Airway Plans and Modifiers

Question 1

Cardiovascular intubation (STEMI with hypotension, dissection):

Answer 1

Priorities are:

• haemodynamically neutral intubation - prevent hypoxic/hypotensive arrest
• difficult physiologic airway

Preparation/position: anticipate dysrhythmias (VT/VF) - have pads on/amiodarone/adrenaline drawn up
- NIV for pre-oxygenation if in APO

Drugs: commence NA/A infusion prior to induction

• modified dose induction 0.5 mg/kg ketamine
• high dose paralytic 1.2 mg/kg rocuronium

Plan: VL, mac blade + tube over bougie, VL hyperangulated, LMA, CICO scalpel/finger/bougie
Post: direct disposition to cath lab or OT

Question 2

Anatomically difficult face - face/neck trauma/Ludwigs intubation plan:

Answer 2

Issues:

• primary survey completed - immediate life threats dealt with
• anatomically difficult due to loss of normal anatomy/obstructed views

Preparation: may need to clear airway of debris/loose teeth, double suction setup
Position: c-spine precautions,
Stuff: front of neck access scrubbed
Drugs: haemodynamically neutral/neuroprotective ? associated head injury
- fentanyl, ketamine, roc
Plan modifications: VL rather than DL, plan C (LMA/NPA)/airway manoeuvres may not be possible, BVM subcut emphysema making surgical airway harder
Post-intubation: closely monitor tube position, consider alternative to tube tie

Question 3

Obese (+/- OSA) intubation modifications:

Answer 3

Anatomically +/- physiologically difficult airway, decreased safe apnoea time

Preparation: NIV, seated position with ramp on the bed ear to sternal notch, reverse TRENDELENBURG
- ELM and CICO/neck person allocated
Stuff: may require DSI to tolerate NIV, ketamine as per IBW titrated
Plan: A - VL with hyperangulated blade/stylet in tube, VL with mac blade, LMA + 2xNPA, front of neck
Post-intubation: position at 30 degrees, higher PEEP, sats aim 88-92%, consider permissive hypercapnoea

Question 4

Neurosurgical intubation modifications:

Answer 4

Priorities are:

• to prevent reflex sympathetic intubation response
• to prevent secondary injury by using neuroprotective measures

Preparation/position: keep at 30-45 degrees, ETCO2 via BVM 35-40
Drugs: mannitol/hypertonic saline peri-intubation
- pre-treat with fentanyl 2 mcg/kg
- reduce induction agent dose based on degree of ALOC/haemodynamically neutral
- short acting paralytic so rapid re-assessment of neurology
Plan: VL, mac blade + tube over bougie, VL hyperangulated, LMA, CICO scalpel/finger/bougie
Post: neuroprotective measures (ETCO2 35-40, sats 95-98%, minimum PEEP, SBP 120-140)
- deep sedation

Question 5

Agitated patient intubation plan:

Answer 5

Priorities are:

• gain control of the situation
• optimise intubation conditions

Preparation: PPE, security present, restraints
DSI - ketamine or PPF + BVM/NIV - to facilitate adequate pre-oxygenation (intubation reserve)
Reposition after sedation
Stuff/drugs: anticipate hypotension if sick + loss of adrenergic surge, avoid sympathetic surge –> fentanyl 4-5 mcg/kg
Plan: VL with mac-blade tube over bougie, VL with hyperangulated blade, LMA, CICO front of neck
High dose sedation post-RSI, paralysis
? COOLING
Seek/treat cause

Question 6

Airway oedema intubation plan (ie difficult view of cords - croup, angio-oedema):

Answer 6

Anatomically difficult intubation; ideally gas-induction with anaesthetics in the operating theatre

If not available I would optimise my first pass success by:
Preparation: allocate/scrub doctor for surgical airway, tray open and ready by bedside, neck marked
- double suction to help with secretions
- staffing to help reposition patient
- IV steroids, adrenaline nebs
- DSI/ketamine to give PEEP up until induction
- alternative: topicalisation with cophenylcaine/lignocaine + ketamine –> have a look prior to paralysing

Position: keep upright in seated position (position of comfort) until last moment prior to induction

Stuff: smaller tube size (down 0.5-1) so can pass through cords

Drugs:

• give ketamine slowly to prevent apnoea
• high dose paralytic 1.2-1.5 mg rocuronium

Plan:
A: topicalisation and ketamine for quick peek, B: VL w/ MAC blade, C: hyperangulated blade with small tube, D: scalpel/finger/bougie

Question 7

Intubation in the context of acidosis plan:

Answer 7

Physiologically difficult intubation - even small rises in a low CO2 can result in cardiac arrest.
Plan to optimise patient prior to induction and to ensure rapid placement of tube.

