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Introduction

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The emergency airway cart (Figure 23-1) is designed to be immediately available in the intensive care setting equipped with a variety of equipment that can be used to facilitate endotracheal intubation or alternative airway management approaches (ie, percutaneous airway) when standard approaches have failed.

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Definitions and Terms

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  • ▪  ETT: Endotracheal tube.
  • ▪  Difficult airway: The clinical situation in which a skilled operator experiences difficulty with face mask ventilation of the upper airway, difficulty with tracheal intubation, or both.
  • ▪  LMA: Laryngeal mask airway.
  • ▪  TTJV: Transtracheal jet ventilation.
  • ▪  Surgical airway: Percutaneous tracheal intubation—techniques include cricothyroidotomy and tracheostomy.
  • ▪  Retrograde intubation: Transtracheal passage of a wire through the vocal cords and into the pharynx where it is retrieved by operator, which is then used to guide (pull) the ETT into correct position in the trachea.
  • ▪  Combined esophageal/tracheal tube: A tube designed so that the distal tip sits in and occludes the esophagus, while proximal orifices are used to permit tracheal ventilation.

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Techniques

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  • ▪  Emergency airway cart equipment may include:
    • —Rigid laryngoscope blades of alternate design and size from those routinely used; this may include a rigid fiberoptic
    • —Laryngoscope
    • —Tracheal tubes of assorted sizes
    • —Masks of various sizes
    • —Tracheal tube guides, examples include (but are not limited to) semirigid stylets, ventilating tube changer, light wands, and forceps designed to manipulate the distal portion of the tracheal tube
    • —LMAs of assorted sizes
    • —Flexible fiberoptic intubation equipment
    • —Retrograde intubation equipment
    • —At least one device suitable for emergency noninvasive airway ventilation, examples include (but are not limited to) an esophageal tracheal tube, a hollow jet ventilation stylet, and a transtracheal jet ventilator
    • —Equipment suitable for emergency invasive airway access (ie, cricothyrotomy)
    • —An exhaled CO2 detector
  • ▪  The American Society of Anesthesiology has published a difficult airway algorithm (Figure 23-2) that describes a pathway for handling unexpected problems with ventilation and intubation of the anesthetized patient, which is equally applicable to the intensive care patient.
  • ▪  In the event of difficulties with ventilation:
    • —Consider or attempt placement of an LMA and ventilation.
    • —Call for help.
    • —Attempt endotracheal intubation.
    • —Attempt emergency noninvasive ventilation using:
      • • Esophageal/tracheal tube
      • • TTJV
    • —In the event that the preceding measures are unsuccessful, proceed to surgical airway.
  • ▪  If mask ventilation is adequate and initial intubation unsuccessful.
    • —Attempt endotracheal intubation using alternative approaches including:
      • • Alternate laryngoscope blade
      • • Reposition head
      • • LMA placed as a bridge to intubation, where bronchoscopy is performed through LMA, and ETT threaded over bronchoscope
      • • Bronchoscopic intubation with ETT threaded over bronchoscope
      • • Retrograde intubation
    • —In the event that the preceding measures are unsuccessful, proceed to surgical airway.

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