JOURNAL READING

COMPARISON OF TRACHEAL INTUBATION CONDITIONS

IN OPERATING ROOM AND INTENSIVE CARE UNIT

DAN

DIFFICULT TRACHEAL INTUBATION IN CRITICALLY ILL

Oleh:
Achmad Qinthara 1820221111

Pembimbing:

KEPANITERAAN KLINIK
DEPARTEMEN ILMU ANESTESI DAN TERAPI INTENSIF
RUMAH SAKIT UMUM DAERAH PASAR MINGGU
UNIVERSITAS PEMBANGUNAN NASIONAL ‘VETERAN’
JAKARTA
PERIODE 13 JANUARI 2020 – 15 FEBUARI 2020
 LEMBAR PENGESAHAN

JOURNAL READING
COMPARISON OF TRACHEAL INTUBATION CONDITIONS
IN OPERATING ROOM AND INTENSIVE CARE UNIT

DAN

DIFFICULT TRACHEAL INTUBATION IN CRITICALLY ILL

Diajukan untuk memenuhi syarat mengikuti Ujian

Kepaniteraan Klinik Departemen Ilmu Anestesi dan Terapi Intensif
RSUD Pasar Minggu

Disusun oleh:

ACHMAD QINTHARA 1820221111

Pembimbing

 KATA PENGANTAR

Puji dan syukur penulis panjatkan kehadirat Allah SWT karena berkat rahmat
dan hidayah-Nya penulis dapat menyelesaikan penulisan Journal Reading
“comparison of tracheal intubation conditions in operating room and intensive care
unit" dan "difficult tracheal intubation in critically ill” dengan baik. Jurnal reading
ini merupakan salah satu syarat dalam mengikuti ujian kepaniteraan klinik
Pendidikan Profesi Dokter di SMF Ilmu Anestesi dan Terapi Intensif RSUD Pasar
Minggu.
Dalam menyelesaikan tugas ini penulis mengucapkan rasa terima kasih
kepada dr. selaku pembimbing. Penulis menyadari bahwa dalam penyusunan jurnal
reading ini banyak terdapat kekurangan dan juga masih jauh dari kesempurnaan,
sehingga penulis mengharap kritik dan saran yang bersifat membangun dari
pembaca. Semoga kasus ini dapat bermanfaat bagi teman-teman dan semua pihak
yang berkepentingan bagi pengembangan ilmu kedokteran. Aamiin.

Jakarta, 2020

Penulis
Perbandingan antara Kondisi Intubasi Trakea di Ruang Operasi dan ICU
Manuel Taboada, M.D., Ph.D., Patricia Doldan, M.D., Andrea Calvo, M.D., Xavier
Almeida, M.D., Esteban Ferreiroa, M.D., Aurora Baluja, M.D., Ph.D., Agustin
Cariñena, M.D., Paula Otero, M.D., Valentin Caruezo, M.D., Alberto Naveira,
M.D., Pablo Otero, M.D., Julian Alvarez, M.D., Ph.D.

Abstrak
Latar belakang: Intubasi trakea adalah intervensi umum di ruang operasi dan di
unit perawatan intensif (ICU). Penulis berhipotesis bahwa intubasi trakea
menggunakan laringoskopi langsung akan dikaitkan dengan kondisi intubasi yang
lebih buruk dan lebih banyak komplikasi di unit perawatan intensif dibandingkan
dengan ruang operasi.

Metode: Penulis mengevaluasi secara prospektif selama 33 bulan pasien yang

diintubasi trakeal dengan laringoskopi langsung di ruang operasi, dan kemudian di
ICU (dalam jangka waktu 1 bulan). Tujuan utama adalah membandingkan
perbedaan dalam visualisasi glotis menggunakan Cormack-Lehane grade yang
dimodifikasi antara intubasi yang dilakukan pada pasien yang sama di unit
perawatan intensif dan sebelumnya di ruang operasi. Tujuan sekunder adalah
membandingkan keberhasilan pertama kali tingkat, kesulitan teknis (jumlah upaya,
kesulitan yang dilaporkan operator, kebutuhan tambahan), dan timbulnya
komplikasi.

