In this talk from BCC4; McManus, an anaesthetist with over 12 years experience in critical care, distills valuable knowledge about airway management.

1. The Ultimate Induction

2. The Ultimate Introduction

3. Outline
• Essentials of Critical Care airway management
in the age of information overload
• Two memorable 2013 airway cases
– Tricky Trauma
– Mediastinal Mega Mass
• Techniques for your induction tool box

4. Personal Perspective
• 12 Years covering Anaesthesia & ICU in FNQ
– Trauma
– Sepsis
– Obstetrics
– Paediatrics
– Tropical Medicine
– Occasional retrieval
• Tertiary referral 400km away

5. Personal Perspective
• Senior role in College of Anaesthetists
– Assess overseas trained Specialists
– Inspect hospitals for training accreditation
– Give expert opinion to Coroner in cases of
anaesthetic misadventure

6. Personal Perspective
• Training future airway managers
–
–
–
–
ANZCA
ACEM
CICM
ACCRM
• Upskilling
– Rural Generalists
– Paramedics
– Residents

7. Personal Perspective
• Anaesthesia Outreach to Cape York
– Weipa, TI, Cooktown
– Dental & ENT
– Large Paediatric Case Load
• Overseas Aid Work with Interplast
–
–
–
–
PNG, Sri Lanka, Fiji
Cleft Lip & Palate
Head and Neck
Mostly Paediatric

9. The Ultimate Induction
• Two rules
– air goes in and out
– blood goes round and round
• Many different recipes
– Pick your own
– As long as the cake rises………………..
• Expertise comes down to time at the wheel

10. Downhill Experts

11. Induction in Critical Care
• A different contract with the patient than
inducing anaesthesia
1.
2.
3.
4.
Keep the alive
Keep them comfortable
Prevent recall
Make them unconscious
• Awareness of induction is not the worst
possible outcome

12. Induction in Critical Care
• Data (e.g. NAP4)
highlights difference
between OT and ICU/ED
• Often no bail out option
• Many things are done
by experts are intuitive
• Induction is a complex
process, need to fly at
high altitude

13. Cautionary tales from 2013

14. Tricky Trauma

15. Patrick
• Executive Director of Medical Services is riding
to work on his Motorbike
• Hit at 0745 5 km from CBH
• Brought in to ED
– # Pelvis
– # Ribs
– Pain ++

16. Patrick
• To OT for urgent pelvic Ex Fix
• Arrives in induction bay
• And said……………………

17. What I should be feeling

18. What I really felt

19. What are our options?
• RSI and look?
• Video Laryngoscope?
• Awake FOI?
• Avoid GA?

20. Meanwhile

21. Discussed plan with Patrick
• Decided FOI was not reasonable
– Pain, Opioids, Moderate Hypoxia
– Unable to sit up
• Plan
A.
B.
C.
D.
Modified RSI +/- bougie
Videolaryngoscopy
Blind bougie +/- proseal (if still not in trachea)
Prearranged second consultant backup

22. Plan A……….
• Normal modified RSI
• Attempted laryngoscopy
– Proper Grade 4
– Narrow crowded teeth
– Early use of bougie – unable to find trachea
– Abandoned while sats still OK
– Bag & mask
– Pulse Ox lag ++++

23. Plan B…………….
• Attempt with Videolaryngoscope
– Unable to get into mouth
– Pulled apart – no joy
– Bailed 2nd time
– Able to bag/mask
– Called for assistance

24. Plan ??????????
• Second Anaesthestist inserted Proseal
• Attempted to use FO scope down Proseal to
guide bougie – unsuccessful
• Things are starting to look ugly

26. 15 Years of Anaesthetic Adventures
• Airway not ideal……………
• Air going in and out
• Relatively short case
• Decided to accept the supraglottic airway

27. Elaine Bromiley

28. A failure of airway management
• Anxious in my first week back as a consultant
• Unfamiliar with the VDL
• The second consultant was not involved in the
airway management planning
• I bailed on my own plan – never got to C

29. Lessons Learnt
• It is better to be lucky than good!
• Accepting a less than perfect airway is sometimes
appropriate
– Air goes in and out
– Repeated goes at the larynx is not wise
– FOI can be tricky in trauma
• Maintaining situational awareness and dynamic
decision making ability

30. Dynamic Decision Making
Input
Feedback for Evaluation
Decision
Analysis
Action
Influences
Objectives
Preconceptions
Workload
Skill
Training
Experience
Regulations
Rules
S.O.P.S
Captain Julian Hipwell, Cathay Pacific Airlines

