*" with PS, and "*keep the lung open*" with PEEP.

The combination of preoxygenation/denitrogenation (with FiO<sup>2</sup> 100%) and the apneic period associated with the OTI procedure can dramatically decrease the pulmonary ventilation volume ratio, causing atelectasis.

Recruitment maneuver (RM) consists of a transient increase in inspiratory pressure, and there are several possible maneuvers such as applying a CPAP of 40 cm H<sup>2</sup> O during 30–40 s immediately after the OTI. When compared with not do, RM is associated with a higher PaO2 (with FiO<sup>2</sup> 100%) 5 min (93 ± 36 vs. 236 ± 117 mmHg) and 30 min (39 ± 180 vs. 110 ± 79 mmHg) after intubation [103, 104].

#### **7.4. Hypotension**

Hypoxemia may favor the complications observed during intubation such as arrhythmias,

Traditional preoxygenation, performed with ventilation at current volume with Mapleson circuit and well-sealed facial mask, using a fresh gas flow of 5 L/min. of 100% oxygen for 3–5 min [94], is insufficient in the critical patient [97]. And only 50% of these patients will experience

In all ICU patients, preoxygenation should be performed using a NIMV with PEEP 5–10 cm

The mean pressure on AM will lead to alveolar recruitment, with the temporary reduction of intrapulmonary shunt [99] and an improvement in oxygenation. However, when this positive pressure is removed for OTI there is a risk of alveolar dis-reclusion, which will cause rapid

Maintenance of continuous positive pressure during intubation with the use of a nasal mask has been shown to be beneficial in the operating room to patients with hypoxemic respiratory insufficiency and may be useful in ICU [100]. This apnea (or apneic) oxygenation is based on the alveolar pressure exerted by the blood circulation in the alveoli at slightly sub-atmo-

Another option is the high-flow nasal cannula (CNAF), a system that can provide up to 100%

at a maximum flow of 60 L/min. [101].

[102], in addition to the generation of a continuous positive pressure in flow-dependent AM

Idea of NIMV use during preoxygenation is to recruit lung tissue available for gas exchange:

associated with the OTI procedure can dramatically decrease the pulmonary ventilation volume

Recruitment maneuver (RM) consists of a transient increase in inspiratory pressure, and there are

before induction. This maneuver aims to

) by replacing it with oxygen (denitrogenation), in order to

reserve that allows the maximum apnea time with the lowest

higher than 5% compared to their baseline values after conventional

100%, a management that has been shown to prevent patient desatu-

clearance due to better pharyngeal space clearance

100%) and the apneic period

O during 30–40 s immediately

O to 60 L/min), with the reduction of respiratory resistance and main-

myocardial ischemia, cardiac arrest, and hypoxia in the brain.

Preoxygenation is the administration of 100% FiO<sup>2</sup>

spheric levels, generating a negative pressure gradient.

"*open the lung*" with PS, and "*keep the lung open*" with PEEP.

The combination of preoxygenation/denitrogenation (with FiO<sup>2</sup>

several possible maneuvers such as applying a CPAP of 40 cm H<sup>2</sup>

displace the alveolar nitrogen (N2

obtain an intrapulmonary O2

desaturation [92–96].

28 Bedside Procedures

an increase of their PaO2

O + PS 5–15 with FiO<sup>2</sup>

warm and humidified FiO<sup>2</sup>

(CPAP) (up to 7.4 cm H<sup>2</sup>

tenance of alveolar opening.

**7.3. Recruitment maneuver**

ratio, causing atelectasis.

This system allows an increase in CO<sup>2</sup>

H2

desaturation.

preoxygenation for 4 min [98].

ration during the procedure [98].

Peri-OTI hypotension is a risk factor for adverse events, including cardiorespiratory arrest related to the management of AM, and up to 30% of critically ill patients may present post-OTI cardiovascular collapse [21, 54, 105–107].

Systolic blood pressure (SBP) <70 mmHg complicates 10% of intubations in ICU patients [9, 54, 106, 107], and when the patient has a preinduction gravity HR/SBP > 0.8, hemodynamic optimization should be performed pre-OTI and use inducing drugs with little response.

In responder patients, resuscitation with volume [108–110] can be made, while in the nonresponders, a perfusion of noradrenaline will be initiated [111, 112].

If pre-OTI resuscitation is not feasible due to the critical situation of the patient, vasoactive drugs will be prepared for bolus administration in order to maintain blood pressure during OTI and subsequent resuscitation. Although there is insufficient evidence, adrenaline diluted at a concentration of 1–10 mcg mL−1, to be administered in boluses of 10–50 mcg, may be most indicated because of its inotropic effect [16, 109, 110, 113, 114].

In patients who are not in shock but exhibit a transient drop in post-OTI blood pressure due to the vasodilatory effects of induction agents or the onset of positive pressure ventilation, diluted phenylephrine at a concentration of 100 mcg mL−1 will be administered in boluses at 50–200 mcg [16, 109, 110].

#### **7.5. Severe metabolic acidosis**

When acidemia develops from respiratory acidosis, it can be corrected rapidly by increasing alveolar ventilation. However, when acidemia depends on metabolic acidosis, maintenance of acid-base homeostasis depends on compensatory respiratory alkalosis based on alveolar hyperventilation.

In situations of severe metabolic acidosis such as diabetic ketoacidosis, poisoning salicylate, or severe lactic acidosis, the patient may not be able to make an alveolar hyperventilation that achieves buffering generated organic acids with a worsening acidosis [9, 16, 19, 20, 105, 115].

When OTI is required in these patients, even a brief apnea time can lead to a significant drop in pH given the loss of respiratory compensation that was already insufficient.

Therefore, OTI should be avoided in patients with severe metabolic acidosis in whom adequate ventilation with the ventilator cannot be ensured, and NIV can be used to adequately support respiratory work until correction of underlying metabolic acidosis.

If the OTI cannot be delayed, getting the patient to maintain spontaneous ventilation becomes a critical action during intubation and mechanical ventilation, as this will allow the patient to maintain their own minute ventilation. For this, agents with a low probability of generating apnea should be used. In addition, rapid sequence intubation should be avoided if possible, and if deemed necessary, a short-acting neuromuscular blocker such as succinylcholine should be used.

Once OTI is achieved, a ventilator mode should be chosen that allows the patient to establish and maintain their own minute ventilation to maintain respiratory compensation better.

#### **7.6. Right ventricular failure**

The main function of the right ventricle and pulmonary circulation is gas exchange. Under normal conditions, these are a low pressure and high-volume system which, in addition, must dampen the dynamic changes in volume and blood flow resulting from breathing, positional changes, and changes in left ventricular cardiac output. The adaptations needed to meet these conflicting requirements result in reduced compensation capacity in the event of a rise in afterload or pressure [105, 113, 116].

The failure of the system generates right heart failure, so that the right ventricle becomes unable to meet the demands, dilating, retrograde flow, decreased coronary perfusion and, ultimately, systemic hypotension and cardiovascular collapse [107, 110, 117].

When a patient with right heart failure requires OTI, increased afterload and decreased preload associated with invasive mechanical ventilation often leads to this cardiovascular collapse [21, 54, 105, 107, 113, 118].

In these patients, we should try to achieve pre-OTI hemodynamic optimization, including reduction of afterload with inhaled pulmonary artery vasodilators such as inhaled nitric oxide (INO) [119] or inhaled epoprostenol (Flolan) [113, 120].

In addition, good preoxygenation due to the reduction of intrapulmonary shunt [99], as well as apneic oxygenation [98, 106] will be essential, as well as avoid hypercapnia and high alveolar pressures, because they lead to vasoconstriction.

## **8. Critical airway management algorithm**

As in the surgical setting, in order to limit the incidence of serious complications during OTI in the ICU, the entire process (pre-, peri-, and post-intubation) should be guided by protocols oriented to patient safety [2, 46, 121–124].

This critical AM algorithm will be based, firstly, on the outcome of the assessment of the difficulty of intubation according to the MACOCHA score [51] (**Figure 7**).

Always check the availability of the equipment for the AM and an eventual DA before the OTI.And, in the case of desaturation <80% during the procedure, the patient will be ventilated.

In the case of failure of intubation and ventilation, emergency ventilation through NIMV through a SAD allowing intubation [125] will be performed.

**Figure 7.** Macocha score protocol.

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety

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Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety http://dx.doi.org/10.5772/intechopen.72658 31

to maintain their own minute ventilation. For this, agents with a low probability of generating apnea should be used. In addition, rapid sequence intubation should be avoided if possible, and if deemed necessary, a short-acting neuromuscular blocker such as succinylcholine

Once OTI is achieved, a ventilator mode should be chosen that allows the patient to establish and maintain their own minute ventilation to maintain respiratory compensation better.

The main function of the right ventricle and pulmonary circulation is gas exchange. Under normal conditions, these are a low pressure and high-volume system which, in addition, must dampen the dynamic changes in volume and blood flow resulting from breathing, positional changes, and changes in left ventricular cardiac output. The adaptations needed to meet these conflicting requirements result in reduced compensation capacity in the event of a rise in

The failure of the system generates right heart failure, so that the right ventricle becomes unable to meet the demands, dilating, retrograde flow, decreased coronary perfusion and, ultimately,

When a patient with right heart failure requires OTI, increased afterload and decreased preload associated with invasive mechanical ventilation often leads to this cardiovascular col-

In these patients, we should try to achieve pre-OTI hemodynamic optimization, including reduction of afterload with inhaled pulmonary artery vasodilators such as inhaled nitric oxide

In addition, good preoxygenation due to the reduction of intrapulmonary shunt [99], as well as apneic oxygenation [98, 106] will be essential, as well as avoid hypercapnia and high alveo-

As in the surgical setting, in order to limit the incidence of serious complications during OTI in the ICU, the entire process (pre-, peri-, and post-intubation) should be guided by protocols

This critical AM algorithm will be based, firstly, on the outcome of the assessment of the dif-

Always check the availability of the equipment for the AM and an eventual DA before the OTI.And, in the case of desaturation <80% during the procedure, the patient will be ventilated. In the case of failure of intubation and ventilation, emergency ventilation through NIMV

ficulty of intubation according to the MACOCHA score [51] (**Figure 7**).

through a SAD allowing intubation [125] will be performed.

systemic hypotension and cardiovascular collapse [107, 110, 117].

(INO) [119] or inhaled epoprostenol (Flolan) [113, 120].

lar pressures, because they lead to vasoconstriction.

**8. Critical airway management algorithm**

oriented to patient safety [2, 46, 121–124].

should be used.

30 Bedside Procedures

**7.6. Right ventricular failure**

afterload or pressure [105, 113, 116].

lapse [21, 54, 105, 107, 113, 118].

Two operators should always be present, especially if an AD with a MACOCHA score ≥3 is predicted, an extraglottic device (e.g. FROVA or an Eschmann introducer) should be used, and a rapid sequence induction be performed.