Hasil: Sebanyak 208 pasien memenuhi kriteria inklusi. Intubasi trakea di ICU
dikaitkan dengan visualisasi glotis yang lebih buruk (Cormack-Lehane grade I / IIa
/ IIb / III / IV: 116/24/47/19/2) dibandingkan dengan ruang operasi (Cormack-
Lehane grade I / IIa / IIb / III / IV: 159/21/16/12/0; P <0,001). Tingkat keberhasilan
intubasi pertama kali lebih rendah di ICU (185/208; 89%) dibandingkan dengan
ruang operasi (201/208; 97%; P = 0,002). Intubasi trakea di ICU mengalami
peningkatan insiden intubasi sedang dan sulit (33/208 [16%] vs 18/208 [9%]; P
<0,001), dan perlu tambahan untuk mengarahkan laringoskopi (40/208 [19%] vs
21/208 [10%]; P = 0,002), dibandingkan dengan ruang operasi. Komplikasi lebih
sering terjadi selama intubasi trakea di ICU (76/208; 37%) dibandingkan dengan
ruang operasi (13/208; 6%; P <0,001).

Kesimpulan: Dibandingkan dengan ruang operasi, intubasi trakea di unit

perawatan intensif dikaitkan dengan kondisi intubasi yang lebih buruk dan
peningkatan komplikasi.

Pendahuluan
Intubasi trakea adalah hal yang intervensi umum dan kritis di unit perawatan
intensif. Prosedur ini dikaitkan dengan tingginya insiden intubasi sulit dan
komplikasi parah.1–7 Sebaliknya, di bawah kondisi elektif di ruang operasi, tingkat
komplikasi intubasi rendah.
Tingginya insiden intubasi sulit di ruang ICU dapat dipengaruhi oleh faktor yang
terkait dengan operator, pasien, dan lingkungan.8,9 Faktor yang terkait dengan
operator mencakup tingkat pengalaman dan pelatihan operator, dan oleh
penggunaan agen farmakologis yang memfasilitasi prosedur. Faktor yang
berhubungan dengan pasien termasuk fitur anatomi yang dihasilkan visualisasi
glotis inlet atau kemampuan untuk memasukan tabung trakea sulit, dan faktor
fisiologis yang membatasi durasi upaya laringoskopi, seperti hipoksemia dan
ketidakstabilan hemodinamik pasien yang kritis. Faktor lingkungan termasuk ruang
yang terbatas, pencahayaan yang buruk, dan karakteristik tempat tidur pasien yan
kurang optimal dapat membatasi kemampuan memposisikan dengan benar atau
akses ke kepala dan jalan napas pasien.
Kami berhipotesis bahwa intubasi trakea di ICU menggunakan laringoskopi
langsung akan dikaitkan dengan kondisi intubasi yang lebih buruk dan lebih banyak
komplikasi dibandingkan dengan intubasi trakea di ruang operasi. Tujuan utama
penelitian ini adalah untuk membandingkan perbedaannya dalam visualisasi glotis
menggunakan Cormack-Lehane grade yang telah dimodifikasi, antara intubasi
trakea yang dilakukan oleh ahli anestesi pada pasien yang sama di ICU dan
sebelumnya di ruang operasi. Tujuan sekunder adalah untuk membandingkan
tingkat keberhasilan pertama kali, kesulitan teknis intubasi, dan timbulnya
komplikasi pada keduanya tindakan tersebut.
Bahan dan Metode
Kami secara prospektif mengevaluasi semua pasien yang dirawat di ICU di Clinical
University Hospital of Santiago, Spanyol, antara 1 Maret 2015 dan 30 November
2017, yang diintubasi trakea dengan menggunakan laringoskopi langsung di ICU
dan pada bulan sebelumnya di ruang operasi. Kriteria eksklusi adalah kehamilan,
berusia lebih muda dari 18 tahun, atau intubasi trakea memanfaatkan bronkoskop
atau laringoskopi video. Semua intubasi dilakukan oleh spesialis anestesi atau
residen anestesi yang diawasi oleh spesialis anestesi. Semua residen anestesi
memiliki setidaknya 2 tahun pengalaman anestesi intraoperatif. Studi ini disetujui
oleh komite etika Galicia (Santiago-Lugo, kode No. 2015-012). Karena
pengamatan, desain noninterventional, dan noninvasif dari penelitian ini,
kebutuhan akan persetujuan tertulis dihapuskan.
Posisi sniffing secara umum digunakan sebagai standar posisi kepala untuk
laringoskopi langsung dan intubasi trakea, 10 namun setiap ahli anestesi bebas untuk
memvariasikan posisi kepala pasien, disesuaikan dengan situasi klinis (mis., posisi
ramped untuk pasien obesitas jika perlu). Tekanan darah arteri dan saturasi oksigen
diamati sebelum, selama (antara induksi anestesi dan penyisipan tabung), dan
dalam periode 30 menit setelah intubasi trakea. Induksi anestesi dan percobaan
yang gagal dilakukan kemudian dikelola atas kebijaksanaan ahli anestesi. Jika
saturasi oksigen menurun kurang dari 90% selama upaya intubasi, ahli anestesi
menarik laringoskop dan memulai ventilasi masker.
Setelah setiap intubasi trakea di ruang operasi, operator mengisi formulir
pengumpulan data, yang termasuk informasi berikut: demografi pasien, skor
klasifikasi Mallampati (I-IV), identifikasi intubator pertama (spesialis anestesi atau
residen), tipe operasi, agen sedatif, agen paralitik, Cormack-Lehane grade pandang
glottis yang terbaik, jumlah upaya intubasi trakea, perlunya tambahan untuk
mengarahkan laringoskopi (gum-elastic bougie), kesulitan yang dilaporkan
operator dari intubasi, dan komplikasi selama intubasi trakea.

