IERC SimMan/HPS Simulation Scenario Builder

Course/Author: Amanda Murray, MD

Course/Instructor: Amanda Murray, MD, Mojca Remskar Konia, MD
Patient Name: Jim Smith
Scenario Subject: Unanticipated Difficult Airway in the ICU

Educational goals:
1. Develop the learner’s ability to make a safe plan for induction and airway
management during an airway code in the ICU.
2. Review the indications and contraindications for rapid sequence induction.
3. Develop the learner’s communication skills and ability to utilize ICU staff during
an airway code.
4. Recognize a difficult airway, appropriately utilize resources to aid airway
management. Recognize when you need help with an airway and ask for help
early.
5. Effectively use the ASA difficult airway algorithm to manage a “cannot
intubate/cannot ventilate” situation.
6. Develop familiarity and proficiency with a variety of airway management
techniques and devices.
7. Teach the basic anatomy and skills to perform a cricothyroidotomy.

Learning Objectives:
1. Describe and perform airway and clinical assessment in an ICU patient.
2. Identify potential risk factors for a difficult ventilation and intubation.
3. Optimize monitoring and positioning of the ICU patient prior to induction.
4. Discuss indications/contraindications for rapid sequence induction.
5. Discuss various strategies for induction of anesthesia in the ICU patient.
6. Familiarize yourself with the code airway backpack contents, ensure ability to
find and utilize equipment needed from airway backpack for induction.
7. Recognize a difficult airway, recognize when you need help with an airway and
ask for help from your senior resident or staff. Direct available resources to
manage and secure a difficult airway.
8. Demonstrate proficiency in advanced airway management, including bag-mask
ventilation, use of oral and nasal airways, LMA placement, direct laryngoscopy
and cricothyroidotomy.
9. List alternative options for airway management when a given technique fails.
10. Identify landmarks and describe technique to perform a cricothyroidotomy.

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Learners/Level:
-first year anesthesia residents
-oral surgery residents

Agenda

16:00 Short orientation to the “Airway Backpack” and general discussion of ICU airway
management. Highlight the following:
▪Clinical assessment: clinical history, airway exam, previous intubation notes,
important labs/weight
▪Monitoring: turn on pulse oximeter tones, cycle BP Q3min, ensure you can see
monitor well from the head of the bed
▪Position patient in sniffing position with shoulder roll if needed and bed at
appropriate height to optimize intubation conditions
▪Clearly communicate airway plan to ICU team

16:10 Group I: scenario

Group II: airway backpack, cricothyroidotomy teaching

16:30 Group I: airway backpack, cricothyroidotomy teaching

Group II: scenario

16:50 Debriefing-Groups I and II

17:00 Learners complete session evaluation forms

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Learner preparation

Prior to the session all learners are encouraged to review Miller’s Anesthesia Chapter 42,
Airway Management and read the airway articles provided prior to the session. They are
also encouraged to explore the airway backpacks on their own and to accompany CA2
residents to floor intubations for firsthand experience.

Instructor preparation

Prior to session, instructors should be familiar with the scenarios and the SimMan human
patient simulator. Specifically, instructors will need to know how to change the
physiologic parameters in response to learner’s actions. Be prepared to discuss your
approach to ICU intubations with learners. Be prepared to discuss the ASA Difficult
Airway Algorithm and to teach the anatomy and technique necessary to perform a
cricothyroidotomy.

3
Written Didactics:

Miller’s Anesthesia, Ch.42, Airway Management

Articles: Please locate and read the two articles indicated below in preparation for the
simulation.
1. Practice Guidelines for Management of the Difficult Airway, Anesthesiology
2003: 1269-77.
2. Reynolds, S., Heffner, J. Airway Management of the Critically Ill
Patient: Rapid Sequence Intubation. Chest 2005; 127: 1397-1412.

ICU intubation references: References #1 and #2 are found at the end of this curriculum;
click on the hyperlinks below to be directed to the corresponding reference. Please read
in preparation for the simulation.
1. Airway Management In The Intensive Care Unit, Dr. Richard Prielipp M.D.
2. Needle Cricothyroidotomy worksheet

SimLab Large Group Didactics:

Medical Knowledge
▪ obtain critical patient information (weight, potassium, airway information/exam)
▪ pre-induction set-up in ICU
▪ induction drug selection
▪ standard induction versus rapid sequence
▪ identify “can’t ventilate/can’t intubate” situation, call for help if needed

Procedures
▪ ensure all essential monitors are on, working and easily visible according to the
situation
▪ optimize patient positioning
▪ mask ventilation, use of adjuncts such as oral or nasal airway
▪ placement of LMA
▪ direct laryngoscopy
▪ cricothyroidotomy

Interpersonal and communication skills

▪ obtain pertinent clinical information
▪ clearly communicate airway plan to the ICU team
▪ communicate need for backup help early
▪ utilize ICU team and extra help effectively

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Scenario
Learner orientation

It is assumed that learners have been previously oriented to the SimMan and SimLab
setup.
Points to reinforce:
-familiarity with airway backpack, review of all available drugs and equipment
-review rapid sequence (see Chest article)
-optimize monitors and patient positioning
-obtain and prepare all equipment needed for airway management (mask, suction, oral
airway/nasal airway, endotracheal tube with stylet and cuff-tested for leak with a 10cc
syringe, end tidal carbon dioxide detector, possibly a bougie and laryngeal mask airway
set out of the back table if you are worried about the airway on initial assessment.)
-perform appropriate induction of anesthesia
-recognize a difficult airway, recognize a need for help, ask for and utilize help
appropriately
-apply ASA difficult airway algorithm
-highlight anatomy and technique for cricothyroidotomy

Instructions prior to clinical scenario

▪ Two groups of 3 learners
▪ Roles:
1. CA1 resident:
▪ Manages airway:
- assesses the patient
- induces anesthesia
- noninvasively and invasively manages the airway
- organizes activities of others
2. RT
▪Performs tasks when asked:
-assists with bag-mask ventilation
-applies cricoid pressure
-removes ETT stylet
-holds ETT in place, helps apply ETCO2 detector
3. RN
▪Performs tasks when asked:
-gives clinical information about the patient
-assist with positioning, changes monitor setup
-draws up induction drugs in syringes, administers drugs
-calls for help