• Intubation. The RSI should allow us to intubate in a time no longer than 60 s from the ad-

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Apnea following induction and neuromuscular relaxation may lead to rapid desaturation in the critical patient, if not in severe complications. In patients with previously DA [6, 40, 128, 129] or in those who were suspected according to a MACOCHA score ≥ 3, awake intubation would represent a valid option from the point of view of safety of the procedure [23, 29, 123, 130–133]. This intubation with the awake patient can be performed with a noninvasive technique or with an invasive technique (surgical or percutaneous), and among its advantages is that, by maintaining muscle tone, permeability of the airway and spontaneous ventilation, awake patients are easier to intubate because inducing general anesthesia tends to shift the larynx anterior.

• Previously difficult airway scenario or positive predictive signs (MACOCHA score ≥ 3).

• *Oxygenation with adequate face mask*: insisting repeatedly on a technique that has not resolved the situation will increase the risk of complications. Therefore, change to an alternative device (e.g. MCcoy blade), use an extraglottic device, use a VL, or a SAD intubation device. • *Unsuitable oxygenation with face mask*: given the limited period of safe apnea of the critically ill patient, oxygenation, and not intubation, is the absolute priority in this scenario.

There are different SAD that have been used to rescue ventilation with a difficult facial mask. The usual in ICU after ensuring oxygenation is that endotracheal intubation is necessary, so it is recommended to have some of the SAD that allow intubation through it [3]. In the case of failure, a CICO scenario will be declared, the worst of the possible scenarios.

ministration of inducing drugs. • Checking the placement of the ETT.

**8.2. The anticipated difficult airway**

• Patient cooperation.

Contraindications:

• Adequate AM preparation.

• Human team inexperience.

• Allergy to local anesthetics.

**8.3. Difficult airway rescue**

• Hemorrhage in oropharyngeal cavity.

• Negative of the patient.

The prerequisites for awake intubation in the ICU are:

• Equipment familiar with awake intubation techniques.

Before an intubation failure, we can find two possible scenarios:

The use of a VL is also recommended in cases of difficult intubation. Nonetheless, in cases of abundant secretions, even after aspiration, direct laryngoscopy will be preferable to videolaryngoscopy.

Finally, in case of failure of intubation, an extraglottic device (e.g. FROVA or an Eschmann introducer) will be used first, followed by a VL if it was not initially used, rescue with a supraglottic airway device (SAD) that allows intubation, fiber optic bronchoscopy (FOB) and, at last, percutaneous or surgical rescue in situations of failure of intubation, ventilation, and oxygenation (CICO).

#### **8.1. "***Not seemingly difficult***" airway management**

It will be those patients who present a MACOCHA score <3.

The R rapid sequence induction (RSI) SI techniques are indicated in these cases, among others, in the ICU, hospital emergency services and out-of-hospital emergencies.

#### *8.1.1. Rapid sequence intubation*

The purpose of the RSI is to make emergency intubation easier and safer, and thus increase the success rate and reduce potential complications.

There is no single RSI technique due to its numerous indications, so the choice of the drug and the regimen of administration will be conditioned, not only by the reduction of the risk of aspiration and the facilitation of intubation but also by the characteristics of patient [88, 115, 126, 127]. However, the key elements that remain in all RSI protocol are:


In spite of the lack of a single RSI technique, the main steps could be summarized in [85, 88, 126, 127]:


Two operators should always be present, especially if an AD with a MACOCHA score ≥3 is predicted, an extraglottic device (e.g. FROVA or an Eschmann introducer) should be used,

The use of a VL is also recommended in cases of difficult intubation. Nonetheless, in cases of abundant secretions, even after aspiration, direct laryngoscopy will be preferable to

Finally, in case of failure of intubation, an extraglottic device (e.g. FROVA or an Eschmann introducer) will be used first, followed by a VL if it was not initially used, rescue with a supraglottic airway device (SAD) that allows intubation, fiber optic bronchoscopy (FOB) and, at last, percutaneous or surgical rescue in situations of failure of intubation, ventilation, and

The R rapid sequence induction (RSI) SI techniques are indicated in these cases, among oth-

The purpose of the RSI is to make emergency intubation easier and safer, and thus increase

There is no single RSI technique due to its numerous indications, so the choice of the drug and the regimen of administration will be conditioned, not only by the reduction of the risk of aspiration and the facilitation of intubation but also by the characteristics of patient [88, 115,

ers, in the ICU, hospital emergency services and out-of-hospital emergencies.

126, 127]. However, the key elements that remain in all RSI protocol are:

• Prevention of hypoxia and hypotension during induction and intubation.

• Use of a cuffed ETT, and capnographic confirmation of the placement of the tube.

In spite of the lack of a single RSI technique, the main steps could be summarized in [85, 88,

and a rapid sequence induction be performed.

**8.1. "***Not seemingly difficult***" airway management**

the success rate and reduce potential complications.

• Preoxygenation/denitrogenation to prolong apnea time.

• Valuation, planification, and preparation.

• Application of the Sellick maneuver.

It will be those patients who present a MACOCHA score <3.

videolaryngoscopy.

32 Bedside Procedures

oxygenation (CICO).

*8.1.1. Rapid sequence intubation*

126, 127]:

• Preoxygenation.

• Premedication.

• Laryngoscopy.

• Induction and relaxation.

#### **8.2. The anticipated difficult airway**

Apnea following induction and neuromuscular relaxation may lead to rapid desaturation in the critical patient, if not in severe complications. In patients with previously DA [6, 40, 128, 129] or in those who were suspected according to a MACOCHA score ≥ 3, awake intubation would represent a valid option from the point of view of safety of the procedure [23, 29, 123, 130–133].

This intubation with the awake patient can be performed with a noninvasive technique or with an invasive technique (surgical or percutaneous), and among its advantages is that, by maintaining muscle tone, permeability of the airway and spontaneous ventilation, awake patients are easier to intubate because inducing general anesthesia tends to shift the larynx anterior.

The prerequisites for awake intubation in the ICU are:


Contraindications:


#### **8.3. Difficult airway rescue**

Before an intubation failure, we can find two possible scenarios:


There are different SAD that have been used to rescue ventilation with a difficult facial mask. The usual in ICU after ensuring oxygenation is that endotracheal intubation is necessary, so it is recommended to have some of the SAD that allow intubation through it [3].

In the case of failure, a CICO scenario will be declared, the worst of the possible scenarios.

#### **8.4. Can't-intubate-Can't-oxygenate scenario**

CICO scenario is the end of the algorithms, and always constitutes a medical emergency that forces to explore an alternative plan based on transtracheal access, either through a percutaneous cricothyrotomy (choice for its speed), a surgical tracheotomy or through retrograde intubation.

Those responsible for the training of each service should develop training programs based on simulation to maintain competencies with different devices: direct laryngoscopy, extraglottic devices, supraglottic devices, videolaryngoscopes, fiber optic bronchoscopes and cri-

Videolaryngoscopy in the Intensive Care Unit: We could Improve ICU Patients Safety

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35

Also, each ICU should have immediate access 24 h a day to a difficult airway trolley that must

Tracheal intubation in the critical patient is always potentially dangerous. Critically ill patients with acute respiratory, neurological, or cardiovascular failure requiring invasive mechanical ventilation are at high risk of difficult intubation and have organ dysfunctions associated with complications of intubation and anesthesia such as hypotension and hypoxemia. The complication rate increases with the number of intubation attempts. Videolaryngoscopy improves

Every professional in ICU should have a basic knowledge about airway management, be familiar with algorithms to handle possible complications, and know correct use and interpretation of capnography. The algorithms that are usually handled by anesthesiologists in our routine clinical practice are not always useful in ICU because they contemplate alternatives such as awakening the patient or postponing the procedure that cannot be applied in a critical/ emergency situation. The implementation of an intubation protocol in the ICU can contribute to significantly reduce the immediate severe complications associated with this procedure.

Airway management of patients admitted to the ICU is a challenge. New videolaryngoscopes have been proposed to improve management, but most studies comparing videolaryngoscopes with a standard direct laryngoscope (DL) have been performed in operating rooms. Therefore, the role of videolaryngoscopy in the ICU is still discussed, where there is a lack of scientific evidence and intubation conditions are worse than in the operating room. The Montpellier group has proposed and implemented a package for intubation care in its ICU which includes, among others, the use of two operators, fluid overload, preoxygenation, and, above all, the rapid detection of the position of the ETT by capnography. Including the use of videolaryngoscopy in this package, as described by De Jong et al. [51], the safety of tracheal

The overall impact of VL on the anesthetic literature is weighed due to marked heterogeneity in the patient population, devices studied, operator experience, and confusion including manikin studies. While VL improves the ease of obtaining a view of the larynx, insertion of the ETT may be more difficult. VL may reduce the number of failed intubations, particularly among patients presenting with a difficult airway. They improve the glottic view and may reduce laryngeal/airway trauma. Currently, no evidence indicates that use of a VL reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications, and no evidence indicates that use of a VL affects the time required for intubation [134].

include the same devices that the one usually available in the operating room.

cothyrotomy set.

**9. Conclusions**

elective endotracheal intubation.

intubation could be further improved.

This situation is reached when the attempt to AM had failed through tracheal intubation, facial mask ventilation, and a SAD. At this point, if the situation is not resolved quickly, hypoxic brain damage and death will occur.

The key points of the non-intubatable/non-oxygenable AM plan are:


#### **8.5. Adequate staff—adequate material—adequate procedure**

Through the training program of those specialists who develop their professional activity in ICU must be guaranteed the acquisition of skills in critical patient's advanced airway management (**Figure 8**).

**Figure 8.** Teamwork, roles, goals and communication.

Those responsible for the training of each service should develop training programs based on simulation to maintain competencies with different devices: direct laryngoscopy, extraglottic devices, supraglottic devices, videolaryngoscopes, fiber optic bronchoscopes and cricothyrotomy set.

Also, each ICU should have immediate access 24 h a day to a difficult airway trolley that must include the same devices that the one usually available in the operating room.

#### **9. Conclusions**

**8.4. Can't-intubate-Can't-oxygenate scenario**

hypoxic brain damage and death will occur.

**Figure 8.** Teamwork, roles, goals and communication.

(**Figure 8**).

34 Bedside Procedures

The key points of the non-intubatable/non-oxygenable AM plan are:

mal minute ventilation with a standard ventilation system.

• All operators must be trained in performing a surgical approach.

**8.5. Adequate staff—adequate material—adequate procedure**

• The CICO scenario must be declared and proceed to anterior neck access.

