Airway Management in the ICU Don A. Koenigsberg DO Chairman, Department of Anesthesia Saint Agnes Medical Center Philadelphia, PA

Etiologic Factors in Acute Respiratory Failure b Thoracic Trauma b Sepsis b Acute Pancreatitis b Aspiration of Gastric Contents b Necrotizing Pneumonia b Near Drowning b Oxygen FIO2 <60 b Brain Injury b Altitude b Drug Overdose b Fat Embolism b Pulmonary Thromboembolism b Amniotic Fluid Embolism b Inhalation of Toxic Vapors, Smoke, Gasses b Fluid Overload b Disseminated Intervascular Coagulation b Acquired Immunodeficiency Syndrome

Routes of Endotracheal Intubation b Nasotracheal b Orotracheal b Pericutaneous Cricothyroidotomy b Tracheotomy

Endotracheal Intubation b Inserted Through Nose or Mouth b Nasal Route Preferred in Awake Patients b Oral Route Preferred in Comatose or Uncooperative Patients b Tracheotomy Preferred for Long Term Intubation

Complications of Intubation b Epistaxis b Esophageal Intubation b Nasal, Septal Necrosis b Bacteremia b Dental Trauma b Occlusion from Biting on Tube b Laryngeal Damage

History of Mechanical Ventilation b PPV was first developed in the OR to facilitate anesthesia and thoracic surgery. b The PACU developed and evolved into ICU’s in the 1950’s. b Concepts of PPV, endotracheal intubation, sedation/analgesia and neuromuscular blockade were introduced and accepted. b Acceptance of preset tidal volume to support patients with respiratory failure.

Positive Airway Pressure Therapy b Full vs. Partial Ventilatory Support b Minimal Excursion Ventilation

Ventilator Modes b Control-Mode b Assist-Control b Pressure-Control b Intermitent Mandatory b Synchronized Intermittent Mandatory b Pressure-Support

Mimimal-Excursion Ventilation b Permissive Hypercapnia b Elimination of Dead Space b High Frequency Ventilation

Initiation of PPV b Establish Patent Airway b Not Uncommon To Experience Cardiovascular Instability Following Establishing the Airway And Beginning of Positive Pressure Ventilation.

Causes of Cardiovascular Instability b Decrease in Circulating Catacholamines Due to a Relief From Respiratory Distress Cause Vasodilation and Decreased Cardiac Output. b Decreased Venous Return Related to Airway Pressure. b Combination of Thereof.

Fighting The Ventilator b When a Ventilated Patient Actively Attempts to Impede Flow During The Inspiratory Cycle, The Process is Known As Fighting the Ventilator. b Breathing Efforts During the Expiratory Cycle Have Little Detrimental Effect In Most Patients.

Reasons Patients Fight The Ventilator b Inadequate Ventilation (Hypercapnea) b Acidemia b Inadequate Oxygenation b CNS Dysfunction b Pain or Anxiety

Sedation and Analgesia b Decreases Stress That can be Detrimental To Critically Ill Patients. b Human Compassion

Parameters For IV Sedation & Analgesia for Adults in the ICU According to the Society for Critical Care Medicine (SCCM) b Morphine Sulfate is preferred for critically ill patients b Fentanyl for critically ill with hemodynamic instability or morphine allergy b Hydromorphone is an alternative to morphine b Midazolam or Propofol for short term anxiety <24 hours. b Lorazepam for prolonged treatment of anxiety in the critically ill adult b Haloperidol for the treatment of delirium

ANALGESIA b Analgesia connotes the absence of sensibility to pain or noxious stimuli in the conscious patient. b Pain can lead to tachycardia increased myocardial oxygen consumption, hypercoagulability, immunosupression, and persistant catabolism. b ICU patients experience pain from diagnostic and theraputic procedures as well as their pathology. b Intravenous opiates are the mainstay of analgesic therapy

Common Concerns of Opiates b Unwarranted concerns about inducing opiate addiction b Respiratory Depression in spontaneously breathing patients and patients receiving partial ventilator support. b Hypotension - more likely related to hypovolemia b Gastric Retension and Ileus which are common in critically ill people are enhanced by opiates

Morphine Sulfate b Intravenous half-life of hours may vary up or down in ICU patients due to abnormal protein binding and distribution b May induce histamine release causing hypotension and other adverse effects b Administer intravenously and titrate to effect. Loading dose of 0.05mg/kg over 5-15 minutes. Most adults require 4-6 mg/hr after an adequate loading dose. b Bolus therapy should be every 1-2 hours. b Multiple loading doses may be required with continuous infusion therapy b Causes euphoric effect