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Equipment

▪ SimMan simulator with patent PIV, standard monitors in place per ICU protocol
▪ Airway “cold pack” (the plastic container with all necessary drugs for induction)
- 20 cc propofol
- 20 cc etomidate
- 10 cc succinylcholine
- 5 cc rocuronium
- 1 cc atropine
- 1cc glycopyrrolate
-10 cc phenylephrine (100mcg/cc)
-10 cc ephedrine (5mg/cc)
▪ “Airway backpack” with all standard equipment available
- ETT, stylet, syringe
- laryngoscope handle
- laryngoscope blades: Miller 2, 3 and MacKintosh 3, 4
- oral and nasal airways
- face masks in small adult and large adult sizes
- Yankauer suction
- ETCO2 detector
- laryngeal mask airways in sizes 1,1.5, 2, 2.5, 3, 4 and 5
- 10cc syringe (for endotracheal tube)
- 20 cc syringe (for laryngeal mask airway)
- bougie/endotracheal tube introducer

6
Simulation

You are a brand new Clinical Anesthesiology year 2 resident and are called to the
medical intensive care unit to intubate a patient who has just been transferred from an
outside hospital with pneumonia and increasing respiratory distress. On entering the
room, you observe an obese, middle-aged male in respiratory distress with oxygen
saturations of 88-92% on 15 liters non-rebreather face mask. He has a patent 18gauge
peripheral intravenous line and all standard ASA monitors are in place. There are no
records or previous airway notes. The patient is somnolent and cannot answer your
questions or participate in an airway examination.

History and Physical

HPI: 54 year old male transferred from outside hospital with pneumonia, now with
increasing respiratory distress and probable early sepsis. He was reportedly confused at
the outside hospital and was somnolent on arrival to the medical intensive care unit.

PMH: chronic obstructive pulmonary disease, obstructive sleep apnea, hypertension

PSH: Right inguinal hernia repair, 2006

ROS: unable to obtain

Medications: hydrochlorothiazide, aspirin, albuterol, Advair Diskus, tiotropium

Exam:
Vital Signs: blood pressure 90/56, heart rate 120, respiratory rate 40 breaths/min, oxygen
saturation 88% on 15 liter non-rebreather face maks, weight 134kilograms
General: obese middle aged male, lying in bed, in respiratory distress, face mask in place
Airway: thyromental distance=6cm, thick neck, unable to assess neck range of motion,
dentition or mallampati class due to lack of patient cooperation
CV: tachycardic, regular rate and rhythm, no murmurs
Pulm: heaving retractions, significant increased work of breathing, scattered rhonchi
bilaterally
Neuro: unresponsive to voice, withdraws to painful stimuli

Laboratory:
Hemoglobin 14.3
Sodium 141
Potassium 4.2
Chloride 104
HCO2 17
BUN/creat 18/1.2
Glucose 145
ABG: 7.28/55/110/18 on 15 liters non-rebreather face ma

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Background and briefing information for coordinator’s eyes only:
In this simulation the learner is expected to obtain history and pertinent clinical data,
perform a brief clinical evaluation including airway exam, prepare and lay out all
necessary airway equipment, ensure all necessary monitors are in place and set
appropriately, optimize patient position, relay airway plan to ICU team, perform an IV
induction based on their clinical judgment, attempt mask ventilation, place oral or nasal
airway, ask for help from ICU team when needed, attempt direct laryngoscopy with grade
4 view and pull back laryngoscope, recognize the need to ask for help from more senior
skilled airway expert early, place LMA and check for ability to ventilate patient with the
LMA, reassesses and optimizes situation, asks for appropriate help from team, secures
airway following the ASA Difficult Airway Algorithm.

Simulation scenario narrative:

Time Course Patient status Desired learner Learner teaching

1. preinduction ▪ Obtunded, obese male
in acute respiratory
distress, on BiPAP, PIV
and standard ASA
monitors in place,
unresponsive to
questions, withdraws to
pain
▪ VS:
NIBP 105/56 (cycling
Q20 minutes),
HR 120 (no tones on
pulse ox),
RR 40,
SaO2 88% on BiPAP
▪ Clinical information
available when team
asked:
Wt 134kg,
Potassium 4.2
▪ monitor is turned away
so the learner cannot see
it.
2. induction ▪ patient is obtunded,
high flow O2 in place,
SaO2 stable in 88-90%
range
▪ after induction, patient
RR to 15, then 5, then 0
▪ patient SaO2 starts to
drop slowly (every 5
seconds) after induction,
not being ventilated
▪ SaO2 slowly trends
down despite addition of
adjuncts such as
actions points
▪ asks for brief clinical ▪ obtain/review patient
history, pertinent labs, information in an
weight efficient manner
▪ performs brief patient ▪ optimize patient
evaluation monitors, positioning
▪ inquires about monitor and IV access prior to
set up, requests NIBP induction
cycles Q3min, pulse ox ▪ clearly communicate
tones turned on plan for induction to
▪ checks IV access ICU team
▪ prepares all induction ▪ prepare all needed
drugs, informs RN intubation equipment
clearly about drug doses ▪ ensure pre-
▪ prepares airway oxygenation as you set
equipment, optimizes up for intubation
set-up at head of bed, ▪ utilize ICU team to
▪ discusses plan for speed preparations for
airway management intubation if needed
with ICU team
▪ preoxygenates patient ▪ ICU team is there to
▪ announces when help you and should be
induction should begin, utilized
repeats drug doses to
RN
▪ communicates inability
to ventilate patient with
one-handed mask
▪ utilizes adjuncts such
as oral/nasal airway or
two-handed mask with
help from ICU team