CICO scenario is the end of the algorithms, and always constitutes a medical emergency that forces to explore an alternative plan based on transtracheal access, either through a percutaneous cricothyrotomy (choice for its speed), a surgical tracheotomy or through retrograde intubation. This situation is reached when the attempt to AM had failed through tracheal intubation, facial mask ventilation, and a SAD. At this point, if the situation is not resolved quickly,

• A didactic technique has been described using a scalpel to promote standardized training. • Placing an endotracheal balloon tube through the cricothyroid membrane facilitates nor-

• High-pressure oxygenation through a fine cannula is associated with increased morbidity.

Through the training program of those specialists who develop their professional activity in ICU must be guaranteed the acquisition of skills in critical patient's advanced airway management

• Training should be repeated at regular intervals to ensure that skills are not lost.

Tracheal intubation in the critical patient is always potentially dangerous. Critically ill patients with acute respiratory, neurological, or cardiovascular failure requiring invasive mechanical ventilation are at high risk of difficult intubation and have organ dysfunctions associated with complications of intubation and anesthesia such as hypotension and hypoxemia. The complication rate increases with the number of intubation attempts. Videolaryngoscopy improves elective endotracheal intubation.

Every professional in ICU should have a basic knowledge about airway management, be familiar with algorithms to handle possible complications, and know correct use and interpretation of capnography. The algorithms that are usually handled by anesthesiologists in our routine clinical practice are not always useful in ICU because they contemplate alternatives such as awakening the patient or postponing the procedure that cannot be applied in a critical/ emergency situation. The implementation of an intubation protocol in the ICU can contribute to significantly reduce the immediate severe complications associated with this procedure.

Airway management of patients admitted to the ICU is a challenge. New videolaryngoscopes have been proposed to improve management, but most studies comparing videolaryngoscopes with a standard direct laryngoscope (DL) have been performed in operating rooms. Therefore, the role of videolaryngoscopy in the ICU is still discussed, where there is a lack of scientific evidence and intubation conditions are worse than in the operating room. The Montpellier group has proposed and implemented a package for intubation care in its ICU which includes, among others, the use of two operators, fluid overload, preoxygenation, and, above all, the rapid detection of the position of the ETT by capnography. Including the use of videolaryngoscopy in this package, as described by De Jong et al. [51], the safety of tracheal intubation could be further improved.

The overall impact of VL on the anesthetic literature is weighed due to marked heterogeneity in the patient population, devices studied, operator experience, and confusion including manikin studies. While VL improves the ease of obtaining a view of the larynx, insertion of the ETT may be more difficult. VL may reduce the number of failed intubations, particularly among patients presenting with a difficult airway. They improve the glottic view and may reduce laryngeal/airway trauma. Currently, no evidence indicates that use of a VL reduces the number of intubation attempts or the incidence of hypoxia or respiratory complications, and no evidence indicates that use of a VL affects the time required for intubation [134].

The study of VL in the ICU is difficult for similar reasons, although they are increasing in popularity [10, 36]. However, there is a need for randomized controlled trials (RCTs) of VL vs. DL in the ICU [31], the truth is that the use of VL in ICU is so widespread that such studies are impractical. A RCT could help determine which devices are most useful, and could study the impact of VL on both technical and human factors [135].

**References**

18604519

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[3] Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. British Journal of Anaesthesia [Internet]. 2015 Dec 1 [cited 2017 Aug 7];**115**(6):827- 848. Available from: https://academic.oup.com/bja/article-lookup/doi/10.1093/bja/aev371

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If randomized controlled trials demonstrating a benefit of videolaryngoscopy are designed in the future, it could become a new standard for tracheal intubation in the ICU, particularly in educational institutions, where tracheal intubations are often performed by residents in training.

Nevertheless, the introduction of videolaryngoscopy in the ICU should always be accompanied by formal training programs in the management of the DA and simulation using manikins with the specific device [47, 71, 121, 136, 137].

Best way to avoid the serious consequences associated with a DA is the constant preparation by all those who could be able to handle it, an adequate prior assessment of the patient and the capacity to face this situation with the different rescue alternatives, from the use of SAD, VL, and flexibility in the use of the FOB, to the management of cervical surgical neck access.

Finally, we must implement the capnography in the ICU, so that the capnograph will be used in every intubation maneuver in the critical patient. Capnography should be monitored continuously in all critical intubated patients requiring assisted ventilation, and all ICU staff should be trained in the interpretation and recognition of abnormal capnography tracings.

In summary, if we consider the latest data, exclusive use of VL in out-of-OR airway management, or disdain them, appears premature, and we agree with the authors that future research would be necessary to demonstrate the safe utility of videolaryngoscopy in the ICU context. Even though it is surely the future to follow.

## **Author details**

Eugenio Martinez Hurtado<sup>1</sup> \*, Miriam Sanchez Merchante<sup>2</sup> , Sonia Martin Ventura<sup>3</sup> , Maria Luisa Mariscal Flores<sup>3</sup> and Javier Ripolles Melchor<sup>1</sup>

\*Address all correspondence to: eugeniodaniel.martinez@salud.madrid.org

1 Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Hospital Universitario Infanta Leonor, Madrid, España

2 Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Hospital Universitario Fundación Alcorcón, Madrid, España

3 Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Hospital Universitario de Getafe, Madrid, España

## **References**

The study of VL in the ICU is difficult for similar reasons, although they are increasing in popularity [10, 36]. However, there is a need for randomized controlled trials (RCTs) of VL vs. DL in the ICU [31], the truth is that the use of VL in ICU is so widespread that such studies are impractical. A RCT could help determine which devices are most useful, and could study

If randomized controlled trials demonstrating a benefit of videolaryngoscopy are designed in the future, it could become a new standard for tracheal intubation in the ICU, particularly in educational institutions, where tracheal intubations are often performed by residents in

Nevertheless, the introduction of videolaryngoscopy in the ICU should always be accompanied by formal training programs in the management of the DA and simulation using mani-

Best way to avoid the serious consequences associated with a DA is the constant preparation by all those who could be able to handle it, an adequate prior assessment of the patient and the capacity to face this situation with the different rescue alternatives, from the use of SAD, VL, and flexibility in the use of the FOB, to the management of cervical surgical

Finally, we must implement the capnography in the ICU, so that the capnograph will be used in every intubation maneuver in the critical patient. Capnography should be monitored continuously in all critical intubated patients requiring assisted ventilation, and all ICU staff should be trained in the interpretation and recognition of abnormal capnography

In summary, if we consider the latest data, exclusive use of VL in out-of-OR airway management, or disdain them, appears premature, and we agree with the authors that future research would be necessary to demonstrate the safe utility of videolaryngoscopy in the ICU context.

\*, Miriam Sanchez Merchante<sup>2</sup>

and Javier Ripolles Melchor<sup>1</sup>

1 Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Hospital

2 Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Hospital

3 Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Hospital

\*Address all correspondence to: eugeniodaniel.martinez@salud.madrid.org

, Sonia Martin Ventura<sup>3</sup>

,

the impact of VL on both technical and human factors [135].

kins with the specific device [47, 71, 121, 136, 137].

Even though it is surely the future to follow.

Universitario Infanta Leonor, Madrid, España

Universitario de Getafe, Madrid, España

Universitario Fundación Alcorcón, Madrid, España

training.

36 Bedside Procedures

neck access.

tracings.

**Author details**

Eugenio Martinez Hurtado<sup>1</sup>

Maria Luisa Mariscal Flores<sup>3</sup>


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[121] Jaber S, Jung B, Corne P, Sebbane M, Muller L, Chanques G, et al. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: A prospective, multiple-center study. Intensive Care Medicine [Internet]. 2010 Feb 17 [cited 2017 Aug 7];**36**(2):248-255. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19921148

[122] Langeron O, Amour J, Vivien B, Aubrun F. Clinical review: Management of difficult


[134] Lewis SR, Butler AR, Parker J, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. In: Lewis SR, editor. Cochrane Database of Systematic Reviews [Internet]. Chichester, UK: John Wiley & Sons, Ltd; 2016 [cited 2017 Aug 8]. p. CD011136. Available from: http://www.ncbi.nlm. nih.gov/pubmed/27844477

**Chapter 3**

**Provisional chapter**

**Endotracheal Intubation in Children: Practice**

**Endotracheal Intubation in Children: Practice** 

Maribel Ibarra-Sarlat, Eduardo Terrones-Vargas,

Maribel Ibarra-Sarlat, Eduardo Terrones-Vargas, Lizett Romero-Espinoza, Graciela Castañeda-Muciño, Alejandro Herrera-Landero and Juan Carlos Núñez-Enríquez

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

Lizett Romero-Espinoza,

**Abstract**

**1. Introduction**

Graciela Castañeda-Muciño, Alejandro Herrera-Landero and Juan Carlos Núñez-Enríquez

http://dx.doi.org/10.5772/intechopen.70356

safe ventilation to patients that need this care.

**Recommendations, Insights, and Future Directions**

Management of airway is mandatory in a critically ill child with severe trauma or any other situation that threatens his or her life. It is important, that clinicians who attend critically ill pediatric patients requiring airway management know the rapid sequence intubation (RSI) procedure, identify a patient with difficult airway, know the devices and techniques for the management of difficult airway, and look for receiving a formal training in endotracheal intubation (ETI). Future strategies for teaching and/or training clinicians in pediatric and neonatal ETI should be evaluated through conducting controlled clinical trials to identify which type will be the most effective by considering the less number of attempts and complications.

**Keywords:** endotracheal intubation, children, review, training, procedure

**Recommendations, Insights, and Future Directions**

DOI: 10.5772/intechopen.70356

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Management and securing permeability of airway are mandatory in a critically ill child with severe trauma or any other situation that threatens his or her life. Airway's management can be defined as the performance of maneuvers and the use of devices that enable a correct and


#### **Endotracheal Intubation in Children: Practice Recommendations, Insights, and Future Directions Endotracheal Intubation in Children: Practice Recommendations, Insights, and Future Directions**

DOI: 10.5772/intechopen.70356

Maribel Ibarra-Sarlat, Eduardo Terrones-Vargas, Lizett Romero-Espinoza, Graciela Castañeda-Muciño, Alejandro Herrera-Landero and Juan Carlos Núñez-Enríquez Maribel Ibarra-Sarlat, Eduardo Terrones-Vargas, Lizett Romero-Espinoza, Graciela Castañeda-Muciño, Alejandro Herrera-Landero and Juan Carlos Núñez-Enríquez Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70356

#### **Abstract**

[134] Lewis SR, Butler AR, Parker J, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. In: Lewis SR, editor. Cochrane Database of Systematic Reviews [Internet]. Chichester, UK: John Wiley & Sons, Ltd; 2016 [cited 2017 Aug 8]. p. CD011136. Available from: http://www.ncbi.nlm.

[135] Cook TM, Astin JP, Kelly FE. Airway Management in ICU: Three Years on from NAP4.