Setelah setiap intubasi trakea di ICU, operator mengisi formulir pengumpulan data,
yang termasuk informasi berikut: demografi pasien, alasan masuk di unit perawatan
intensif, identifikasi intubator pertama (spesialis anestesi atau residen), indikasi
untuk intubasi, penggunaan ventilasi noninvasive sebelum intubasi, urgensi
intubasi, obat sedative. agen paralitik, Cormack-Lehane grade pandang glottis yang
terbaik, jumlah upaya intubasi trakea, perlunya tambahan untuk mengarahkan
laringoskopi (gum-elastic bougie), kesulitan yang dilaporkan operator dari intubasi,
dan komplikasi selama intubasi trakea.
Visualisasi inlet laring dinilai sesuai dengan klasifikasi modifikasi Cormack dan
Lehane11,12: I, pemandangan glottis penuh; IIa, pandangan sebagian glotis; IIb,
hanya tampak arytenoid atau bagian posterior pita suara; III, hanya epiglotis yang
terlihat; IV, glotis atau epiglotis tidak terlihat.
Upaya intubasi didefinisikan sebagai penyisipan bilah laringoskop ke dalam
orofaring, terlepas dari apakah upaya dilakukan untuk memasukan tabung
endotrakeal. Penyesuaian blade laringoskopi dihitung sebagai upaya tunggal.
Intubasi yang berhasil didefinisikan sebagai penempatan yang benar dari tabung
endotrakeal di trakea. Usaha percobaan pertama didefinisikan sebagai intubasi
trakea yang sukses, seperti sebelumnya didefinisikan, pada upaya awal. Kesulitan
yang dilaporkan operator mengenai intubasi diklasifikasikan sebagai: mudah,
ringan, sedang, atau berat. Urgensi intubasi diklasifikasikan sebagai: emergent,
urgent (dalam 30 menit), atau semi-elektif (lebih dari 30 menit). Komplikasi selama
intubasi termasuk intubasi esofagus, hipoksemia (saturasi oksigen kurang dari
80%), dan hipotensi (tekanan darah sistolik lebih rendah dari 80 mmHg) selama
intubasi, atau 30 menit setelahnya. Pilihan obat bius diserahkan kepada
kebijaksanaan spesialis anestesi.