31. Checklists

32. Information Overload

33. M.A.I.D.E.
For Every Induction
• Monitoring
• Assistance
• Intravenous access
• Drugs
• Equipment

34. Monitoring
• Check it is connected
and reading
• NIBP Cycle time
• Arterial line?
• ETCO2

35. Assistance
• Need skilled help
• Two questions to assess
level of experience
– Cricoid pressure?
– Pass the bougie?
• Critical Care Induction
will often require
another doctor
– Delineate roles

36. Intravenous Access
• Often overlooked in a
crisis
• In non-haemorragic
induction, don’t need
huge bore
• Must run freely
• Low threshold for
replacing

37. Drugs
• What you will use plus
emergency drugs
• Endless debate about best
induction recipe
• Ketamine/Rocuronium seems
reasonable in shock
• Use what you know best
• Don’t skimp on paralysis

38. Equipment
• Airways – 3 options
– Through Cords (ETT)
– Over Cords (LMA)
– Under Cords (Crico)
• Laryngoscopes
– Classic
– Video
– Fibreoptic
• Positive Pressure
– Bag/Mask
– O2 outlet
• Negative Pressure
– Sucker under head
• Adjuncts
– Guedel
– Bougie

39. Sounds Sweet?

40. Mega Mediastinal Mass

41. Mega Mediastinal Mass
• 39 year old lady from TI admitted to ICU on
the 16th of April with stridor
• Seen in Feb by the respiratory team for
investigation of a mediastinal mass
• FNA done, awaiting result

42. Mega Mediastinal Mass
• Deteriorated over the last few days, presented
to TI hospital acutely distressed
• Flown to CBH ED, survived a CT chest
• Admitted to ICU overnight

45. CT Report
• “A large mass extends from the anterior
mediastinum into the middle
mediastinum, and superiorly towards the
left, partially compressing the left pulmonary
artery. There is severe compression of the
trachea from the carina to the thoracic
inlet, with a minimum diameter of 3.6mm”

46. ICU Ward Round
• Seen by team at 8am Monday morning
• Awake, maintaining airway sitting up, unable
to lie flat
• Appeared likely to obstruct at some time
during the day

47. Plan?
• Thoughts……………………
• Options………………………..
• The only thing going through my head was…..

49. We consulted Townsville
• Definitive diagnosis via mediastinal biopsy
• Possible Cardiothoracic resection
• Probable Radiotherapy
• Advised us to secure her airway for transfer….

50. Mission Impossible?

51. What are the options?
• Standard Induction – “Sux and see?”
• Awake FOI – Smallest bronchoscope is 4mm
• Gas induction?
• Retrieval with ECMO/CPB?

52. Group Mined
• Collaborative decision making
• Robust discussion with trust
• Anaesthesia, Intensive Care, ENT and General
Surgery
• We came to a consensus…………..

53. This is a crisis, a large crisis
In fact, if you got a
moment, it's a twelve-storey
crisis with a magnificent
entrance hall, carpeting
throughout, 24-hour
portage, and an enormous sign
on the roof, saying 'This Is a
Large Crisis'.
A large crisis requires a large
plan. Get me two pencils and a
pair of underpants.

54. “Two pencils and a pair of undies”

55. M.A.I.D.E.
For Every Induction
• Monitoring
• Assistance
• Intravenous access
• Drugs
• Equipment

56. First use of ‘Staged Intubation’
• Airway too narrow for anything other than a
wire
• Big team involved, clear communication of
plan
• Principle was to keep patient awake and in
control of her own airway for as long as
possible

57. Precarious Position
• Three senior anaesthetists + two techs
– FO Scope
– Staged Extubation Kit
– Drugs and Monitoring
• Theatre cleared of all unnecessary personnel
• ENT surgeons scrubbed and standing by

58. Steady, steady
• Regulation topicalization and fibreoptic
visualisation of cords
• Through cords and guidewire fed down
bronchoscopic biopsy channel
• Position confirmed with Image Intensifier

59. Point of no return
• IV Induction
• Bougie fed over guidewire
• Size 6 Microlaryngoscopy ETT railroaded over
bougie into right main bronchus
• Confirmed with subsequent brochoscopy

60. Transferred to Townsville
• Poorly differentiated tumour
• Extubated after 22 days post radiotherapy
• First time it has been done (we think),
submitted for publication
• Rejected!

61. Additions to your toolkit

62. Anaesthetists Trade Secrets
• New Zealand Crisis Algorithm
– Assume nothing
– Trust no-one
– Give oxygen
• We always ventilate in RSI
• Cricoid pressure tells everyone the airway is
important, but doesn’t really help the patient

63. Anaesthetists Trade Secrets
• Dealing with a beard

64. Anaesthetists Trade Secrets
• Optimal Positioning
– ‘Sniffing the morning air’
– ‘Drinking a pint of lager’
• Need flexion of cervical
spine
• Only use for Voluven

65. Proseal-Bougie Technique

66. • http://b.vimeocdn.com/ts/429/815/42981573
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