Position: optimise prior to induction, may need to have patient seated
Stuff: pre-load second tube on to hyperangulated stylet
Drugs: 1 mmol/kg of NaHCO3, 1.5 mg/kg rocuronium for rapid intubating conditions
Plan: most experienced operator, set lower threshold for bagging/front of neck access
Plan A: VL with MAC blade, Plan B: VL with hyperangulated blade
Post-intubation: match pre-intubation RR, blood gas ASAP to check pH and CO2

Question 8

Massive ENT/Resp/GI haemorrhage intubation plan:

Answer 8

This is both a physiologically and anatomically difficult intubation.
Intubation is complicated by haemorrhagic shock and hypoxia, high risk of aspiration and obstructed views of the cords.
Staff risk of exposure.

Preparation: PPE for staff

• correct hypotension - 250-500 ml 0.9% saline boluses IV, max of 1.5 L (or blood preferred) AIMS!, NA infusion, add adrenaline
• correct hypoxia - prolonged pre-oxygenation, may need DSI if agitated - ? increase risk of aspiration
• ? opportunity for bleeding cessation/reduction: topical agents, packing, nebs of TXA/adrenaline
• front of neck access doctor scrubbed/kit open by bedside

Position: head up 45 degrees

Stuff: 2 large bore suction with 2 assistants to hold them in the mouth, ? meconium aspirator

Drugs: consider pro-kinetics pre-RSI to reduce aspiration risk

Plan: A - DL w/ bougie (to feel tracheal rings) - look for bubbling, hyperangulated DL, LMA unlikely successful

Post-Intubation: bleed specific care - reversal of coagulopathy, TXA
- lung protective ventilation if aspirated

Question 9

COPD/asthma intubation plan:

Answer 9

Physiologically difficult - high risk of hypoxic cardiac arrest peri-intubation/induction

• anticipate difficult ventilation, difficult BVM
• high risk for barotrauma

Preparation:

• optimise pre-oxygenation: may need DSI with ketamine to facilitate NIV
• optimise management - continuous nebs, IV steroids, IV mag, IV adrenaline to bronchodilate
• PEEP valve set at <5 on BVM

Position: upright to optimise lung capacity
Stuff: ventilator set to obstructive lung ventilation settings, pre-load second tube on to hyperangulated stylet
Drugs: ketamine 1-1.5 mg/kg for bronchodilation
Plan: A: VL w/ tube over bougie, VL with hyperangulated blade, LMA and CICO plan

Post-Intubation: obstructive lung ventilation, permissive hypercapnoea, avoid excessive PEEP/TV

Question 10

C-spine immobility/injury intubation:

Answer 10

Anatomically (+/- physiologically if trauma) difficult
Limited neck mobility reduces first pass success

Preparation: assign a staff to MILS if injury, mark neck
Position: neutral, c-spine precautions
Stuff: extra staff member
Drugs: standard
Plan modification: Plan A hyperangulated VL, Plan B bougie/VL with mac blade, front of neck access may be harder as cannot position
Post-intubation: reapply collar, imaging of neck, monitor for neurology

Question 11

Toxicology intubation plan:

Answer 11

Physiologically difficult intubation, anatomically difficult ? Vomit/obstructed cord views

Preparation: ? pre-RSI antidote administration
- address: agitation, hypotension, acidosis as required
Position: ear to sternal notch
Stuff: early NGT post-intubation for decontamination
Drugs: antidotes, specifics based on toxic ingestion
Post-intubation: decontamination, toxicology consult

Question 12

Pregnancy changes:

Answer 12

Two patients
A: Airway oedema/congestion, aspiration risk, enlarged breasts
B: Reduced FRC, ventilation harder – gravid uterus, diaphragm higher
C: Manual displacement (aortocaval compression), expanded blood volume, relative anaemia
D: Prone to DIC, uterine blood flow 10% of total,
Other: social supports

Question 13

Paediatric considerations in resus:

