Indian Journal of Critical Care Medicine

Register      Login

SEARCH WITHIN CONTENT

FIND ARTICLE

Volume / Issue

Online First

Archive
Related articles

VOLUME 21 , ISSUE 3 ( 2017 ) > List of Articles

GUIDELINES

Republication: All India Difficult Airway Association 2016 Guidelines for Tracheal Intubation in the Intensive Care Unit

Sabyasachi Das, Pankaj Kundra, Amit Shah, Syed Moied Ahmed, Apeksh Patwa, Ubaradka S. Raveendra, Sumalatha Radhakrishna Shetty, Jeson Rajan Doctor, Dilip K. Pawar, Singaravelu Ramesh

Keywords : Complications, emergency department, intensive care, intubation bundle, ketamine, noninvasive positive pressure ventilation, tracheal intubation

Citation Information : Das S, Kundra P, Shah A, Ahmed SM, Patwa A, Raveendra US, Shetty SR, Doctor JR, Pawar DK, Ramesh S. Republication: All India Difficult Airway Association 2016 Guidelines for Tracheal Intubation in the Intensive Care Unit. Indian J Crit Care Med 2017; 21 (3):146-153.

DOI: 10.4103/ijccm.IJCCM_57_17

License: CC BY-ND 3.0

Published Online: 01-02-2018

Copyright Statement:  Copyright © 2017; The Author(s).


Abstract

Tracheal intubation (TI) is a routine procedure in the Intensive Care Unit (ICU) and is often lifesaving. In contrast to the controlled conditions in the operating room, critically ill patients with respiratory failure and shock are physiologically unstable. These factors, along with under evaluation of the airway and suboptimal response to preoxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxemia and cardiovascular collapse during TI in the ICU. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for safe management of the airway in critically ill patients. These guidelines have been developed based on available evidence; Wherever, robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the (AIDAA) and Indian Society of Anaesthesiologists. Noninvasive positive pressure ventilation for preoxygenation provides adequate oxygen stores during TI for patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnea before hypoxemia sets in. High flow nasal cannula oxygenation at 60–70 L/min may also increase safety during intubation of critically ill patients. Stable hemodynamics and gas exchange must be maintained during rapid sequence induction. It is necessary to implement an intubation protocol during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.