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 oral/nasal airway/two-
handed mask ventilation
3. unsuccessful ▪ VS:
intubation attempt BP 140/95,
HR 130,
SaO2 84%
▪ grade 4 view on direct
laryngoscopy, SaO2
80%
▪ if resident continues to
to intubate SaO2
continues to fall to 60%
▪ easy LMA placement
with adequate
ventilation after
placement
▪ SaO2 improves to 92%
4. team planning for ▪ SaO2 92% with LMA
definitive airway in place
▪ BP 115/56, HR 115
5. secures airway ▪ SaO2 rises to 95%, BP
125/65, HR 120
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▪ grade 4 view on direct ▪ Do not repeat failed
laryngoscopy x 1 technique-change
▪ communicates grade 4 blades, optimize patient
view to team, requests position, etc
cricoid pressure without ▪ LMA as rescue device
improved view in difficult airway
▪ requests and places algorithm
LMA correctly ▪ discuss potential for
▪ Recognizes chest rise, additional airway
fog in LMA, confirms trauma/fixation errors
breath sounds with multiple DL
▪ calls for attempts, consequences
anesthesiology and of delaying definitive
surgical backup, prepare management of hypoxia
for cricothyroidotomy ▪ call for anesthesiology
/tracheostomy if and possibly surgery
necessary help early in potential
difficult airway situation
▪ assesses and ▪ consider alternatives to
summarizes situation secure airway-
with ICU team alternative blade, LMA
▪ calls for as intubating conduit,
anesthesiology and FOB, etc
surgical backup, prepare ▪ ensure optimal patient
for cricothyroidotomy positioning
/tracheostomy if ▪ clear leadership and
necessary communication critical
during management of
airway
▪ call for help early with
difficult airway, before
problem becomes life-
threatening
▪ communicates grade 3 ▪ inform team and write
view to team with a detailed airway note-
change to airway highlight what was
management (new effective for this patient
blade/position, etc) ▪ call for help early with
▪ communicates difficult airway, before
successful intubation to problem becomes life-
team threatening
▪ confirms ETCO2,
+EBBS after intubation
▪ helps RT secure ETT
and get patient on vent
▪ calls for
anesthesiology and
surgical backup, prepare
for cricothyroidotomy
/tracheostomy if
necessary
Debriefing Note
I. General
1. What went well?
2. What was difficult?
3. Is there anything you think you should have done differently?
4. Is there anything you think others should have done differently?

II. Specific
1. What were your main concerns from the patient history? From the clinical scenario?
2. What induction drugs did you choose for this patient? Why?
3. What adjuncts can you use when ventilation is difficult?
4. Were you effective as the team leader? Is there anything you could have done
differently?
5. Were there any fixation errors during the scenario?
6. Were there any deviations from the difficult airway algorithm?
7. What would your next step have been if you were unable to ventilate the patient at all?
Able to ventilate but unable to intubate after your second DL?
8. What did you change in order to successfully intubate your patient? Was this a
realistic change that has worked for you in real life?
9. How would your plan for airway management have changed in an obese patient with a
thick, short neck? What resources and/or strategies are available to you to help secure
this type of airway?

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Unanticipated Difficult Airway Evaluation
Name:____________________________

General
□ acts professionally
□ reviews history, obtains critical labs, performs brief clinical exam
□ wears gloves

Equipment and Set Up

□ optimizes monitors: sets NIBP to cycle, turns on pulse ox tones, can see monitor
from head of bed
□ ETT, stylet and syringe
□ laryngoscope handle with functioning light
□ laryngoscope blades
□ oral/nasal airway
□ working suction
□ ETCO2 detector
□ Ensures patent IV access
□ Ensures pre-oxygenation during set-up

Induction/Difficult airway sequence

□ clearly communicates plan for intubation with team
□ clearly communicates induction drugs and doses to RN
□ optimizes patient position
□ attempts bag-mask ventilation-one person
□ attempts bag-mask ventilation-two people
□ uses oral/nasal airway
□ attempts LMA
□ attempts intubation ≤ 2 times on own
□ does not repeat failed technique
□ calls for help
□ confirms ETCO2 and EBBS after successful intubation
□ helps secure ETT
□ continually reassesses vital signs during scenario

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Unanticipated Difficult Airway Evaluation
Name:_____________________________

General
□ acts professionally
□ reviews history, obtains critical labs, performs brief clinical exam
□ wears gloves

Equipment and Set Up

□ optimizes monitors: sets NIBP to cycle, turns on pulse ox tones, can see monitor
from head of bed
□ ETT, stylet and syringe
□ laryngoscope handle with functioning light
□ laryngoscope blades
□ oral/nasal airway
□ working suction
□ ETCO2 detector
□ Ensures patent IV access
□ Ensures pre-oxygenation during set-up

Induction/Difficult airway sequence

□ clearly communicates plan for intubation with team, communicates changes in
plan as needed
□ clearly communicates induction drugs and doses to RN
□ optimizes patient position
□ attempts bag-mask ventilation-one person
□ attempts bag-mask ventilation-two people
□ uses oral/nasal airway
□ attempts LMA
□ attempts intubation ≤ 2 times on own
□ does not repeat failed technique
□ asks for help from team-cricoid pressure/two handed mask, etc.
□ confirms ETCO2 and EBBS after successful intubation
□ helps secure ETT
□ continually reassesses vital signs during scenario

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Simulation Evaluation Form
Unanticipated Difficult Airway in ICU
Level of Training: CA1 Residents
Date 11/3/2009

Goals and objectives:

1. Orient residents to airway backpack
2. Orient residents to floor intubation routines, discuss potential problems and differences
between OR inductions and intubations versus floor inductions and intubations
3. Review the ASA Difficult Airway Algorithm

Was it helpful to do the scenario?

strongly agree agree neutral disagree strongly disagree

1 2 3 4 5
Comments:______________________________________________________________
_______________________________________________________________________

strongly agree agree neutral disagree strongly disagree

1 2 3 4 5
Comments:______________________________________________________________
_______________________________________________________________________

What did you learn from the scenario? What was most helpful?
________________________________________________________________________
________________________________________________________________________

What was the least helpful aspect of the scenario?

________________________________________________________________________
________________________________________________________________________

What would you change to make this more helpful/instructive?

________________________________________________________________________
________________________________________________________________________

What other scenarios do you think would be helpful to your education?

________________________________________________________________________
________________________________________________________________________

13
Needle cricothyroidotomy (Back to Written Didactics)

Anatomy

Image retrieved on December 15th from:

www.wikipedia.org/wiki/File:Larynx_external_en.svg

Creative Commons license associated: creativecommons.org/licenses/by-nc-nd/3.0/

Technique

1. ID landmarks as above, clean area over cricothyroid membrane with alcohol swab
2. Advance sterile, 14 gauge angiocatheter with a syringe attatched ½”-3/4”,
aspirating continually until you get air return. If you go too far, you may puncture
the esophagus, so use care and aspirate slowly.
3. Once you aspirate air, direct needle toward sternal notch and cast off 14 gauge
angiocatheter from needle, so catheter remains in trachea. Remove and safely
dispose of your needle.

