The All India Difficult Airway Association 2016 guidelines for tracheal intubation in the Intensive Care Unit

Abstract

Tracheal intubation (TI) is a routine procedure in the Intensive Care Unit (ICU) and is often life-saving. 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 a suboptimal evaluation of the airway and limited oxygen reserves despite adequate pre-oxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxaemia 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 the Indian Society of Anaesthesiologists. Non-invasive positive pressure ventilation during pre-oxygenation improves oxygen stores in patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnoea before the occurrence of hypoxaemia. High-flow nasal cannula oxygenation at 60–70 L/min may also increase safety during TI in critically ill patients. Stable haemodynamics 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.

Indian resuscitation council (IRC) suggested guidelines for comprehensive cardiopulmonary life support (CCLS) for suspected or confirmed coronavirus disease (COVID-19) patient

“…The rescuers need to follow the standard algorithm for difficult intubation. [ 17 18 ] The correct placement of tracheal tube needs to be ascertained by continuous waveform capnograph. Mechanical ventilation should be started with heat and moisture exchanger filters (HMEF)at the inspiratory and expiratory limb, besides one between the tracheal tube and the patient.…”

Cervical plexus anesthesia versus general anesthesia for anterior cervical discectomy and fusion surgery

“…Moreover, difficult airway in GA is not common, but could inevitably increase the endotracheal intubation time. [ 14 , 15 ] After termination of operation under GA, the anesthetic drugs were discontinued, and neuromuscular blockade was reversed by using neostigmine and atropine. Recovery of consciousness occurred when the concentration of anesthetics in the brain dropped below a certain level.…”

Difficult tracheal intubation in critically ill

“…Extending duration of preoxygenation from 4 to 8 min has been shown to be only marginally effective or even harmful in one study on critically ill patients [ 12 ]. Current guidelines recommend 3 min of preoxygenation in critically ill patients, which should be done if possible by using non-invasive positive pressure ventilation (inspiratory pressure 5 to 15 cm, PEEP 5 cm and target tidal volume 6 to 8 ml/kg) in a head up position or with high-flow nasal cannula with oxygen flow at 70 l per min [ 4 ].…”

“…More than 70% of ICU-related airway deaths in NAP4 study were associated with failure to use capnography in patients dependent on artificial airway [ 3 ]. Therefore, current guidelines recommend use of continuous capnography during intubation and tracheostomy for confirmation of correct placement of endotracheal or tracheostomy tube as well as for monitoring in all anaesthetised patients and patients requiring life support irrespective of their location [ 4 , 5 ].…”

“…Apart from patient factors, there are several factors including the environment of the ICU and the skill of the operators and assistants in the ICU that are different from operation theatre [ 4 , 5 ].…”