Answer 13

A: Large adenoids, tonsils and floppy epiglottis, narrow angled, higher larynx, cricoid narrowest, loose teeth
B: Higher oxygen extraction/consumption, diaphragmatic breathers, decompress stomach early, more rapid desaturation
C: Incredible capacity to vasoconstrict, CO more dependent on HR, higher fluid requirement
D: Prone to hypoglycaemia, hypothermia
Other: Non-verbal
Social supports

Question 14

Neonatal considerations in resus:

Answer 14

A: Large occiput, large tonsils, floppy epiglottis, no dentition, omega shaped epiglottis
B: Diaphragmatic breathers, obligate nasal breather, horizontal ribs, high oxygen extraction ratio
C: Incredible capacity to vasoconstrict, CO more dependent on HR
D: Prone to hypoglycaemia, hypothermia
Non-verbal
Social supports

Question 15

Geriatric modifiers:

Answer 15

A: Dentures, friable mucosa, limited neck ROM (arthritis) –> difficult BVM/LMA
B: Decreased chest wall compliance, comorbidities, reduced respiratory reserve, more susceptible to hypoxic brain injury
C: Anticoagulants, no tachycardia, underlying chronic heart failure/valvular lesions
D: Prone to hypothermia, increase risk of skin break down, reduced pain perception

? Non-verbal
Ethical considerations
Goals of care

Question 16

Pregnancy intubation plan changes:

Answer 16

Opening: two patients, obstetric emergency.
RESUSCITATION/MX of the mother is the priority.

Automatically physiologically and anatomically difficult intubation.

Preparation: advise obstetrics, allocate a role to cricoid pressure, decreased safe apnoea time so maximise pre-oxygenation

Position: left lateral tilt/uterine displacement, ramped

Stuff: Small-handled size 3 laryngoscope, smaller sized tube (6), pre-load the second tube on a stylet

Drugs: avoid longer-acting opioids (neonatal apnoea)

Plan: 
A: small handled size 3 MAC blade + bougie
B: hyperangulated blade + stylet
C: two-handed LMA + adjuncts 
D: surgical airway 

Post-Intubation: ? obstetric delivery, lung protective ventilation

Question 17

Paeds emergency intubation changes:

Answer 17

Significant anatomical and physiological differences with adults. Also need to consider psychosocial and situational issues.

Preparation: allocate staff member to care for parents, full external monitoring including ETCO2

• ?pre-treatment with atropine
• small dose of fentanyl to tolerate pre-oxygenation + have apnoeic oxygenation

Position: larger occiput so may require towel under shoulders

Stuff: weight-based
ETT: age/4 + 4, Broselow tape 
Straight Miller blade <2 years, if >2 years MAC 2
2xETT = NGT/OGT/IDC
3xETT = depth of ETT
4xETT = ICC size 

Drugs: atropine drawn up (20 mcg/kg IV), ketamine 1-2 mg/kg IV, rocuronium 1.5 mg/kg

Plan: A - Miller blade/MAC 2/3 + ETT, B - may change tube size, use bougie/Macgills/ELM, C - LMA, D - CICO pack

Post-intubation: verify tube placement, ventilation, post-intubation sedation, NGT/IDC, CXR/VBG

Question 18

Neonatal intubation modifiers:

Answer 18

Anatomical and physiological differences Psychosocial and situational issues.

Preparation: pre-treatment with atropine considered

Position: folded towel under shoulders, large occiput

Stuff: uncuffed tube - 3/3.5/4, straight miller blade 1 for full term baby, umbi vein access equipment

Drugs: atropine drawn up 20 mcg/kg, fentanyl 2-5 mcg/kg IV and sux 2 mg/kg IV

Plan A: Miller blade + ETT, Plan B: modify, Plan C: LMA, Plan D: CICO

Question 19

Severe hypoxia modifiers:

Answer 19

Modified RSI/DSI if not tolerating NIV
Physiologically (+/- anatomically difficult)
Avoid apnoea and worsening acidaemia –> arrest

Preparation: pre-oxygenate with NIV/HFNPO2, apnoeic oxygenation
Position: upright to improve ventilation mechanics
Stuff: pre-load a second tube with stylet for Plan B and have CICO kit by bedside
Drugs: high-dose paralytic, slow admin of ketamine to help prevent prolonged apnoea
Post-Intubation: ventilation strategy dependent on cause for hypoxia
- early NGT, position at 45 degrees, keep deeply sedated/paralysed so easier to ventilate
- treat reversible cause for hypoxia aggressively
- early insertion of in-line suction