14
4. Attach the plastic connector from a 4.0 ETT to the hub of your 14 gauge
angiocatheter.
5. Provide ventilation via a bag-valve device with the highest available
concentration of oxygen.
6. Call for jet ventilator to oxygenate patient at 20psi per breath. If a jet ventilator is
not available, move to step #7.
7. Thread guidewire through angiocatheter down into trachea, remove angiocatheter,
enlarge vertical cricothyroidotomy incision with scalpel and insert a 5.5 or 6.0
endotracheal tube through the incision site, over the guidewire. Secure
endotracheal tube and bag-mask ventilate.
8. Confirm chest rise and bilateral breath sounds.
9. Assess ability to oxygenate.
10. Assess ability to ventilate if an endotracheal tube has been placed by guidewire
via the cricothyroidotomy incision.
11. Secure airway by wrapping tape around catheter well, then from catheter around
back of neck and back to catheter on opposite side.

15
 AIRWAY MANAGEMENT CONSIDERATIONS IN THE
ADULT INTENSIVE CARE UNIT
(Written Didactics)

Learning Objectives:
1. To appreciate the increased morbidity/mortality profile of airway interventions in
the adult intensive care unit.
2. To understand the multiple variables affecting airway management decisions in
the critically ill adult and how they may significantly differ from adults presenting
to the operating room.
3. To integrate pertinent critical care literature into airway management decision
making in adult critical care patients.

Introduction:
Anesthesia providers are frequently summoned to provide airway management expertise
for nonoperative patients in clinical areas outside of the operating room. One particularly
challenging environment commonly requesting such services is the intensive care unit
(ICU). The critically ill represent a unique subset of patients whose underlying
pathophysiologic derangements geometrically increase their risks of morbidity and
mortality from a variety of airway interventions, which often must occur urgently or
emergently under uncontrolled conditions. As such, it is incumbent upon anesthesia care
givers to understand the multiple variables affecting airway manipulations in the adult
critical care patient and associated factors that often differ from more routine surgical
patients presenting to the operating room.

Airway Management Adverse Outcomes: The American Society of Anesthesiologists

(ASA) Closed Claims Study
The ASA Closed Claims Study represents our specialty’s systematic evaluation of
adverse events associated with suboptimal airway management outcomes. While this
database is primarily derived from intraoperative and immediate perioperative recovery
periods, it provides a useful foundation from which to project the likelihood of such
outcomes from airway management misadventures in the critically ill. Current
information derived from this multi-decade effort is temporally summarized in the table 1
below (1-4):

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TABLE 1: SUMMARY OF ASA CLOSED CLAIMS STUDY RESULTS
% DEATH/BRAIN
EVENT(S) % CLAIMS DAMAGE (BD) ASSOCIATED COMMENTS
Adverse Respiratory 37.2% 74.8% single largest class of injury
Inadequate 7% >90% Cheney, 1991; Miller, 2000
oxygenation/ventilation
Esophageal intubation 4.5% >90% Cheney, 1991; Miller, 2000
Airway obstruction 3% 87% 70% upper airway
Difficult intubation (DI) 6.4% 57% ▪ risk factors: increased age, ASA
3 or 4, obesity
▪ DI anticipated in only 50%
▪ airway history or physical exam
in only 25%, respectively
Airway (AW) injuries 6% 8% (death) ▪ trachea, pharynx, or esophagus
in 2/3rds
▪ pharyngoesophageal (PE) and
tracheal injuries associated with DI
▪ PE injury risk factors – female,
age >60
Difficult AW <4% 63% ▪ 67% induction, 12% extubation,
5% recovery
▪ death/BD during induction ↓ 44%
after Diff. AW algorithm; no
change in death/BD during other
time periods
▪ 25% AW emergencies (can’t
intubate, can’t ventilate): 86%
death/BD
▪ persistent intubation attempts,
airway “rescue maneuvers" during
AW emergencies: poor outcomes

What Do We Know About The Risks of Airway Management Interventions in the

ICU?
Airway management literature from the critical care environment is significantly
confounded by the heterogenous nature of this patient population, their underlying critical
illness/comorbidities, and their various indications for definitive airway control. As such,
these data must be carefully scrutinized and interpreted with caution.

Unplanned extubation (UE) of mechanically ventilated ICU patients is one particularly

common scenario generating emergent calls for anesthesia airway expertise. Reintubation
rates after UE range between 23-77%, with surgical ICU (SICU) patients appearing less
likely to require reintubation compared to those in the medical ICU (MICU) (5-6).
Reintubation rates also appear lower in younger patients and those undergoing active
weaning from mechanical ventilation (5-7). Not surprisingly, factors such as inadequate
sedation and agitation have been consistently associated with UE in many series. While
the timing of reintubation after UE is arbitrarily limited to a specific time period in some
studies (typically within 24-72 hours after UE) (5-8) or not specified in others (9), studies
reporting such data suggest that the majority of UE patients requiring reintubation do so
within the first 2 hours (7,10). Although ICU patients experiencing UE do not have worse

17
outcomes compared to either the ICU study population or matched case controls (6-9),
some data suggest that UE patients requiring reintubation have an increased risk of ICU
and/or in-hospital mortality compared to those not requiring reintubation (6-7).

Are the risks associated with reintubation after UE higher, the same, or lower than these
same risks during intubation in the operating room? Table 2 below summarizes recent
literature on adverse outcomes from out-of-OR airway management and emphasizes the
increased risk profile associated with intubating an ICU patient (10-14):

TABLE 2: COMPLICATIONS OF ICU AIRWAY MANAGEMENT

EVENT % INCIDENCE
Difficult Intubation (DI)
Esophageal Intubation (EI)
Right Mainstem Intubation
Hypoxemia (SpO2 < 90%)
Severe Hypoxemia (SpO2 < 70-
80%)
Hypotension
Surgical Airway
Cardiac Arrest
ASSOCIATED COMMENTS
8-14% ▪ historical incidence in anesthesia
literature 1-3%
5-14% ▪ increased incidence with > 2 DLs
4-5%
12-26% ▪ increased incidence with > 2 DLs
▪ increased incidence with EI
▪ increased incidence with regurgitation
and/or aspiration
6-26% ▪ same as hypoxemia above
25-35% - no relationship to # of DLs
2-20% ▪ highest incidence in cardiac arrest
associated with DI
2-3% ▪ more likely with preintubation ↓ BP
▪ increased incidence with > 2 DLs
▪ common pattern: severe hypoxemia →
bradycardia → asystole
▪ approx. 25% had preDL SpO2 < 90%
▪ 15-20% required surgical airway
▪ up to 38% survival to hospital discharge