[136] Wetsch WA, Carlitscheck M, Spelten O, Teschendorf P, Hellmich M, Genzwurker H V, et al. Success rates and endotracheal tube insertion times of experienced emergency physicians using five video laryngoscopes: A randomised trial in a simulated trapped car accident victim. European Journal of Anaesthesiology [Internet]. 2011;**28**(12):849-

[137] Martínez-Hurtado E, Lucena de Pablo E, Sanchez Merchante M, De Luis Cabezón N. Videolaryngoscopy data record. A reality that is possible. In: Conference: World Airway Management Meeting Website—WAMM2015, At Dublin [Internet]. 2015. Available from: https://www.researchgate.net/publication/283720966\_Videolaryngoscopy\_

858. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21986981

nih.gov/pubmed/27844477

50 Bedside Procedures

ICU. 2014;**142**(2). Matrix (https://goo.gl/a8wKhi)

Data\_Record\_A\_Reality\_That\_Is\_Possible

Management of airway is mandatory in a critically ill child with severe trauma or any other situation that threatens his or her life. It is important, that clinicians who attend critically ill pediatric patients requiring airway management know the rapid sequence intubation (RSI) procedure, identify a patient with difficult airway, know the devices and techniques for the management of difficult airway, and look for receiving a formal training in endotracheal intubation (ETI). Future strategies for teaching and/or training clinicians in pediatric and neonatal ETI should be evaluated through conducting controlled clinical trials to identify which type will be the most effective by considering the less number of attempts and complications.

**Keywords:** endotracheal intubation, children, review, training, procedure

#### **1. Introduction**

Management and securing permeability of airway are mandatory in a critically ill child with severe trauma or any other situation that threatens his or her life. Airway's management can be defined as the performance of maneuvers and the use of devices that enable a correct and safe ventilation to patients that need this care.

and reproduction in any medium, provided the original work is properly cited.

Endotracheal intubation (ETI) is one of the procedures that every physician attending critically ill pediatric patients must not only know but also getting the skills and experience necessaries to effectively perform.

**2. Practice recommendations for pediatric endotracheal intubation**

more of the following features related with a difficult airway [2]:

mobility, and/or an evidence of partial upper airway obstruction.

drome and/or Treacher Collins Syndrome.

benefits of performing the procedure [3].

**2.** All the materials to be used should be functional. **3.** Team should consist of three persons (at least).

must have pressures around 80–120 mm Hg.

(providing a tidal volume of 1000 ml) [3–5].

when available) must be monitored during the procedure.

By using rapid sequence intubation (RSI) method, a clinician can effectively achieve pediatric endotracheal intubation (ETI), however, we previously must identify if the patient has one or

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53

• To have congenital abnormalities related with a difficult airway such as Pierre Robins Syn-

• A poor mouth opening, large tongue or tonsils, small chin, short mandible, decreased neck

Note: later in this chapter, you can find information about the causes, techniques, and a variety of devices a clinician may use for the management of children with difficult airway.

**1.** If it is not performed in an emergency setting (elective intubation), an informed consent must be obtained from the child's parents explaining the technique, complications, and

**4.** Patient's heart and respiratory rate, blood pressure, oxygen saturation, (capnography

**5.** Oxygen supply must be at least 10 l/min and suction equipment must be available and it

**1.** An appropriate mask and bag for ventilation. We must select the mask size that fits the nasal bridge and the chin of the patient without covering the eyes (**Figure 1**). Bag used for infants and young children is named pediatric bag (which provides a tidal volume of approximately 400–500 ml); for older children and adolescents, an adult bag should be used

**2.** Endotracheal tubes (ETs). Uncuffed ETs are mainly indicated for neonates, infants, and young children (<8 years). The correct size of these ETs can be calculated according to the equation (child's age/4) + 4. On the other hand, the formula (child's age/2) + 3.5 might be used for cuffed ETs. Other methods to calculate ETs size include comparing the child's fifth finger with the internal diameter of the ET or by using resuscitation tape such as the Broselow Luten tape, and it is recommendable to have one size larger and smaller of the selected tube.

**3.** Stylet. Adult sized for 5.5 tubes and beyond, pediatric ones for lower endotracheal tubes.

**2.1. Rapid sequence intubation**

• A previous difficult ETI.

*2.1.1. Preparation*

*Equipment*

In this chapter, we will summarize the most practical recommendations of ETI technique in children. In addition, we will discuss important anatomical particularities of the children's airway. We include a section of devices that could help permeate the airway of pediatric patients with a difficult airway; and recent results of studies conducted regarding the association between the level of previous training in pediatric ETI and success rates.

#### **1.1. Indications of ETI in children**

	- **a.** Hypoxia. One of the most common indications of ETI. Clinically, the patient presents with respiratory distress, tachypnea, increased work of breathing, and an increase in alveolar-arterial gradient. Some causes of hypoxia are airway obstruction, hypoventilation, ventilation/perfusion mismatch, hemoglobinopathies, abnormal pulmonary diffusion, and intracardiac right to left shunt.
	- **b.** Hypercarbia. The pathophysiologic phenomenon consists of alteration in ventilation. There exists a reduced lung compliance and a V/Q mismatch increasing physiologic dead space. Alteration in ventilation can also be secondary to muscle weakness, altered mental status, exposure to toxins, or iatrogenic oversedation.

## **2. Practice recommendations for pediatric endotracheal intubation**

#### **2.1. Rapid sequence intubation**

Endotracheal intubation (ETI) is one of the procedures that every physician attending critically ill pediatric patients must not only know but also getting the skills and experience neces-

In this chapter, we will summarize the most practical recommendations of ETI technique in children. In addition, we will discuss important anatomical particularities of the children's airway. We include a section of devices that could help permeate the airway of pediatric patients with a difficult airway; and recent results of studies conducted regarding the asso-

**1.** Patient with an unstable airway. In this category, integrity of airway is affected by different infectious, anatomical and neurological diseases. Some examples are: (a) upper airway infectious (CROUP, bacterial tracheitis, etc.), (b) traumatisms, (c) congenital syndromes accompanied with macroglossia or micrognathia, (d) cystic hygroma, (e) branchial cleft cyst, (f) thyroglossal duct cyst, and (g) those patients with a large anterior mediastinal mass (non-Hodgkin lymphoma, acute leukemia, etc.). During childhood, the most com-

**2.** Patient with neurological dysfunction secondary to trauma, seizures, metabolic disease, or toxic ingestion. Classically, we can find patients with a Glasgow Coma Scale (GCS) score

**a.** Hypoxia. One of the most common indications of ETI. Clinically, the patient presents with respiratory distress, tachypnea, increased work of breathing, and an increase in alveolar-arterial gradient. Some causes of hypoxia are airway obstruction, hypoventilation, ventilation/perfusion mismatch, hemoglobinopathies, abnormal

**b.** Hypercarbia. The pathophysiologic phenomenon consists of alteration in ventilation. There exists a reduced lung compliance and a V/Q mismatch increasing physiologic dead space. Alteration in ventilation can also be secondary to muscle weak-

ness, altered mental status, exposure to toxins, or iatrogenic oversedation.

**4.** Patient with lower airway obstruction. Hypercarbia, tachypnea, increased work of breathing, wheezing, and a prolonged expiratory phase are characteristic. As lower obstruction progresses, dynamic hyperinflation and air trapping worsen, leading to a silent chest (inaudible breath sounds). This obstruction is common in asthma and bronchiolitis. We must remember that children can get intubated by this indication but it has been described an increase in mean airway pressure that may impede venous return. Therefore, under this indication children should only be intubated in EXTREME CIRCUMSTANCES [1].

**5.** Patient with a reduction of mechanical load, as seen in shock state and some patients with

of 8 or less, or a deterioration in the GCS score from 14 to 10.

pulmonary diffusion, and intracardiac right to left shunt.

ciation between the level of previous training in pediatric ETI and success rates.

saries to effectively perform.

52 Bedside Procedures

**1.1. Indications of ETI in children**

mon cause is infections [1].

**3.** Patient with impaired gas exchange:

cardiovascular dysfunction.

By using rapid sequence intubation (RSI) method, a clinician can effectively achieve pediatric endotracheal intubation (ETI), however, we previously must identify if the patient has one or more of the following features related with a difficult airway [2]:


Note: later in this chapter, you can find information about the causes, techniques, and a variety of devices a clinician may use for the management of children with difficult airway.

#### *2.1.1. Preparation*


#### *Equipment*


**4.** Laryngoscope handle and blade. The first one can be an adult or pediatric one, and the second can be straight or curved depending on the experience of the laryngoscopist. The blades used in pediatrics ranged from 00 (extremely premature neonates) to 4. Blades 0–1 are used for preterm and full-term neonates, size 1 for infants. At age 2, size 2 blade; at this age, a curved blade can be used. For ages 10 and above, a number 3 blade is recommended.

*2.1.2. Preoxygenation phase*

phase:

bag (**Figure 4**).

3–5 min.

of the chest is observed (**Figure 3**).

With all the necessary tools already prepared, next, we must position the patient for the denominated preoxygenation phase. This position consists in a sniffing situation avoiding hyperextension and/or hyperflexion of the neck. The correct sniffing position is the one with

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Selection of ventilation technique relies on the number of persons available at preoxygenation

**Figure 2.** (A) Correct sniffing position is shown the external auditory canal is anterior to the shoulders of the patient. (B) Incorrect position because neck is hyperextended. (C) Incorrect position because patient's neck has hyperflexion.

• One-person ventilation technique. The head must be positioned backwards, using the C-E technique and the chin must be elevated pressing and sealing the mask to the face. Sealing is very important. We may corroborate that ventilation technique is correct when elevation

• Two-person ventilation technique. One member of the health care professional team will use the C-E technique but now with two hands while the other person will be pressing the

After patient is positioned, then, ventilation must start with 100% inspired oxygen creating an oxygen reservoir. It is important to avoid hyperventilation. Therefore, a slow ventilation lasting around a second each must be applied being overall preoxygenation phase duration

exterior auditory canal anterior to the shoulders (**Figure 2**).


**Figure 1.** (A) The correct size for the child because it covers the area between nasal bridge and chin. (B) The mask elected is not correct, it covers part of the eyes of the patient. (C) The mask elected is not correct it covers the area far from the chin.

#### **Tips and tricks**

**To remember all the preparatory equipment before starting intubation**

You can use the **STOP MAID** mnemonic to remember all the preparatory equipment before starting ETI procedure:

**S**uction;

**T**ools for intubation;

**O**xygen;

**P**ositioning (sniffing position so that the external auditory canal is anterior to shoulder);

**M**onitors;

**A**ssistant, Ambu bag with facemask, airway devices;

**I**ntravenous access;

**D**rugs (sedation, neuromuscular blocking medications).

#### *2.1.2. Preoxygenation phase*

**4.** Laryngoscope handle and blade. The first one can be an adult or pediatric one, and the second can be straight or curved depending on the experience of the laryngoscopist. The blades used in pediatrics ranged from 00 (extremely premature neonates) to 4. Blades 0–1 are used for preterm and full-term neonates, size 1 for infants. At age 2, size 2 blade; at this age, a curved blade can be used. For ages 10 and above, a number 3 blade is recommended.