Question 20

Severe hypotension modifiers:

Answer 20

Modified RSI approach; peri-intubation hypotension –> incr mortality
Physiologically (+/- anatomically difficult)

Preparation: optimise pre-load with fluid boluses, commence pressor infusion prior to induction
- time permits: insert arterial line pre-induction for real time monitoring
Drugs: modified half-dose stable induction agent 0.5 mg/kg ketamine + high dose rocuronium 1.2-1.5 mg/kg
- push-dose adrenaline 10 mcg/ml drawn up + NA/A infusions made up
- articulate BP threshold and allocate drug-administrator to give 5-10 mcg of adrenaline if BP <75 systolic

Post-intubation: avoid excessive TV, PEEP and dynamic hyperinflation as reduce venous return

Question 21

IBW vs TBW drugs:

Answer 21

IBW: ketamine, roc/vec
TBW: midaz, fentanyl, propofol

Question 22

Post-intubation:

Answer 22

Confirm tube position (CXR, ETCO2, clinically)
Secure tube and document depth
Connect ventilator
Ventilator settings
Adequate analgesia/sedation/paralysis
Head of bed up 30-45 degrees
NGT/IDC/art line/CVC/in-line suction
Blood gas, CXR, ECG and other bloods 
Definitive treatment (ie OT, angio)
Referral to inpatient + ICU + transport
HOT DEBRIEF + schedule cold debrief

Question 23

Obstructive lung ventilation

Answer 23

TV 6 ml/kg
RR 8-10 - PERMISSIVE HYPERCAPNOEA
I:E 1:4-5
Inspiratory flow 100 L/min
fiO2 1.0
PEEP 0-5 
Pplateau 30, pH >7.2
Elevate head
NGT
Paralyse

Question 24

Lung protective ventilation:

Answer 24

6 ml/kg predicted body weight
Limit plateau pressures to <30
Set PEEP >5 (>8/>10)
sats aim 90-95%
set rate to 20-30 breaths monitoring iPEEP
Elevate head of bed to 30 degrees
Place NGT early
Sedate paralyse

Question 25

Techniques in difficult ventilation:

Answer 25

OPA, NPA, dentures in
Two-person mask ventilation
Change grip - vice to c-shaped
LMA
Re-position

Question 26

Techniques in difficult intubation

Answer 26

Alternative laryngoscope blades 
Awake intubation (VL/fibreoptic)
Blind intubation using bougie
Fibreoptic intubation
Intubating stylet
LMA as a conduit
Light want
Retrograde intubation
Surgical airway

Question 27

Difficult LMA

Answer 27

RODS: restricted mouth opening, obstruction, distorted anatomy/dentures missing, stiff lungs/c-spine issues

Question 28

Difficult surgical airway:

Answer 28

SHORT

Surgery, haematoma, obesity, radiation, trauma

Question 29

Difficult intubation

Answer 29

LEMON

Look externally, evaluate 3-3-2, mallampati score, obstruction, neck mobility

Question 30

Difficult BVM

Answer 30

MOANS

mask seal, obesity/obstruction, age >55, no teeth

Question 31

Standard airway plan:

Answer 31

A: VL with tube over bougie, max 2 attempts in 2 mins
B: VL hyperangulated blade, preloaded stylet, max 2 attempts in 2 mins
C: LMA
D: if sats <75% with plan C –> scalpel, finger, bougie, tube surgical airway

Question 31

Standard airway plan:

Answer 31

A: VL with tube over bougie, max 2 attempts in 2 mins
B: VL hyperangulated blade, preloaded stylet, max 2 attempts in 2 mins
C: LMA
D: if sats <75% with plan C –> scalpel, finger, bougie, tube surgical airway

Question 32

My surgical airway plan

Answer 32

Scalpel-finger-bougie cricothyrotomy

SEDATION/PARALYSIS

1) Stand on same side of the patient as dominant hand (left)
2) Stabilise the larynx using thumb and MF (laryngeal handshake) and palpate membrane with IF of non-dominant hand
3) Scalpel - make horizontal/transverse incision
4) Palpate through incision to confirm the CTM and puncture through - extend incision laterally without removing blade
5) Remove blade and insert non-dominant index finger into incision until touches back wall of cricoid
6) Dominant hand slide bougie –> ETT into the space