Two studies derived from a large quality improvement database of non-OR intubations
by anesthesia providers utilizing direct laryngoscopy (DL) over more than a decade
warrant specific mention. Approximately 70% of these intubations occurred in the ICU
and another 10% in the Emergency Department (which I would consider a critical care
environment). The first reported a series of 2833 emergency intubations over a 10 year
period and demonstrated a 10% incidence of difficult intubation. One particularly
ominous finding was that rates of hypoxemia (SpO2 < 90%), severe hypoxemia (SpO2 <
70%), esophageal intubation, and cardiac arrest within 5 minutes of intubation were 70%,
28%, 51%, and 11%, respectively, in the DI group compared to 10.5%, 1.9%, 4.8%, and
0.7% in those patients requiring 1 or 2 DLs (12). A more recent study utilizing the same
database subsequently reported 60 cardiac arrests within 5 minutes of emergency
intubation in 3035 patients over an 11 year period. These arrests exhibited a consistent
pattern initially heralded by severe hypoxemia precipitously followed by bradycardia and
asystole. The rates of DI and EI in this series were 62% and 63% respectively, and a
surgical airway was ultimately performed in 20% of cases. One- and 7-day mortality rates

18
were 27% and 50%, respectively, and only 38% of arrest victims survived neurologically
intact to hospital discharge (13).

For those who remain unconvinced about the high-risk nature of ICU airway
management, the ASA Closed Claims Study recently contributed further sobering support
of this concept. Peterson and colleagues reported a subset of 23 difficult airway claims
occurring in “outside locations” other than the operating room. The vast majority of this
group was sick (ASA 3 or 4) inpatients and approximately half were emergency
situations in nonsurgical patients. Reintubation for postoperative swelling of the
head/neck and ETT exchange each accounted for 25% of these claims. The incidence of
death or brain damage in this subgroup was 100%. The authors felt these results “may
reflect the lack of operating room resources of standard airway management equipment
or the lack of immediate availability of healthcare providers skilled in airway
management” (4).

ICU Airway Management: Initial Considerations

My general approach to managing the ICU airway involves emergently responding to the
patient’s bedside with as many airway options as can be expediently accessed at the time
expertise is requested (i.e., an airway “bag”). Once at the bedside, I simultaneously
acquire a brief, focused history of the patient’s current hemodynamic and pulmonary
status from the bedside providers while rapidly performing a screening airway
/cardiorespiratory “primary survey” (table 3).

TABLE 3: RAPID ICU AIRWAY MANAGEMENT “PRIMARY SURVEY”

Color/cyanosis/conjunctiva
Retractions/paradoxical respiratory efforts
Snoring/stridor/hoarseness
Difficult airway traits
Presence/absence of protective reflexes
Carotid pulse/capillary refill/JVD
Tracheal position/surgical AW landmarks
Breath sounds/chest excursion
Mental status/agitation
Vital signs/ SpO2

My goal from this process is to triage the airway situation into 1 of 3 categories within 5
minutes of arrival: (1) a true, high-risk, life-threatening airway emergency requiring
immediate intervention under current conditions (these are usually self evident), (2) an
urgent, moderate risk airway situation which can potentially be managed semi-electively
under more controlled conditions, or (3) an elective clinical scenario where conditions
should be optimized to maximize success of the chosen airway intervention while
minimizing the risk of patient decompensation. Ongoing vigilance, close clinical
monitoring, and frequent reevaluation are mandatory in the latter two categories, and
providers should be fully prepared to “kick it up a notch” should the patient begin to
deteriorate.

An underrepresented, but equally important component to successful ICU airway

management is the mental and psycho-emotional preparation of the airway provider(s).
These are commonly dynamic, highly stressful, and poorly controlled clinical situations
with the constant potential for precipitous, life-threatening deterioration. Such high-risk
scenarios are the antithesis of a well-planned, methodical, controlled anesthetic induction
with which anesthesia providers are most comfortable. Emergent clinical decisions must

19
frequently be based on skimpy, incomplete information, and the patient is often less than
fully cooperative due to hypoxemia, respiratory distress, sepsis, shock, sedatives/
analgesics, and/or their underlying critical illness. Death from inability to successfully
manage an ICU airway can devastate the confidence of the airway provider irrespective
of level or experience (15), and anesthesia team members must accept that their well-
intentioned airway efforts will occasionally result in a devastating outcome.

ICU Airway Management: The Unsecured Airway

The ASA Practice Guidelines for Management of the Difficult Airway (16) represents the
criterion standard by which airway management issues should be approached irrespective
of location, and I would argue it is as equally applicable in the ICU as it is in the
Operating Room. That said, consistent implementation of the guideline’s
recommendations in the ICU may prove problematic due to lack of advanced airway
equipment, knowledge/skill deficiencies of ancillary bedside staff, and/or patient-specific
contraindications (for example, nasal intubation in an anticoagulated patient).

Rather than expend time and energy reviewing the ASA Difficult Airway algorithm
(which we have all seen countless times), I have elected to focus on airway management
aspects unique to the ICU based upon my 20+ years of ICU experience and pertinent
critical care literature. Please consider the following “Kelly’s Tips for ICU Tubes”
(presented in no particular order) as adjuncts to the ASA Difficult Airway algorithm in
appropriately managing the ICU airway.

Tip #1: “Tag – You’re It”. Respond anticipating this will be a high-risk, emergency
airway situation requiring immediate stabilization in a setting of limited airway
equipment availability and suboptimal assistance from bedside paramedical personnel.
Frustration is the enemy of performance under duress, and it is much better to be
pleasantly surprised when adequate equipment and help are indeed available.
Tip #2: “You’re Not In Kansas Anymore, Dorothy”. The ICU is an ergonomically
challenging environment for managing an unstable airway. Ventilators, infusion pumps,
continuous dialysis machines, central lines, and intracranial pressure monitors crowd the
head of the bed. Nasogastric/feeding tubes and cervical collars interfere with mask
ventilation and laryngoscopy. Inflatable skin care beds make it difficult to optimally
position patients, particularly if head of bed elevation is required. This is the OR – NOT!
Tip #3: Is Intubation/Reintubation Clinically Indicated At This Time? Avoid the
urge to be a technician and independently evaluate whether intubation is clinically
indicated under current conditions. In my experience, most situations requiring
immediate intubation are readily apparent upon arrival at the bedside and should be
handled accordingly. In the remainder of cases, a more systematic evaluation of the
patient’s current condition and anticipated near-term course (which may require direct
communication with the patient’s physician team) may be warranted before making a
decision to intubate (or not). The 40% TBSA burn patient with inhalation injury may
need intubated early while clinically stable knowing that he/she will likely develop
significant upper/lower airway edema during their Parkland formula fluid resuscitation.
Alternatively, a young patient S/P exploratory laparotomy for traumatic liver and splenic
lacerations who self-extubates during active weaning from mechanical ventilation and