**Figure 1.** (A) The correct size for the child because it covers the area between nasal bridge and chin. (B) The mask elected is not correct, it covers part of the eyes of the patient. (C) The mask elected is not correct it covers the area far from the chin.

You can use the **STOP MAID** mnemonic to remember all the preparatory equipment before starting ETI procedure:

**5.** Colorimetric end tidal carbon dioxide devices or capnography monitors.

**6.** Tape or a commercial holder to secure the endotracheal tube.

**To remember all the preparatory equipment before starting intubation**

**A**ssistant, Ambu bag with facemask, airway devices;

**D**rugs (sedation, neuromuscular blocking medications).

**P**ositioning (sniffing position so that the external auditory canal is anterior to shoulder);

**7.** Syringe for cuff inflation.

54 Bedside Procedures

**Tips and tricks**

**T**ools for intubation;

**I**ntravenous access;

**S**uction;

**O**xygen;

**M**onitors;

**8.** Nasogastric and orogastric tubes.

With all the necessary tools already prepared, next, we must position the patient for the denominated preoxygenation phase. This position consists in a sniffing situation avoiding hyperextension and/or hyperflexion of the neck. The correct sniffing position is the one with exterior auditory canal anterior to the shoulders (**Figure 2**).

**Figure 2.** (A) Correct sniffing position is shown the external auditory canal is anterior to the shoulders of the patient. (B) Incorrect position because neck is hyperextended. (C) Incorrect position because patient's neck has hyperflexion.

Selection of ventilation technique relies on the number of persons available at preoxygenation phase:


After patient is positioned, then, ventilation must start with 100% inspired oxygen creating an oxygen reservoir. It is important to avoid hyperventilation. Therefore, a slow ventilation lasting around a second each must be applied being overall preoxygenation phase duration 3–5 min.

*2.1.4. Procedure*

through a scissor maneuver (not shown).

Clinician may most easily perform direct laryngoscopy by standing behind to the patient's head and with height of the bed adjusted to the level of the laryngoscopist xiphoid appendix (**Figure 5**). After sedation and neuromuscular blocking, the clinician must perform a scissor maneuver to open mouth before laryngoscopy. Then, laryngoscope must be held in the left hand (regardless of dominance), inserting the blade in the right side of the patient's mouth along the base of the tongue following the contour of the pharynx, and sweeping the tongue to the left.

**Medications Indications Doses (IV)** Sedation Etomidate Hemodynamic instability, neuroprotective 0.3 mg/kg Ketamine Hemodynamic instability, patients with

NM blockers Rocuronium For children in which succinylcholine is

contraindicated

myopathy

Succinylcholine Do not use in extensive crush injury, chronic

**Table 1.** Drugs, indications, doses for achieving sedation and neuromuscular (NM) blockade during pediatric ETI.

bronchospasm and septic shock

Midazolam It can cause hemodynamic instability 0.2–0.3 mg/kg Propofol In hemodynamically stable patients 1–1.5 mg/kg Thiopental Neuroprotection 3–5 mg/kg

Endotracheal Intubation in Children: Practice Recommendations, Insights, and Future Directions

1–2 mg/kg

57

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0.6–1.2 mg/kg

2 mg/kg

Once the tongue and soft tissues are retracted, clinician must recognize the following anatomic structures: epiglottis, arytenoid cartilage, and esophagus (**Figure 6**). After identifying epiglottis, this must be elevated exposing the vocal cords by handling laryngoscope at a 45° angle. Next step, endotracheal tube (ET) must be inserted into the trachea by holding it (with right hand) like a pencil (**Figure 7**).

ET insertion in airway must be confirmed by the observation chest wall rise and down with ventilations, auscultation of breath sounds in both axillae and not heard over stomach, and, to observe an adequate oxygen saturation (>90%). Radiographically, a correct position of the

**Figure 5.** Proper position of laryngoscopist and correct introduction of laryngoscope after opening patient's mouth

**Figure 3.** One-person C-E ventilation technique is illustrated.

**Figure 4.** Two-person C-E ventilation technique. First person is doing a double hand C-E maneuver while a second person (not shown in the image) is pressing the bag.

#### *2.1.3. Sedation and neuromuscular blockade*

Premedication increases success rate of pediatric ETI independently from degree of previous training [6]. By using the rapid sequence intubation in children, success rate of 52% and a complication rate of 61% can be achieved [7], however, sedation can be omitted in obtunded or comatose patients and neuromuscular blockade must be avoided in patients with difficult airway. **Table 1** summarizes the drugs, indications, and doses used for sedation and neuromuscular blockade during pediatric ETI procedure.

Endotracheal Intubation in Children: Practice Recommendations, Insights, and Future Directions http://dx.doi.org/10.5772/intechopen.70356 57


**Table 1.** Drugs, indications, doses for achieving sedation and neuromuscular (NM) blockade during pediatric ETI.

#### *2.1.4. Procedure*

*2.1.3. Sedation and neuromuscular blockade*

person (not shown in the image) is pressing the bag.

**Figure 3.** One-person C-E ventilation technique is illustrated.

56 Bedside Procedures

muscular blockade during pediatric ETI procedure.

Premedication increases success rate of pediatric ETI independently from degree of previous training [6]. By using the rapid sequence intubation in children, success rate of 52% and a complication rate of 61% can be achieved [7], however, sedation can be omitted in obtunded or comatose patients and neuromuscular blockade must be avoided in patients with difficult airway. **Table 1** summarizes the drugs, indications, and doses used for sedation and neuro-

**Figure 4.** Two-person C-E ventilation technique. First person is doing a double hand C-E maneuver while a second

Clinician may most easily perform direct laryngoscopy by standing behind to the patient's head and with height of the bed adjusted to the level of the laryngoscopist xiphoid appendix (**Figure 5**). After sedation and neuromuscular blocking, the clinician must perform a scissor maneuver to open mouth before laryngoscopy. Then, laryngoscope must be held in the left hand (regardless of dominance), inserting the blade in the right side of the patient's mouth along the base of the tongue following the contour of the pharynx, and sweeping the tongue to the left.

Once the tongue and soft tissues are retracted, clinician must recognize the following anatomic structures: epiglottis, arytenoid cartilage, and esophagus (**Figure 6**). After identifying epiglottis, this must be elevated exposing the vocal cords by handling laryngoscope at a 45° angle. Next step, endotracheal tube (ET) must be inserted into the trachea by holding it (with right hand) like a pencil (**Figure 7**).

ET insertion in airway must be confirmed by the observation chest wall rise and down with ventilations, auscultation of breath sounds in both axillae and not heard over stomach, and, to observe an adequate oxygen saturation (>90%). Radiographically, a correct position of the

**Figure 5.** Proper position of laryngoscopist and correct introduction of laryngoscope after opening patient's mouth through a scissor maneuver (not shown).

**Figure 6.** A comparison between a real larynx and a model. Structures of the larynx must be identified before trying to insert ET. (A) Glottis, (B) Vocal cords. (C) Epiglottis.

**Figure 8.** Sellick's Maneuver (also known as cricoid pressure).

**Figure 9.** X-ray on the left shows a misplaced endotracheal tube which is in the right bronchus. Right X-ray shows a

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correct placement of the endotracheal tube, where the tip is located above the carina.

**Figure 10.** ET located in esophagus.

**Figure 7.** ET is introduced like a pencil into the airway.

#### **Tips and tricks**

#### **To identify epiglottis and/or glottic structures**

If epiglottis and/or glottic structures are not visible, blade must be pulled back slowly until they are visible. Other useful technique for helping to identify epiglottis and/or glottic structures is the named "Sellick maneuver" or so known as "cricoid pressure" (**Figure 8**). To perform it, another member of the reanimation team slightly push the region of cricoid cartilage while laryngoscopist observes the structures and introduce ET.

#### **To calculate ETT length insertion**

ET length insertion can be determined by any of the following two formulas [5, 8, 9]:

#1- (Patient's age (in years)/2) + 12

#2- ET internal diameter \* 3

Note: we recommend first equation because it has been reported as more accurate.

tube is below the thoracic inlet and 3 cm above the carina (**Figure 9**). In case of ETT is located at esophagus or right bronchus, immediate measures must be taken to remove it and secure an adequate ventilation of patient (**Figures 9** and **10**).

Endotracheal Intubation in Children: Practice Recommendations, Insights, and Future Directions http://dx.doi.org/10.5772/intechopen.70356 59

**Figure 8.** Sellick's Maneuver (also known as cricoid pressure).

**Figure 9.** X-ray on the left shows a misplaced endotracheal tube which is in the right bronchus. Right X-ray shows a correct placement of the endotracheal tube, where the tip is located above the carina.

**Figure 10.** ET located in esophagus.

tube is below the thoracic inlet and 3 cm above the carina (**Figure 9**). In case of ETT is located at esophagus or right bronchus, immediate measures must be taken to remove it and secure

If epiglottis and/or glottic structures are not visible, blade must be pulled back slowly until they are visible. Other useful technique for helping to identify epiglottis and/or glottic structures is the named "Sellick maneuver" or so known as "cricoid pressure" (**Figure 8**). To perform it, another member of the reanimation team slightly push the region of cricoid

**Figure 6.** A comparison between a real larynx and a model. Structures of the larynx must be identified before trying to

an adequate ventilation of patient (**Figures 9** and **10**).

cartilage while laryngoscopist observes the structures and introduce ET.

ET length insertion can be determined by any of the following two formulas [5, 8, 9]:

Note: we recommend first equation because it has been reported as more accurate.

**Tips and tricks**

58 Bedside Procedures

**To identify epiglottis and/or glottic structures**

**Figure 7.** ET is introduced like a pencil into the airway.

insert ET. (A) Glottis, (B) Vocal cords. (C) Epiglottis.

**To calculate ETT length insertion**

#1- (Patient's age (in years)/2) + 12 #2- ET internal diameter \* 3

#### Tips and tricks [5, 10]

#### **In case of acute respiratory deterioration after intubation**

**Remember the mnemonic DONE** which can help you to identify the probable causes:

**Deviation** of ETT to the main bronchus or misplacement during suction. Signs that can suggest this are asymmetric elevation of the thorax or asymmetric auscultation, specially the right hemithorax.

On the other hand, each attempt of intubation in neonates provokes injury of the mucosa which subsequently leads to an inflammation decreasing the caliber of the field of observation, and therefore, making the intubation less effective. Currently, it has been recommended a limit of 20 s for each intubation attempt in neonates, and if it fails, the ET must be removed

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Two methods may be used, and the objective is to place the tip of ET in the middle portion of

We must add 1 cm to the distance (cm) between the newborn's nasal septum and ear tragus

**c.** "7-8-9 rule" method: in 1979, Tochen described a simple equation for the ET insertion

and patient must be ventilated with a mask-bag reservoir until recovery [11, 15, 16].