PDF Share
  1. Schwartz DE, Matthay MA, Cohen NH. Death and other complications of emergency airway management in critically ill adults. A prospective investigation of 297 tracheal intubations. Anesthesiology 1995;82:367-76.
  2. Jaber S, Amraoui J, Lefrant JY, Arich C, Cohendy R, Landreau L, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the Intensive Care Unit: A prospective, multiple-center study. Crit Care Med 2006;34:2355-61.
  3. Griesdale DE, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of endotracheal intubation in the critically ill. Intensive Care Med 2008;34:1835-42.
  4. Jabre P, Avenel A, Combes X, Kulstad E, Mazariegos I, Bertrand L, et al. Morbidity related to emergency endotracheal intubation – A substudy of the KETAmine SEDation trial. Resuscitation 2011;82:517-22.
  5. Breckwoldt J, Klemstein S, Brunne B, Schnitzer L, Mochmann HC, Arntz HR. Difficult prehospital endotracheal intubation – Predisposing factors in a physician based EMS. Resuscitation 2011;82:1519-24.
  6. Divatia JV, Khan PU, Myatra SN. Tracheal intubation in the ICU: Life saving or life threatening? Indian J Anaesth 2011;55:470-5.
  7. Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: Intensive care and emergency departments. Br J Anaesth 2011;106:632-42.
  8. Myatra SN, Shah A, Kundra P, Patwa A, Ramkumar V, Divatia JV, et al. All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in adults. Indian J Anaesth 2016;60:885-98.
  9. Mort TC. Emergency tracheal intubation: Complications associated with repeated laryngoscopic attempts. Anesth Analg 2004;99:607-13.
  10. Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S. 3,423 emergency tracheal intubations at a university hospital: Airway outcomes and complications. Anesthesiology 2011;114:42-8.
  11. Mayo PH, Hegde A, Eisen LA, Kory P, Doelken P. A program to improve the quality of emergency endotracheal intubation. J Intensive Care Med 2011;26:50-6.
  12. Bowles TM, Freshwater-Turner DA, Janssen DJ, Peden CJ; RTIC Severn Group. Out-of-theatre tracheal intubation: Prospective multicentre study of clinical practice and adverse events. Br J Anaesth 2011;107:687-92.
  13. Simpson GD, Ross MJ, McKeown DW, Ray DC. Tracheal intubation in the critically ill: A multi-centre national study of practice and complications. Br J Anaesth 2012;108:792-9.
  14. Sakles JC, Chiu S, Mosier J, Walker C, Stolz U. The importance of first pass success when performing orotracheal intubation in the emergency department. Acad Emerg Med 2013;20:71-8.
  15. Mort TC. The incidence and risk factors for cardiac arrest during emergency tracheal intubation: A justification for incorporating the ASA Guidelines in the remote location. J Clin Anesth 2004;16:508-16.
  16. Mallampati SR, Gatt SP, Gugino LD, Desai SP, Waraksa B, Freiberger D, et al. A clinical sign to predict difficult tracheal intubation: A prospective study. Can Anaesth Soc J 1985;32:429-34.
  17. Wilson ME, Spiegelhalter D, Robertson JA, Lesser P. Predicting difficult intubation. Br J Anaesth 1988;61:211-6.
  18. Levitan RM, Everett WW, Ochroch EA. Limitations of difficult airway prediction in patients intubated in the emergency department. Ann Emerg Med 2004;44:307-13.
  19. De Jong A, Molinari N, Terzi N, Mongardon N, Arnal JM, Guitton C, et al. Early identification of patients at risk for difficult intubation in the Intensive Care Unit: Development and validation of the MACOCHA score in a multicenter cohort study. Am J Respir Crit Care Med 2013;187:832-9.
  20. Schmidt UH, Kumwilaisak K, Bittner E, George E, Hess D. Effects of supervision by attending anesthesiologists on complications of emergency tracheal intubation. Anesthesiology 2008;109:973-7.
  21. Mosier JM, Hypes CD, Sakles JC. Understanding preoxygenation and apneic oxygenation during intubation in the critically ill. Intensive Care Med 2017;43:226-8.
  22. Baillard C, Fosse JP, Sebbane M, Chanques G, Vincent F, Courouble P, et al. Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients. Am J Respir Crit Care Med 2006;174:171-7.
  23. Vourc'h M, Asfar P, Volteau C, Bachoumas K, Clavieras N, Egreteau PY, et al. High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic patients: A randomized controlled clinical trial. Intensive Care Med 2015;41:1538-48.
  24. Miguel-Montanes R, Hajage D, Messika J, Bertrand F, Gaudry S, Rafat C, et al. Use of high-flow nasal cannula oxygen therapy to prevent desaturation during tracheal intubation of intensive care patients with mild-to-moderate hypoxemia. Crit Care Med 2015;43:574-83.
  25. Jaber S, Monnin M, Girard M, Conseil M, Cisse M, Carr J, et al. Apnoeic oxygenation via high-flow nasal cannula oxygen combined with non-invasive ventilation preoxygenation for intubation in hypoxaemic patients in the Intensive Care Unit: The single-centre, blinded, randomised controlled OPTINIV trial. Intensive Care Med 2016;42:1877-87.