20
who is breathing comfortably with adequate oxygen saturation may warrant a “trial of
extubation” with close clinical monitoring.
Tip #4: Time Permitting, Find Any Previous Intubation Notes and Read Them. The
details found in intubation notes provide valuable information (intubating provider, blade,
taping depth, etc.) regarding what was previously successful (or unsuccessful) in the
same patient. Such information must then be extrapolated to the patient’s current
condition to evaluate its applicability (or lack thereof). Documentation of previous airway
management difficulties earlier in the patient’s hospitalization portends similar problems
with current airway management unless the patient has improved significantly in the
interim. Conversely, an uneventful intubation 2 weeks previously for elective surgery
may no longer be applicable in a patient who subsequently develops postoperative sepsis
and multisystem organ failure.
Tip #5: Place A Large (Preferably ≥ 7.5 mm), High Volume, Low Pressure
Endotracheal Tube (ETT) If Possible. While any ETT is better than no ETT in a patient
death spiraling toward cardiac arrest, a high volume, low pressure ETT better distributes
a lower ETT cuff pressure along the tracheal mucosa and may decrease the incidence of
post-intubation airway complications. I also recommend strong consideration for placing
a 7.5 mm (or larger) ETT in almost all adults in the ICU to allow for diagnostic and/or
therapeutic fiberoptic bronchoscopy (FOB) during the patient’s ICU course and minimize
requests for ETT exchange to permit same.
Tip #6: Strongly Consider The Pros and Cons Of Maintaining Spontaneous
Ventilation. To quote my mentor, Dr. Donald Prough, “The only thing worse than a
critically ill patient with a bad airway is a critically ill patient with no airway.”
The pharmacodynamic effects of sedatives, anesthetic agents, and/or neuromuscular
blocking drugs superimposed upon the patient’s underlying critical illness have an
unpredictable interaction that may turn a bad airway situation into a crisis. Alternatively,
maintenance of airway patency and spontaneous ventilation potentially allows
insufflation of supplemental oxygen during airway manipulations while not
pharmacologically “burning any bridges.” Many ICU airway scenarios unfortunately
mandate taking a “safety first, comfort second” approach, and I have personally found air
hunger to be a valuable factor in securing patient cooperation for unsedated DL attempts.
Tip #7: “Ah, Yes, The Nose, The Nose” (See Allen, Woody, “Sleeper”). Blind
nasotracheal intubation is a vastly underutilized technique (in my opinion) and can
potentially stabilize the airway in rapid fashion with minimal equipment and limited
patient cooperation when spontaneous respiratory effort is present. Air hunger is again a
valuable adjunct with this technique, and some patients literally “suck the tube in” due to
their exaggerated inspiratory efforts. If successful, the nasotracheal tube should be
replaced with an orotracheal tube or tracheostomy as soon as the patient stabilizes due to
the association between nasotracheal intubation and nosocomial sinusitis (17).
Tip #8: “Hear The Sirens Of Oxygen Desaturation”. Critically ill patients commonly
have a significant imbalance between low oxygen supply (low functional residual
capacity, low PAO2, hypercapnia, hypovolemia, low cardiac output, anemia) and high
oxygen consumption (catabolic stress, fever, tachycardia, tachypnea, seizures, agitation,
etc.) (18). The current transfusion trigger in many ICUs is a hemoglobin < 7 grams/dl
based upon data supporting lower mortality with restrictive transfusion strategies (19).
These lower hemoglobin concentrations (which disproportionately lower arterial oxygen

21
content relative to a low PaO2) significantly magnify the limited efficacy of
preoxygenation prior to DL in the critically ill (20). The oxygen desaturation data
summarized above in table 2 are thus not particularly surprising given such conditions
and in large part explain my preference to maintain spontaneous ventilation if at all
possible.
Tip #9: Should Your Plan “B” Be A Surgical Airway? While the majority of
anesthesia providers are confident in their supraglottic airway management skills and
have a historically high rate of translaryngeal intubation success, it is also true that some
critically ill patients would be best served by skilled surgical airway expertise (either
primarily or as a backup at the bedside or in the operating room). The thrombocytopenic
leukemia patient with trismus, drooling, 1 finger breadth mouth opening, and an
exquisitely tender fist-sized mass filling the sublingual space down to 2 finger breadths
above the suprasternal notch (an actual case I was presented with recently) obviously
mandates extremely cautious airway manipulation, and it is no “sign of weakness” to
defer to a skilled otolaryngologist under such circumstances. It is similarly intuitive that
surgical airways performed semi-electively or electively will likely result in better
outcomes. Sixty-four percent of tracheal injuries reported from the ASA Closed Claims
Study were related to surgical tracheostomy, 84% of which were emergently performed
during DI situations (2). Peterson’s more recent report from this same database
documented 75 closed claims from emergency airway situations. Seventy-six percent of
these cases had surgical airways attempted; the incidence of death/BD in these cases was
84% (4). Anesthesia providers practicing in hospitals where surgical airway expertise is
not immediately available may want to consider acquiring skill in performing a surgical
cricothyroidotomy. Percutaneous cricothyroidotomy kits utilizing the Seldinger technique
are commercially available and may warrant routine ICU stocking under such conditions.
Tip #10: “Never Do The ICU Airway Boogie Without A Bougie”. In my experience,
the gum elastic bougie (GEB) is the most valuable, easily available adjunct for ICU
intubations and may be particularly useful in patients with limitations in mouth opening
or cervical spine mobility (21). A recently published Australian study of 147 DIs
demonstrated that 46% were successfully managed utilizing a GEB (22).
Tip #11: Helpful Colleagues May Be Unhelpful. A recent emergency medicine cadaver
study suggests that cricoid pressure and backward-upward-right(ward) pressure (BURP)
applied by assisting practitioners significantly worsens laryngoscopic views using a
curved blade compared to laryngoscopist-directed thyroid cartilage manipulation (23).
These findings are consistent with the above mentioned Australian study, which found
only 11% of the DIs were ultimately intubated utilizing patient repositioning, cricoid
pressure, or BURP (22).
Tip #12: Consider Using A Straight Blade. Limited mouth opening and inability to
consistently place ICU patients in a reasonable “sniffing position” makes a straight blade
more efficacious in my hands under such circumstances. Indeed, one recent study from
the anesthesia literature suggests that laryngoscopic views obtained with a straight blade
were statistically superior to those obtained with a curved blade (24). Furthermore, the
posterior oropharynx commonly contains orogastric and/or feeding tubes, making the
lower straight blade profile advantageous. The GEB is particularly valuable under such
circumstances.