In neonates, premedication phase must be only used as part of an elective ETI and not for emergency situations.

**Weight (g) Gestational age (weeks) ET size (internal diameter in mm)**

The American Academy of Pediatrics (AAP) and the Canadian Pediatric Society (CPS) recommend a combination of vagolytic agents and neuromuscular blockers for premedication phase in neonates. Also, the AAP recommends that

**3.3. Estimating length insertion of ET in neonates**

Election of ET size based on neonate's weight and gestational age:

<1000 <28 2.5 1000–2000 28–34 3.0 >2000 >34 3.4

**Premedication phase in neonates is different from older children**

muscular blockers and sedatives must not be used alone without analgesia [3].

trachea.

**Tips and tricks**

**Tips and tricks**

**ET size election for neonates**

**a.** DNT method

(**Figure 11**) [17].

**b.** Gestational age method (**Table 2**)

length based on patient's weight at birth. Formula: 1.17 \* weight at birth (kg) + 5.58.

**Obstruction** due to secretions obstructing tube's lumen.

**Pneumothorax** if are present signs as breath sounds diminished on the affected side, conduction of vocal vibrations to the surface of the chest may be increased, and hyperresonant at percussion.

**Equipment**, if problem is in the ventilator hardware or software.

#### **3. Neonatal intubation**

#### **3.1. Indications**

ETI in neonates can be most commonly performed as an emergency procedure or as part of an elective or semi-elective treatment:


#### **3.2. Important anatomical considerations in neonates**

In comparison to older children, adolescents and adults, anatomy of neonatal upper airway structures is different, being neonates a subpopulation where the ETI becomes a challenge. Some of these differences are the following: (a) a tongue proportionately larger, in consequence, trying to sweep it during ETI might be difficult and its backward movement might result in an airway obstruction; (b) epiglottis is longer, narrower, less flexible, and sometimes omega-shaped; (c) a cranial position of larynx can be an obstacle for observing the glottis during laryngoscopy, being this issue the reason why is preferable to use straight blades rather than curved ones in neonates; and (d) trachea is proportionally shorter and narrower [12, 13].

It is important to highlight, that neonates <1000 g, >4000 g, or those with congenital craniofacial abnormalities have less chance to be intubated at first attempt, representing a subgroup of neonates with a difficult airway which require special attention [14].

On the other hand, each attempt of intubation in neonates provokes injury of the mucosa which subsequently leads to an inflammation decreasing the caliber of the field of observation, and therefore, making the intubation less effective. Currently, it has been recommended a limit of 20 s for each intubation attempt in neonates, and if it fails, the ET must be removed and patient must be ventilated with a mask-bag reservoir until recovery [11, 15, 16].

#### **Tips and tricks**

#### **Premedication phase in neonates is different from older children**

In neonates, premedication phase must be only used as part of an elective ETI and not for emergency situations.

The American Academy of Pediatrics (AAP) and the Canadian Pediatric Society (CPS) recommend a combination of vagolytic agents and neuromuscular blockers for premedication phase in neonates. Also, the AAP recommends that muscular blockers and sedatives must not be used alone without analgesia [3].

#### **Tips and tricks**

**3. Neonatal intubation**

an elective or semi-elective treatment:

**In case of acute respiratory deterioration after intubation**

**Obstruction** due to secretions obstructing tube's lumen.

of the thorax or asymmetric auscultation, specially the right hemithorax.

surface of the chest may be increased, and hyperresonant at percussion. **Equipment**, if problem is in the ventilator hardware or software.

**Remember the mnemonic DONE** which can help you to identify the probable causes:

for direct tracheal aspirations if thick secretions exist [11].

**3.2. Important anatomical considerations in neonates**

ETI in neonates can be most commonly performed as an emergency procedure or as part of

**Deviation** of ETT to the main bronchus or misplacement during suction. Signs that can suggest this are asymmetric elevation

**Pneumothorax** if are present signs as breath sounds diminished on the affected side, conduction of vocal vibrations to the

**1.** Emergency. When mask ventilation or non-invasive mechanical ventilation fails, in case of structural or congenital airway abnormalities, diaphragmatic hernia, prolonged cardiopulmonary resuscitation, if thoracic compressions are needed, surfactant administration and

**2.** Elective/semi elective. Prematurity, positive pressure ventilation lasting more than 1-min,

In comparison to older children, adolescents and adults, anatomy of neonatal upper airway structures is different, being neonates a subpopulation where the ETI becomes a challenge. Some of these differences are the following: (a) a tongue proportionately larger, in consequence, trying to sweep it during ETI might be difficult and its backward movement might result in an airway obstruction; (b) epiglottis is longer, narrower, less flexible, and sometimes omega-shaped; (c) a cranial position of larynx can be an obstacle for observing the glottis during laryngoscopy, being this issue the reason why is preferable to use straight blades rather than curved ones in neonates; and (d) trachea is proportionally shorter and

It is important to highlight, that neonates <1000 g, >4000 g, or those with congenital craniofacial abnormalities have less chance to be intubated at first attempt, representing a subgroup

of neonates with a difficult airway which require special attention [14].

in case of ET must be changed, and in patients with an unstable airway [11].

**3.1. Indications**

Tips and tricks [5, 10]

60 Bedside Procedures

narrower [12, 13].

#### **ET size election for neonates**

Election of ET size based on neonate's weight and gestational age:


#### **3.3. Estimating length insertion of ET in neonates**

Two methods may be used, and the objective is to place the tip of ET in the middle portion of trachea.

**a.** DNT method

We must add 1 cm to the distance (cm) between the newborn's nasal septum and ear tragus (**Figure 11**) [17].


Formula: 1.17 \* weight at birth (kg) + 5.58.

This equation has been supported by the AAP and the American Heart Association (AHA), establishing ET insertion length can be calculated by adding 6 cm to the newborn weight (e.g., for a newborn weighing 1 kg = 1 + 6 = 7 cm), from the patient's lip [14].

could make difficult to achieve ETI. Among the anatomical factors related with DA are the form and size of mouth, nose, mandible, neck, existence of masses or congenital malformations, and other childhood diseases that eventually could difficult ETI (**Figure 12**, **Tables 3** and **4**) [20–24].

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**4.1. Devices and techniques for the management of the child with DA**

**Figure 12.** Difficult airway for ETI based on modified Mallampati classification [25, 26].

• Cranium's bone displacement. Apert syndrome, Crouzon syndrome, hydrocephalus

• Small oral cavity: Pierre Robin syndrome, Treacher-Collins syndrome

• Airway or neck masses: cystic hygroma, teratomas, hemangiomas

• Abnormal neck mobility. Klippel-Fleil syndrome, Down syndrome, mucopolisacaridosis

and/or on their optical properties [27]:

**Table 3.** Pediatric syndromes associated with DA.

**4.2. Supraglottic airway devices**

• Laryngeal or subglottic anomalies

*4.2.1. Classic laryngeal mask*

DA devices can be classified according to the anatomical structure from where they will act

• Mandible hypoplasia. Pierre Robin syndrome, Treacher Collins syndrome, Goldenhar syndrome, Apert syndrome

• Limited oral aperture: Sheldon Freedman syndrome, Hallerman-Strieff syndrome, bullous epidermolysis

• Macroglossia: hypothyroidism, Beckwith Wiedemann syndrome, Down syndrome, mucopolisacaridosis

It was developed in 1980 by Dr Archie Brain and forms part of the rescue devices in the ASA algorithm for the difficult airway management. It was designed to be situated in the

#### **Tips and tricks**

#### **ET length insertion when nasotracheal intubation is used**

When nasotracheal intubation is performed, the ET length must increase in 20% (e.g., for a newborn weighing 2 kg: (2 kg + 6) × 1.2 = 9.6 cm). We must also take in consideration that the 7-8-9 rule can overestimate the insertion length in newborns with a birth weight less than 1000 g. In consequence, it is preferred to use the gestational age method (**Table 2**) [18].

**Figure 11.** DNT method.


**Table 2.** Gestational age method to calculate ET length insertion [18].

#### **4. Management of the child with difficult airway (DA)**

Difficult airway can be defined as the clinical situation in which a conventionally trained physician has trouble for achieving an effective upper airway ventilation with a face mask, for tracheal intubation or both and where interact patient's factors, setting conditions and operator skills [19]. First, we must evaluate child's airway to identify those clinical, and/or laboratory factors that could make difficult to achieve ETI. Among the anatomical factors related with DA are the form and size of mouth, nose, mandible, neck, existence of masses or congenital malformations, and other childhood diseases that eventually could difficult ETI (**Figure 12**, **Tables 3** and **4**) [20–24].

**Figure 12.** Difficult airway for ETI based on modified Mallampati classification [25, 26].


This equation has been supported by the AAP and the American Heart Association (AHA), establishing ET insertion length can be calculated by adding 6 cm to the newborn weight

When nasotracheal intubation is performed, the ET length must increase in 20% (e.g., for a newborn weighing 2 kg: (2 kg + 6) × 1.2 = 9.6 cm). We must also take in consideration that the 7-8-9 rule can overestimate the insertion length in newborns with a birth weight less than 1000 g. In consequence, it is preferred to use the gestational age method

(e.g., for a newborn weighing 1 kg = 1 + 6 = 7 cm), from the patient's lip [14].

**Tips and tricks**

62 Bedside Procedures

(**Table 2**) [18].

**Figure 11.** DNT method.

**ET length insertion when nasotracheal intubation is used**

**4. Management of the child with difficult airway (DA)**

**Table 2.** Gestational age method to calculate ET length insertion [18].

Difficult airway can be defined as the clinical situation in which a conventionally trained physician has trouble for achieving an effective upper airway ventilation with a face mask, for tracheal intubation or both and where interact patient's factors, setting conditions and operator skills [19]. First, we must evaluate child's airway to identify those clinical, and/or laboratory factors that

**Gestational age (weeks) ET length insertion (cm) from the patient's lips Weight (g)** 23–24 5.5 500–600 25–26 6.0 700–800 27–29 6.5 900–1000 30–32 7.0 1100–1400 33–34 7.5 1500–1800 35–37 8.0 1900–2400 38–40 8.5 2500–3100 41–43 9.0 3200–4200

**Table 3.** Pediatric syndromes associated with DA.

#### **4.1. Devices and techniques for the management of the child with DA**

DA devices can be classified according to the anatomical structure from where they will act and/or on their optical properties [27]:

#### **4.2. Supraglottic airway devices**

#### *4.2.1. Classic laryngeal mask*

It was developed in 1980 by Dr Archie Brain and forms part of the rescue devices in the ASA algorithm for the difficult airway management. It was designed to be situated in the


**Table 4.** Childhood diseases associated with DA.

hypopharynx, with an anterior aperture situated at the glottis entrance, the mask's border is made of a silicone inflatable cuff, sealing the hypopharynx permitting positive pressure ventilation (less than 20 cm H<sup>2</sup> O). The mask is introduced using the index finger of the dominant hand as a guide towards the hypopharynx, following the palate's curvature, until a resistance is felt, then the cuff must be inflated with a determined volume (the specific volume comes in a legend on the mask itself and depends of the number of the mask). Choosing the size mask depends on the weight of the patient. As complications of the procedure we can find aspiration of gastric contents, uvula, and pharyngeal pillars lesions (**Figure 13**).