Fentanyl b Preferred agent for critically ill patients with hemodynamic instability, for patients with symptoms of histamine release or with morphine allergy b Synthetic opiate with greater potency and lipophilic properties than morphine. b No histamine release b Half-life of minutes b Prolonged administration can accumulate and increase half-life to 9-16 hours b Little euphoric effect, no active metabolites, no cross reaction with morphine allergy

Opiates NOT RECOMMENDED Opiates NOT RECOMMENDED b Meperidine (Demerol) has an active metabolite, normeperidine, that may accumulate and cause CNS excitation b Opiate agonist-antagonists (nalbuphine, butorphenol, buprenorphine) b NSAIDS have no analgesic advantage over opiates and may cause GI bleeding, platelet inhibition, and renal insufficiency

Sedative Agents Recommended b Midazolam (Versed) Onset minutes. lipophilic compound in the blood that rapidly penetrates the CNS. b Bolus dose of.03 mg/kg and maintenance dose of.03 mg/kg/hr is recommended b Bolus may be repeated as needed b Propofol (Diprivan) Intravenous general anesthetic that has sedative, hypnotic, anxiolytic and anterograde amnestic properties. Onset in 1-2 minutes and effect is for minutes. Give only as a continuous infusion. Infusion rate of 0.5 mg/kg/hr and titrate rapidly upward in increments of 0.5mg/kg every 5-10 minutes. Typical maintenance doses are mg/kg/hr.

Sedative Agents (cont.) b Lorazepam (Ativan) is an intermediate acting benzodiazepine. It is longer acting than Midazolam, causes less hypotension, causes equally effective anterograde amnesia, is lower cost and with prolonged administration causes more rapid awakening. b Starting dose is 0.44 mg/kg every 2-4 hours but is highly variable. b Usually administered by intermittent bolus but continuous infusion is used.

Sedative Agents (cont.) b Haloperidol (Haldol) Preferred for treatment of delirium in the ICU. Opiates or Benzodiazepines may worsen symptoms of ICU psychosis. b IV use recommended by the SCCM although it is not approved by the FDA b Clinical effects seen within minutes and may last 4- 8 hours. b May cause QT prolongation so use with caution with other drugs with similar effects. b Dose is 2-10 mg Intravenously repeated every 2-4 hours

Sedative Agents NOT RECOMENDED b Etomidate (Amidate) Long term use associated with adrenal suppression b Ketamine (Ketlar) May increase blood pressure, heart rate, and intracranial pressure when used as a sedative. b Thiopental (Pentothal) and Pentobarbital (Nembutal) are used in the ICU primarily to control intracranial pressure or as anticonvulsants. They lack amnestic and analgesic properties and they commonly produce myocardial depression and vasodilation that result in tachycardia and hypotension.

Neuromuscular Blocking Agents b Used when patients fight the ventilator b Often the only alternative in protecting the patient from harm b Neuromuscular blockade should be the last resort after sedation analgesia and amnesia is provided. b Pancuronium is recommended by the SCCM practice parameters. b Vecuronium is also used extensively. b Atracurium or Cisatracurium is recommended for patients with cardiovascular instability,

Associated With Increased Sensitivity To Neuromuscular Blocking Agents b Antiarrhythmics b Antibiotics b Anticonvulsants b Antirheumatic drugs b Beta-blockers b Calcium Channel Blockers b Diuretics b General Anesthetics b Hepatic and Renal diseases b Hypermagnesemia b Hypocalcemia b Hyponatremia b Hypothermia b Steroids b Neuromuscular Diseases b Psychotropic agents b Respiratory Acidosis

Prolonged Paralysis and Muscular Weakness in Critically Ill Patients b Critical Illness Myopathy b Acute Quadriplegic Myopathy b Acute Necrotizing Myopathy b Necrotizing Myopathy of the ICU b Prolonged Reversible Quadriparesis b Corticosteroids and Neuromuscular Blocking agents together are factors

Acute Quadriplegic Myopathy Associated With Asthma b 9 of 22 Asthma patients treated with Corticosteroids and Vecuronium infusion developed myopathies and prolonged weakness. b >24 hours Treatment with muscle relaxants associated with prolonged paralysis in the ICU with or without steroids. b Rehab can take several months.