22
Tip #13: Choose Your Anesthetic And Sedative Agents Wisely (If At All). While
etomidate’s hemodynamic stability makes it an appealing agent for ICU airway
management, emerging evidence suggests its adrenal suppressive properties may have
deleterious consequences in this population (25, 26). Benzodiazepine administration in
the critically ill has been associated with agitation, UE, and delirium (9, 27). Individual
ICU patients manifesting partial upper airway obstruction potentially may worsen with
sedative doses of propofol and midazolam (28). Topical benzocaine can cause
methemoglobinemia and adversely affect systemic oxygenation (29).
Tip #14: “Do You Feel Lucky, Punk?” (see Eastwood, Clint, “Dirty Harry). While
succinylcholine appears to be commonly administered during ICU airway management
(11-14), factors such as thermal burns, disuse atrophy, upper/lower motor neuron
denervation, and therapeutic glucocorticoid administration may predispose the critically
ill to succinylcholine-induced hyperkalemia and subsequent cardiac arrest (30).
Furthermore, a computer model simulating the rate of oxygen desaturation during
complete upper airway obstruction after administration of succinylcholine 1 mg/kg
suggests that critical oxygen desaturation (defined as an SpO2 < 80%) occurs 3-5 minutes
before single twitch height recovers to 50% of control in a typical critical care patient
(18).
Tip #15: Write An Appropriately Detailed Intubation Note, Including Post-
Intubation Chest X-Ray (CXR) Findings (Or Which Physician Has Actively
Assumed Responsibility For Checking Same). See tip #4 above. I am personally aware
of 2 malpractice litigations where anesthesiologists were named defendants primarily
because of questions involving ETT position on the post-intubation CXR. Lack of timely
CXR interpretation and implementation of appropriate corrective actions were alleged to
be the proximate cause of cardiac arrest in both cases.

ICU Airway Management: Anesthesia “Standby” For High-Risk Extubation

Another ICU scenario which anesthesia providers are commonly presented with involves
“standby” for high-risk patients undergoing elective/semi-elective extubation. Typical
examples might be DI patients who were successfully intubated, patients with obstructive
sleep apnea (OSA), mentally challenged adults, high spinal cord injuries, and patients
with impaired sensorium from a variety of causes. While many of the “tips” detailed
above continue to apply to “standby” extubations, some additional ones are worthy of
consideration:

Tip #16: Is This Patient An Appropriate Candidate For A “Trial” Of Extubation?

Anesthesia care givers need to again resist the urge to be technicians and ensure that the
patient has met appropriate criteria for possible extubation. Acceptable mentation,
minimal secretions, presence of protective airway reflexes, adequate oxygenation on
nontoxic oxygen concentrations with minimal PEEP, absence of significant tachypnea or
respiratory extremis, and a limited trial of spontaneous breathing are commonly utilized
(31, 32).
Tip #17: Is Residual Nondepolarizing Neuromuscular Blockade Present? Low
plasma levels of nondepolarizing neuromuscular blocking agents adversely affect upper
airway patency and coordinated pharyngeal swallowing. Both of these vital airway
functions do not reliably return until recovery to a train-of-four ratio ≥ 0.9 occurs, a ratio

23
not exceeded for 2 hours or more in a significant number of patients after a single
intubating dose of an intermediate acting nondepolarizer (33, 34). Because patients
incompletely recovered from nondepolarizing neuromuscular blockade may meet other
criteria commonly used in ICU extubation paradigms (forced vital capacity, negative
inspiratory force), it is important to clinically demonstrate absence of significant residual
blockade (with maneuvers such as sustained head lift and tongue protrusion to command)
since airway obstruction and inability to handle oropharyngeal secretions will not
manifest themselves until the ETT “stent” is removed (35). Incomplete recovery from
long-acting (but not intermediate-acting) nondepolarizing neuromuscular blockade has
been previously associated with the development of postoperative pulmonary
complications (36).
Tip #18: Should I Check For An ETT Cuff Leak? Certain ICU patients (such as those
with significant head/neck edema) present concern about upper airway compromise after
ETT “stent” removal and may warrant testing for an ETT cuff leak. This can be done
using positive pressure and a stethoscope on the anterior neck (as with uncuffed ETTs in
children) or by temporary cuff deflation followed by a request for the patient to cough or
phonate in those awake and cooperative. Absence of a clinical leak (my arbitrary
threshold being ≤ 25 cm of water) in an appropriate situation should lead to thorough
reevaluation regarding whether to proceed. I have on rare occasions taken ICU patients to
the operating room with ENT standby for controlled extubation and immediate post-
extubation monitoring (similar to the “double set-up” approach for children with
epiglottitis).
Tip #19: Should I Consider Extubating Over An Airway Exchange Catheter (AEC)?
In patients with a known or suspected difficult airway, extubation over an indwelling
AEC permits continuous distal insufflation of supplemental oxygen as well as support of
ventilation utilizing either a bag-valve-15 mm adaptor system or a jet venturi apparatus. It
can safely remain in the trachea with acceptable patient tolerance for a number of hours
until the clinical risk of reintubation appears unlikely (37). Should extubation failure
occur, the AEC can be utilized as an intubating stylet while limiting oxygen desaturation
with simultaneous oxygen insufflation during reintubation (37). I am aware of one
institution which has a 90% reintubation success rate with 1-2 attempts utilizing the AEC
for this indication while reporting low rates of hypoxemia, esophageal intubation, and/or
use of airway rescue devices (personal communication). Use of an AEC to support
ventilation with an in situ ETT and its associated risk of barotrauma will be discussed in
the next section.
Tip #20: Is It Known Or Likely That This ICU Patient Has OSA? OSA patients can
be particularly challenging to optimize prior to extubation and require a multifaceted plan
to maximize extubation success while minimizing pharmacologic respiratory depression,
anatomic impairment with ventilation, and subsequent need for reintubation. Analgesic
requirements (regional analgesia, nonsteroidal antiinflammatory agents if applicable),
ETT tolerance during ventilator weaning (dexmetotomidine’s absence of effect on CO2
response is appealing), patient positioning (sitting upright or reverse Trendelenburg),
appropriate application of airway adjuncts (nasopharyngeal airway), and post-extubation
interventions (i.e., immediate application of noninvasive positive pressure ventilation)
should all be considered in plan development. The recent ASA guidelines in this area

24
provide the latest consensus regarding management of this increasingly common problem
(38).