**Figure 14.** ProSeal laryngeal mask airway.

**Figure 15.** FASTRACH or intubation laryngeal mask (ILMA).

place (**Figure 15**).

*4.2.2. ProSeal laryngeal mask airway*

*4.2.3. Fastrach or intubation laryngeal mask (ILMA)*

In 2000 Brain published the description of a new laryngeal mask that tried to improve the airway's protection against gastric aspiration. This was accomplished by including a second tube lateral to the airway's tube and which in its distal end is located on the tip of the mask. This tube has the function of separating the digestive tract from the respiratory, and also

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This type of laryngeal mask is designed with the objective of achieving intubation through the mask itself, it consists of an anatomically curved rigid tube, wide enough to accept in it endotracheal tubes this end is united to rigid metal loop that makes the insertion much easier, removal, and adjustment of the position with one hand only. Once installed, and ventilation achieved an ET is inserted, the mask is then removed maintaining the tube in place, with a specially designed stylet, so that after the mask is removed the ET remains in

Permits accessing the stomach with an orogastric probe (**Figure 14**) [28].

**Figure 13.** Laryngeal mask.

#### *4.2.2. ProSeal laryngeal mask airway*

In 2000 Brain published the description of a new laryngeal mask that tried to improve the airway's protection against gastric aspiration. This was accomplished by including a second tube lateral to the airway's tube and which in its distal end is located on the tip of the mask. This tube has the function of separating the digestive tract from the respiratory, and also Permits accessing the stomach with an orogastric probe (**Figure 14**) [28].

#### *4.2.3. Fastrach or intubation laryngeal mask (ILMA)*

This type of laryngeal mask is designed with the objective of achieving intubation through the mask itself, it consists of an anatomically curved rigid tube, wide enough to accept in it endotracheal tubes this end is united to rigid metal loop that makes the insertion much easier, removal, and adjustment of the position with one hand only. Once installed, and ventilation achieved an ET is inserted, the mask is then removed maintaining the tube in place, with a specially designed stylet, so that after the mask is removed the ET remains in place (**Figure 15**).

**Figure 14.** ProSeal laryngeal mask airway.

hypopharynx, with an anterior aperture situated at the glottis entrance, the mask's border is made of a silicone inflatable cuff, sealing the hypopharynx permitting positive pressure

**Infectious Traumatic Neoplastic Inflammatory Neurologic Other**

• Upper airway tumors (pharynx, larynx) • Inferior airway tumors (trachea, bronchi, mediastinal) • Post-radiation area

• Angioedema • Anaphylactic shock (laryngeal edema) • Anquilosis • Juvenile Rheumatoid arthritis

• Spastic cerebral paralysis • Tetanus

• Lung hemorrhage • Obesity • Cranium-facial malformations • Micrognathia • Superior incisive protrusion • Short and wide neck • Big tongue • Previous intubation difficulty • Oral aperture limitation • Clift lip and palate • Mallampati classes 3 or 4 (**Figure 12**)

dominant hand as a guide towards the hypopharynx, following the palate's curvature, until a resistance is felt, then the cuff must be inflated with a determined volume (the specific volume comes in a legend on the mask itself and depends of the number of the mask). Choosing the size mask depends on the weight of the patient. As complications of the procedure we can find aspiration of gastric contents, uvula, and pharyngeal pillars lesions

O). The mask is introduced using the index finger of the

ventilation (less than 20 cm H<sup>2</sup>

**Table 4.** Childhood diseases associated with DA.

(**Figure 13**).

• Epiglottitis • Abscess (submandibular, retropharyngeal, Ludwig's angina) • Croup • Papillomatosis

64 Bedside Procedures

• Foreign body • Cervical column lesion • Skull base fracture • Maxillary or mandible lesion • Laryngeal fracture • Postintubation laryngeal edema • Facial trauma • Burns

**Figure 13.** Laryngeal mask.

**Figure 15.** FASTRACH or intubation laryngeal mask (ILMA).

**4.3. Transglottic airway devices**

*4.3.2. Lightwand device (Trachlight)*

**Figure 18.** Gum Elastic Bougie (GEB).

**4.4. Optical devices**

*4.4.1. Video laryngoscopes*

**Figure 19.** Lightwand device (Trachlight).

in an approximate time of 25 s (**Figure 19**) [32].

*Eschman Guide* or *Gum Elastic Bougie* (*GEB*) is a semi-flexible guide of polyester covered in resin (to avoid laryngeal trauma). GEB has a 15-Fr diameter and can be introduced in 6 mm internal diameter tubes. Insertion technique consists of sliding the angulated tip underneath the epiglottis, then, dragging at the tracheal cartilages must be perceived (**Figure 18**) [31].

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In some countries, a lighted stylet is used for ETI, this is the called *Trachlight*. It is based on transillumination of the soft tissue of the neck with a high effectivity for achieving intubation

They are laryngoscopes that carry in its distal blade's end a high-resolution video camera to visualize the glottis and to introduce an ET without the need of observing the glottis directly

*4.3.1. Gum Elastic Bougie*

**Figure 16.** New type of Fastrach laryngeal mask.

Other type of *Fastrach laryngeal mask* (*2005*) *with an incorporated camera*, permits once it has been introduced into the hypopharynx, setting a monitor on the outer part of the mask so that it can be possible introducing an ET under direct vision (**Figure 16**).

#### *4.2.4. Combitube*

This device can only be used to ventilate in emergency situations. It was designed in Austria in the year 1980. Insertion is easy for any person and insertion is blindfold. It consists of a double lumen latex tube that combines the functions of an esophageal obturator and a conventional ET. Combitube has two balloons which inflate from the exterior. First one corresponds to an oropharyngeal balloon (85–100 ml of capacity) situated in a proximal position to the pharyngeal perforations with a function of serves as a sealing of the oral and nasal cavity; second one, is called traqueo-esophagic balloon, and needs a volume of 12–15 ml to seal the trachea or esophagus. Combitube can be placed either in the esophagus or in trachea, and in case of tube passes to the esophagus, the patient can still be ventilated because the perforations existing in combitube esophageal lumen, and the stomach can be aspirated from the tracheal lumen. In case of combitube is set in the trachea, the patient can also be ventilated from the trachea lumen (**Figure 17**) [29, 30].

**Figure 17.** Combitube.

#### **4.3. Transglottic airway devices**

#### *4.3.1. Gum Elastic Bougie*

*Eschman Guide* or *Gum Elastic Bougie* (*GEB*) is a semi-flexible guide of polyester covered in resin (to avoid laryngeal trauma). GEB has a 15-Fr diameter and can be introduced in 6 mm internal diameter tubes. Insertion technique consists of sliding the angulated tip underneath the epiglottis, then, dragging at the tracheal cartilages must be perceived (**Figure 18**) [31].

**Figure 18.** Gum Elastic Bougie (GEB).

Other type of *Fastrach laryngeal mask* (*2005*) *with an incorporated camera*, permits once it has been introduced into the hypopharynx, setting a monitor on the outer part of the mask so that

This device can only be used to ventilate in emergency situations. It was designed in Austria in the year 1980. Insertion is easy for any person and insertion is blindfold. It consists of a double lumen latex tube that combines the functions of an esophageal obturator and a conventional ET. Combitube has two balloons which inflate from the exterior. First one corresponds to an oropharyngeal balloon (85–100 ml of capacity) situated in a proximal position to the pharyngeal perforations with a function of serves as a sealing of the oral and nasal cavity; second one, is called traqueo-esophagic balloon, and needs a volume of 12–15 ml to seal the trachea or esophagus. Combitube can be placed either in the esophagus or in trachea, and in case of tube passes to the esophagus, the patient can still be ventilated because the perforations existing in combitube esophageal lumen, and the stomach can be aspirated from the tracheal lumen. In case of combitube is set in the trachea, the patient can also be ventilated from the trachea lumen (**Figure 17**) [29, 30].

it can be possible introducing an ET under direct vision (**Figure 16**).

*4.2.4. Combitube*

66 Bedside Procedures

**Figure 17.** Combitube.

**Figure 16.** New type of Fastrach laryngeal mask.

#### *4.3.2. Lightwand device (Trachlight)*

In some countries, a lighted stylet is used for ETI, this is the called *Trachlight*. It is based on transillumination of the soft tissue of the neck with a high effectivity for achieving intubation in an approximate time of 25 s (**Figure 19**) [32].

**Figure 19.** Lightwand device (Trachlight).

#### **4.4. Optical devices**

#### *4.4.1. Video laryngoscopes*

They are laryngoscopes that carry in its distal blade's end a high-resolution video camera to visualize the glottis and to introduce an ET without the need of observing the glottis directly but through a high-resolution screen which can be located in the same device or at the patient's side. Among the main complications reported are the soft palate lesions (**Figure 20**).

It has also been evaluated the skills for neonatal ETI between residents. Interestingly, skills significantly improved with a success rate from 27% during the first year of formation to 79% for the second year. Number of attempts also improved decreasing from 3.6 to 1.2 from the first to the second year, respectively [38]. This and other study results highlight the relevance of implementing training strategies from early stages of education in medicine to effectively

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achieve ETI in children with the less number of attempts and complications [6, 40, 41].

attempt by comparing groups with and without training [45].