  26. Sakles JC, Mosier JM, Patanwala AE, Arcaris B, Dicken JM. First pass success without hypoxemia is increased with the use of apneic oxygenation during rapid sequence intubation in the emergency department. Acad Emerg Med 2016;23:703-10.
  27. Wimalasena Y, Burns B, Reid C, Ware S, Habig K. Apneic oxygenation was associated with decreased desaturation rates during rapid sequence intubation by an Australian helicopter emergency medicine service. Ann Emerg Med 2015;65:371-6.
  28. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med 2012;59:165-75.e1.
  29. Semler MW, Janz DR, Lentz RJ, Matthews DT, Norman BC, Assad TR, et al. Randomized trial of apneic oxygenation during endotracheal intubation of the critically Ill. Am J Respir Crit Care Med 2016;193:273-80.
  30. Hayes-Bradley C, Lewis A, Burns B, Miller M. Efficacy of nasal cannula oxygen as a preoxygenation adjunct in emergency airway management. Ann Emerg Med 2016;68:174-80.
  31. Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care 2012;27:417.e9-13.
  32. Perbet S, De Jong A, Delmas J, Futier E, Pereira B, Jaber S, et al. Incidence of and risk factors for severe cardiovascular collapse after endotracheal intubation in the ICU: A multicenter observational study. Crit Care 2015;19:257.
  33. Green RS, Turgeon AF, McIntyre LA, Fox-Robichaud AE, Fergusson DA, Doucette S, et al. Postintubation hypotension in Intensive Care Unit patients: A multicenter cohort study. J Crit Care 2015;30:1055-60.
  34. Green RS, Edwards J, Sabri E, Fergusson D. Evaluation of the incidence, risk factors, and impact on patient outcomes of postintubation hemodynamic instability. CJEM 2012;14:74-82.
  35. Kim WY, Kwak MK, Ko BS, Yoon JC, Sohn CH, Lim KS, et al. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PLoS One 2014;9:e112779.
  36. Smischney NJ, Demirci O, Ricter BD, Hoeft CC, Johnson LM, Ansar S, et al. Vasopressor use as a surrogate for post-intubation hemodynamic instability is associated with in-hospital and 90-day mortality: A retrospective cohort study. BMC Res Notes 2015;8:445.
  37. Shah SB, Chowdhury I, Bhargava AK, Sabbharwal B. Comparison of hemodynamic effects of intravenous etomidate versus propofol during induction and intubation using entropy guided hypnosis levels. J Anaesthesiol Clin Pharmacol 2015;31:180-5.
  38. Kaushal RP, Vatal A, Pathak R. Effect of etomidate and propofol induction on hemodynamic and endocrine response in patients undergoing coronary artery bypass grafting/mitral valve and aortic valve replacement surgery on cardiopulmonary bypass. Ann Card Anaesth 2015;18:172-8.
  39. Reich DL, Hossain S, Krol M, Baez B, Patel P, Bernstein A, et al. Predictors of hypotension after induction of general anesthesia. Anesth Analg 2005;101:622-8.
  40. Gu WJ, Wang F, Tang L, Liu JC. Single-dose etomidate does not increase mortality in patients with sepsis: A systematic review and meta-analysis of randomized controlled trials and observational studies. Chest 2015;147:335-46.
  41. Jabre P, Combes X, Lapostolle F, Dhaouadi M, Ricard-Hibon A, Vivien B, et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: A multicentre randomised controlled trial. Lancet 2009;374:293-300.
  42. Mosier JM, Sakles JC, Stolz U, Hypes CD, Chopra H, Malo J, et al. Neuromuscular blockade improves first-attempt success for intubation in the Intensive Care Unit. A propensity matched analysis. Ann Am Thorac Soc 2015;12:734-41.
  43. Lyon RM, Perkins ZB, Chatterjee D, Lockey DJ, Russell MQ; Kent, Surrey and Sussex Air Ambulance Trust. Significant modification of traditional rapid sequence induction improves safety and effectiveness of pre-hospital trauma anaesthesia. Crit Care 2015;19:134.
  44. Marsch SC, Steiner L, Bucher E, Pargger H, Schumann M, Aebi T, et al. Succinylcholine versus rocuronium for rapid sequence intubation in intensive care: A prospective, randomized controlled trial. Crit Care 2011;15:R199.
  45. De Jong A, Molinari N, Conseil M, Coisel Y, Pouzeratte Y, Belafia F, et al. Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the Intensive Care Unit: A systematic review and meta-analysis. Intensive Care Med 2014;40:629-39.
  46. Sakles JC, Patanwala AE, Mosier JM, Dicken JM. Comparison of video laryngoscopy to direct laryngoscopy for intubation of patients with difficult airway characteristics in the emergency department. Intern Emerg Med 2014;9:93-8.
  47. Silverberg MJ, Li N, Acquah SO, Kory PD. Comparison of video laryngoscopy versus direct laryngoscopy during urgent endotracheal intubation: A randomized controlled trial. Crit Care Med 2015;43:636-41.
  48. Cook TM, Kelly FE. Time to abandon the 'vintage' laryngeal mask airway and adopt second-generation supraglottic airway devices as first choice. Br J Anaesth 2015;115:497-9.
  49. 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 Med 2010;36:248-55.
PDF Share
PDF Share

© Jaypee Brothers Medical Publishers (P) LTD.