ICU Airway Management: ETT Exchange

ETT exchange represents the final ICU scenario worthy of comment to anesthesia
providers. Some of my most unsatisfying airway experiences have involved exchanging
ETTs in ICU patients, and I approach this procedure with great respect and guarded
caution. Each ETT exchange must be individually evaluated to ensure appropriate
indication(s) exist, and a technician-like approach is strongly discouraged. Providers can
limit the number of ETT exchange requests by placing ETTs of sufficient diameter to
allow diagnostic/therapeutic FOB (see tip #5). In addition to many of the previously
mentioned “tips”, further consideration should be given to the following:

Tip #21: Should The ETT Be Advanced, Pulled Back, Or Removed (See Tips #15
and 16). Evaluation of ETT insertion depth (say, 18 cm or 26 cm at the lip, respectively),
clinical examination (limited chest excursion/audible air escape or asymmetric chest
rise/breath sounds, respectively) and review of the patient’s daily CXR (ETT tip barely at
the thoracic inlet or in the right main stem bronchus, respectively) may readily explain a
patient’s significant ETT cuff leak or “mucous plug” and dictate appropriate ETT
repositioning (rather than exchange). Similarly, certain patients may meet appropriate
criteria for rapid weaning and “liberation” from mechanical ventilation rather than
subjected to unnecessary (and potentially dangerous) ETT exchange.
Tip #22: Should I Perform The ETT Exchange Under Direct Visualization Or
Utilize A “Blind” Technique? While either approach may be appropriate in a given
patient, I personally favor carefully moving the ETT to the left corner of the mouth and
doing an initial DL to evaluate the “lay of the land” in most circumstances. My rationale
is that DL will almost always be one’s “plan B” should a blind technique go awry, so it is
better to discover a grade 4 laryngoscopic view with an in situ ETT rather than when you
can’t advance the new ETT blindly into the now unsecured airway. Should DL provide
adequate glottic visualization, I proceed with the ETT exchange using a styletted ETT.
Inadequate glottic visualization usually causes me to reevaluate and consider other
options (AEC, FOB, tracheostomy, etc.). While blind ETT exchange has been described
utilizing either a rigid plastic “tube changer” or an AEC (37), significant barotrauma has
been reported with such techniques (39, 40).
Tip #23: ETT Exchange Utilizing An AEC Requires Close Attention To Detail.
While the AEC can be an invaluable adjunct in safely performing ETT exchange,
barotrauma may result when it is used for “rescue” jet ventilation while positioned into a
main stem bronchus through an existing ETT (40). Care must be taken to (a) maintain
AEC position well within the trachea (typically utilizing a combination of ETT insertion
depth and distance from the ETT tip to the carina on CXR) and (b) provide sufficient
room between the AEC outer diameter and the ETT inner diameter to allow for passive
exhalation and avoid air trapping (41).
Tip #24: Consider Providing Chlorhexidine Oral Care Prior To Performing ETT
Exchange. Similar to sterilely prepping the central line site and catheter prior to changing
a preexisting line over a guide wire, it seems intuitive to provide chlorhexidine oral care
prior to ETT exchange given data supporting lower rates of ventilator-associated

25
pneumonia in mechanically ventilated patients receiving such daily care (42). This
recommendation is supported by evidence of an increased rate of nosocomial pneumonia
in patients requiring reintubation due either to UE or extubation failure after appropriate
weaning (8).

Conclusion
ICU airway management presents unique challenges to airway providers in a high-risk
patient care environment. Anesthesia care givers must have sufficient knowledge of
common ICU airway issues to properly apply their judgment, skill, and expertise toward
optimizing patient outcomes while minimizing morbidity and mortality.

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14. Jaber S, Amraoui J, Lefrant JY, et al. Clinical practice and risk factors for
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27. Pandharipande P, Shintani A, Peterson J, et al. Lorazepam is an independent risk
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28. Norton JR, Ward DS, Karan S, et al. Differences between midazolam and
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30. Gronert GA. Cardiac arrest after succinylcholine: mortality greater with
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31. Ely EW, Baker AM, Dunagan DP, et al. Effect on the duration of mechanical
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Med 1996;335:1864-9.
32. Namen AM, Ely EW, Tatter SB, et al. Predictors of successful extubation in
neurosurgical patients. Am J Respir Crit Care Med 2001;163:658-64.
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from neuromuscular blockade. Anesth Analg 2006;102:937-42.
34. Debaene B, Plaud B, Dilly MP, et al. Residual paralysis in the PACU after a
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36. Berg H, Roed J, Viby-Mogensen J, et al. Residual neuromuscular block is a risk
factor for postoperative pulmonary complications. A prospective, randomised,
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vecuronium, and pancuronium. Acta Anaesthesiol Scand 1997;41:1095-103.
37. Loudermilk EP, Hartmannsgruber M, Stoltzfus DP, et al. A prospective study of
the safety of tracheal extubation using a pediatric airway exchange catheter for
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38. Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for the
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39. Seitz PA, Gravenstein N. Endobronchial rupture from endotracheal reintubation
with an endotracheal tube guide. J Clin Anesth 1989; 1: 214-17.
40. Baraka AS. Tension pneumothorax complicating jet ventilation via a Cook airway
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Self-Assessment Questions
1. Factors contributing to rapid oxygen desaturation during intubation in the
critically ill include:
(a) increased oxygen consumption
(b) anemia
(c) low cardiac output
(d) limited preoxygenation efficacy
(e) all of the above

28
2. Airway exchange catheters
(a) should be fully inserted into the tracheobronchial tree during ETT exchange
(b) can be utilized for proximal jet venturi support of ventilation
(c) can remain in the trachea and supply supplemental O2 after extubation
(d) should fit snugly through the ETT when used for difficult extubation

3. Which of the following is true regarding complications from ICU airway

management?
(a) The rate of DI mirrors that reported in the operating room.
(b) Severe hypoxemia is associated with multiple DLs and EI.
(c) Post-intubation cardiac arrest is most commonly from ventricular arrhythmias.
(d) Survival to hospital discharge is extremely rare in ICU patients suffering post-
intubation cardiac arrest.

Answer Key: 1. (e); 2. (c); 3. (b)

Written Didactics

29