, Eduardo Terrones-Vargas<sup>2</sup>

Sánchez", Centro Médico Nacional La Raza, Mexico City, Mexico

\*Address all correspondence to: jcarlos\_nu@hotmail.com

, Alejandro Herrera-Landero<sup>4</sup>

1 UMAE Hospital de Pediatría Centro Médico Nacional Siglo XXI, Instituto Mexicano del

2 Unidad de Cuidados Intensivos Pediátricos, Hospital Infantil de México Federico Gómez,

3 UMAE Hospital Gineco-Obstetricia No.3 "Dr. Victor Manuel Espinosa De Los Reyes

4 Hospital de Traumatología y Ortopedia «Lomas Verdes», Instituto Mexicano del Seguro

*pediatric and neonatal intubation*

**6. Conclusions**

**Author details**

Maribel Ibarra-Sarlat1

Graciela Castañeda-Muciño<sup>1</sup>

Seguro Social, México City, Mexico

Social, State of Mexico, Mexico

Secretaria de Salud, México City, Mexico

*5.2.1. ETI training models, live models, and simulation training sessions for increasing success in* 

Recently, it has been mentioned that there are no differences in the learning curve or the skills for performing neonatal intubation by comparing live models versus ETI training models. Retention curves with a follow-up of 6, 18 and 52 weeks remain constant after 6 weeks and get lost after 18 and 52 weeks; although, retention is higher when skill levels are higher too [42, 43]. Additionally, it has been reported that educational interventions such as training sessions using didactic and simulation components have not been related with an improvement in intubation success rate; even, performance points decrease after 8 weeks of the intervention [44]. Importantly, other studies have not found differences in pediatric ETI success rate at first

It is important to highlight, that clinicians who attend critically ill pediatric patients requiring airway management know the rapid sequence intubation procedure, identify a patient with difficult airway, know the devices and techniques for the management of difficult airway, and look for receiving a formal training. Future strategies for teaching and/or training clinicians in pediatric and neonatal ETI should be evaluated through conducting controlled clinical trials to identify which type is the most effective by considering the less number of attempts and complications.

, Lizett Romero-Espinoza<sup>3</sup>

,

and Juan Carlos Núñez-Enríquez<sup>1</sup>

\*

**Figure 20.** Video laryngoscope.

#### **5. Insights and future directions**

#### **5.1. Direct laryngoscopy vs. video laryngoscopy**

Learning curve (LC) in the case of the direct laryngoscopy requires of approximately of 45–50 previous intubations [33], while LC for video laryngoscopy is around 5 attempts. ETI using a video laryngoscopy is possible with little training, due to transmitted image from the blade's distal tip makes easier the visualization of the larynx entrance. When intubation attempts using Miller or Macintosh laryngoscopes or video laryngoscopy fail other methods to secure pediatric airway are recommended to be used (i.e. supraglottic devices). Recent studies have reported that ETI with video laryngoscopy even performed by less experienced medical personnel, increases significantly the success rate in the first attempt in comparison with direct laryngoscopy [34]; moreover, it has been reported that video laryngoscopy decreases the intubation time with less desaturation and less failure rate when it is compared with conventional laryngoscopy [35, 36]. Nevertheless, other video laryngoscope methods (GlideScope) implying other type of learning (mainly based on exploration), have resulted to be inferior to direct laryngoscopy regarding the time required for ETI [37].

#### **5.2. Importance of formal training in pediatric ETI**

Until date there is no standard definition for the term proficiency in pediatric/neonatal airway ETI. In a recent study, defined a formal training in pediatric airway management as having received at least 2 weeks of training by pediatric anesthesiology teachers. In that study was reported that after formal training, intubation success rate increased from 65.1 to 75.7% (*p* = 0.01), and it was observed a significant decreasing in the number of intubation attempts (*p* = 0.01). However, they did not find statistically significant differences in the time for achieving Intubation nor for the frequency of complications [38].

In a study conducted by Kerrey et al., where rapid sequence intubation technique was used, pediatricians in emergency departments and anesthesiologist had higher success rates (88–91%) in comparison to physicians in formation (45%) [7]. These results were similar to the reported by Goto et al. where intubation success was higher at the first attempt in pediatricians (OR 2.36; CI 95% 1.11–4.97) and in emergency room physicians (OR 3.2; CI 95% 1.78–5.83) in comparison to pediatric residents of the first and second year [39].

It has also been evaluated the skills for neonatal ETI between residents. Interestingly, skills significantly improved with a success rate from 27% during the first year of formation to 79% for the second year. Number of attempts also improved decreasing from 3.6 to 1.2 from the first to the second year, respectively [38]. This and other study results highlight the relevance of implementing training strategies from early stages of education in medicine to effectively achieve ETI in children with the less number of attempts and complications [6, 40, 41].

#### *5.2.1. ETI training models, live models, and simulation training sessions for increasing success in pediatric and neonatal intubation*

Recently, it has been mentioned that there are no differences in the learning curve or the skills for performing neonatal intubation by comparing live models versus ETI training models. Retention curves with a follow-up of 6, 18 and 52 weeks remain constant after 6 weeks and get lost after 18 and 52 weeks; although, retention is higher when skill levels are higher too [42, 43]. Additionally, it has been reported that educational interventions such as training sessions using didactic and simulation components have not been related with an improvement in intubation success rate; even, performance points decrease after 8 weeks of the intervention [44]. Importantly, other studies have not found differences in pediatric ETI success rate at first attempt by comparing groups with and without training [45].

## **6. Conclusions**

but through a high-resolution screen which can be located in the same device or at the patient's side. Among the main complications reported are the soft palate lesions (**Figure 20**).

Learning curve (LC) in the case of the direct laryngoscopy requires of approximately of 45–50 previous intubations [33], while LC for video laryngoscopy is around 5 attempts. ETI using a video laryngoscopy is possible with little training, due to transmitted image from the blade's distal tip makes easier the visualization of the larynx entrance. When intubation attempts using Miller or Macintosh laryngoscopes or video laryngoscopy fail other methods to secure pediatric airway are recommended to be used (i.e. supraglottic devices). Recent studies have reported that ETI with video laryngoscopy even performed by less experienced medical personnel, increases significantly the success rate in the first attempt in comparison with direct laryngoscopy [34]; moreover, it has been reported that video laryngoscopy decreases the intubation time with less desaturation and less failure rate when it is compared with conventional laryngoscopy [35, 36]. Nevertheless, other video laryngoscope methods (GlideScope) implying other type of learning (mainly based on exploration), have resulted to be inferior to direct laryngoscopy regarding the time required for ETI [37].

Until date there is no standard definition for the term proficiency in pediatric/neonatal airway ETI. In a recent study, defined a formal training in pediatric airway management as having received at least 2 weeks of training by pediatric anesthesiology teachers. In that study was reported that after formal training, intubation success rate increased from 65.1 to 75.7% (*p* = 0.01), and it was observed a significant decreasing in the number of intubation attempts (*p* = 0.01). However, they did not find statistically significant differences in the time for achieving Intubation nor for the

In a study conducted by Kerrey et al., where rapid sequence intubation technique was used, pediatricians in emergency departments and anesthesiologist had higher success rates (88–91%) in comparison to physicians in formation (45%) [7]. These results were similar to the reported by Goto et al. where intubation success was higher at the first attempt in pediatricians (OR 2.36; CI 95% 1.11–4.97) and in emergency room physicians (OR 3.2; CI 95% 1.78–5.83) in comparison

**5. Insights and future directions**

**Figure 20.** Video laryngoscope.

68 Bedside Procedures

**5.1. Direct laryngoscopy vs. video laryngoscopy**

**5.2. Importance of formal training in pediatric ETI**

to pediatric residents of the first and second year [39].

frequency of complications [38].

It is important to highlight, that clinicians who attend critically ill pediatric patients requiring airway management know the rapid sequence intubation procedure, identify a patient with difficult airway, know the devices and techniques for the management of difficult airway, and look for receiving a formal training. Future strategies for teaching and/or training clinicians in pediatric and neonatal ETI should be evaluated through conducting controlled clinical trials to identify which type is the most effective by considering the less number of attempts and complications.

## **Author details**

Maribel Ibarra-Sarlat1 , Eduardo Terrones-Vargas<sup>2</sup> , Lizett Romero-Espinoza<sup>3</sup> , Graciela Castañeda-Muciño<sup>1</sup> , Alejandro Herrera-Landero<sup>4</sup> and Juan Carlos Núñez-Enríquez<sup>1</sup> \*

\*Address all correspondence to: jcarlos\_nu@hotmail.com

1 UMAE Hospital de Pediatría Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, México City, Mexico

2 Unidad de Cuidados Intensivos Pediátricos, Hospital Infantil de México Federico Gómez, Secretaria de Salud, México City, Mexico

3 UMAE Hospital Gineco-Obstetricia No.3 "Dr. Victor Manuel Espinosa De Los Reyes Sánchez", Centro Médico Nacional La Raza, Mexico City, Mexico

4 Hospital de Traumatología y Ortopedia «Lomas Verdes», Instituto Mexicano del Seguro Social, State of Mexico, Mexico

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[15] Smereka J. Which laryngoscope method should inexperienced intubators use for child intubation? American Journal of Emergency Medicine. 2016;**34**(8):1729-1730

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[16] O'Donnell CP, Kamlin CO, Davis PG, Morley CJ. Endotracheal intubation attempts during neonatal resuscitation: Success rates, duration, and adverse effects. Pediatrics.

[17] Gray MM, Delaney H, Umoren R, Strandjord TP, Sawyer T. Accuracy of the nasal-tragus length measurement for correct endotracheal tube placement in a cohort of neonatal

[18] Kempley ST, Moreiras JW, Petrone FL. Endotracheal tube length for neonatal intubation.

[19] Auroy Y, Benhamou D, Pequignot F, Bovet M, Jougla E, Lienhart A. Mortality related to

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**Chapter 4**

**Provisional chapter**

**Emergency Pericardiocentesis in Children**

**Emergency Pericardiocentesis in Children**

DOI: 10.5772/intechopen.70700

Cardiac tamponade is a life-threatening condition characterized by compression of the heart due to pericardial accumulation of different types of fluid and requires prompt diagnosis and immediate therapeutic intervention. Echocardiography is the most useful imaging technique to diagnose the cardiac tamponade and to evaluate the size, location, and hemodynamic impact of the pericardial effusion. Emergency pericardiocentesis is the procedure used for the aspiration of the fluid from the pericardial space in patients with significant pericardial effusion which determines hemodynamic compromise (cardiac tamponade). Emergency pericardiocentesis in children is performed under local anesthesia and is echocardiographic-guided. The first step of echocardiographic-guided pericardiocentesis is to assess the dimension and distribution of the pericardial fluid and the optimal trajectory of the needle in order to efficiently evacuate the pericardial fluid. The transducer is situated 3–5 cm from the parasternal border and the trajectory of the needle is established by the angle of the transducer. The needle is positioned between the xiphoid process and the left costal cartilages and is advanced, while a continuous aspiration is performed. It is important to avoid the neighboring vital organs (heart, liver, lung, internal mammary artery, and the intercostal vascular bundle). Complications which can occur are as follows: dysrhythmias, puncture of coronary artery or mammary artery, hemothorax, pneumothorax, pneumopericardium,

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

© 2018 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

and reproduction in any medium, provided the original work is properly cited.

Pericardiocentesis is indicated in hemodynamic unstable children with cardiac tamponade. Echocardiography is a useful imaging tool for liquid effusion visualization and for needle

**Keywords:** pericardiocentesis, emergency, children, cardiac tamponade

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.70700

Cecilia Lazea

**Abstract**

and hepatic injury.

trajectory, reducing the risk of complications.

**1. Introduction**

Cecilia Lazea

**Provisional chapter**