Tujuan utama adalah untuk membandingkan perbedaan visualisasi glotis

menggunakan Cormack-Lehane grade yang dimodifikasi antara intubasi dilakukan
pada pasien yang sama dalam dua keadaan yang berbeda yaitu di ruang operasi dan
ICU. Tujuan sekunder termasuk tingkat keberhasilan intubasi yanag dilakukan
pertama kali, kesulitan teknis intubasi (jumlah upaya intubasi, kesulitan yang
dilaporkan operator intubasi, dan perlunya tambahan untuk laringoskopi langsung),
dan kejadian komplikasi selama prosedur (hipoksia, hipotensi, intubasi esofagus).
Analisis Statistik
Ini adalah penelitian observasional prospektif berpasangan, di mana pasien
dievaluasi baik dalam operasi kamar dan unit perawatan intensif. Data dikumpulkan
selama periode 33 bulan. Statistik ringkasan dihitung untuk kategori (frekuensi,
persentase), dan untuk variabel numeric (rata-rata, median, SD).
Sebelum pengumpulan data, ukuran sampel dihitung untuk Tes McNemar sebagai
161 pasang pengukuran untuk mendeteksi 20% peningkatan minimum (dari 5
hingga 25% dari Cormack-Lehane IIb, III, dan IV) dan penurunan maksimum 5%
(hingga 5% dari semua pasien) pada Cormack-Lehane grade, dengan alpha
kesalahan 1%, dan daya 90% (dua sisi).
Perubahan frekuensi dari ruang operasi ke unit perawatan intensif dinilai
menggunakan uji McNemar chi-square untuk pengukuran berpasangan, dan uji
Wilcoxon berpasangan. Untuk tes McNemar, variabel dicatat dalam kategori biner,
sebagai berikut:
• Cormack – Lehane grade: Kisaran penuh adalah I, IIa, IIb, III, IV; rentang
biner adalah I + IIa, lebih besar dari IIa.
• Jumlah upaya: Kisaran penuh adalah 1, 2, 3, 4, dll .;rentang biner adalah 1,
lebih besar dari 1.
• Kesulitan subjektif: Kisaran penuh adalah 1-Mudah, 2-Ringan, 3-Moderat,
4-Parah; rentang biner adalah 1-Mudah dan kesulitan ringan, 2- kesulitan
sedang dan berat.

Variabel dengan rentang penuh diwakili menggunakan diagram batang berkelit.13

Semua variabel diskrit atau nonparametrik.
Untuk mengevaluasi korelasi antara faktor-faktor ordinal dalam tabel dua arah,
kami menggunakan tes gamma Goodpar-Kruskal nonparametrik dengan CI 95%
yang sesuai. Tes Fisher digunakan untuk menilai signifikansi statistik untuk
pengukuran tunggal, baik di ruang operasi atau di ruang perawatan intensif satuan.
Beberapa pengujian dikoreksi dengan prosedur Bonferroni. Setelah beberapa
pengujian, hanya nilai P lebih besar dari 0,0024 dianggap signifikan secara statistik.
Perangkat lunak yang digunakan adalah R v.3 untuk semua perhitungan, dan paket
Ggplot2 untuk grafik (http://cran.r-project.org, diakses 2018).14 Untuk
perhitungan ukuran sampel McNemar, kami menulis aplikasi web khusus
menggunakan paket Shiny untuk R.

Hasil
Selama masa studi 33 bulan, total 311 pasien diintubasi trakeal di ICU. Dari data
ini, 208 pasien diintubasi trakea sebelumnya (kurang dari 1 bulan sebelumnya) di
ruang operasi, dan masuk dalam kriteria inklusi. Sebanyak 103 (33%) intubasi
dieksklusikan karena alasan berikut: 94 intubasi tidak dilakukan intubasi
sebelumnya di ruang operasi, 4 intubasi serat optic sadar, dan 5 adalah intubasi
laringoskopi video. Tabel 1 menunjukkan karakteristik pasien dan intervensi bedah
mereka. Alasan untuk masuk ke ICU, alasan untuk intubasi di ICU, tingkat urgensi
prosedur intubasi unit perawatan intensif, dan penggunaan ventilasi noninvasif
sebelum intubasi trakea ditunjukkan pada tabel 1. Indikasi yang paling sering untuk
intubasi di unit perawatan intensif adalah kegagalan pernapasan akut (83%), dan
63% pasien membutuhkan ventilasi noninvasive sebelum intubasi.
Tidak ada perbedaan yang signifikan secara statistik antara tingkatan intubator
(spesialis atau residen anestesi) di ruang operasi dan di unit perawatan intensif
(tabel 2, P = 0,35). Jenis hipnosis dan blokade neuromuskuler digunakan di ruang
operasi, dan intubasi trakea unit perawatan intensif ditunjukkan pada tabel 2.

Intubasi trakea di unit perawatan intensif dikaitkan dengan visualisasi glotis yang
memburuk (Cormack-Lehane grade I / IIa / IIb / III / IV: 116/24/47/19/2),
dibandingkan dengan ruang operasi (Cormack-Lehane gtade I / IIa / IIb / III / IV:
159/21/16/12/0, (P <0,001; gambar 1A). Intubasi trakea di ICU memperburuk
visualisasi glotis pada 69 pasien (33%), dan meningkatkan visualisasi glotis. glotis
pada 14 pasien (7%). Proporsi kesuksesan pertama tingkat intubasi adalah 97%
(201/208) di ruang operasi, lebih tinggi daripada di unit perawatan intensif
(185/208, 89%; P = 0,002). Jumlah upaya intubasi trakea adalah lebih tinggi pada
pasien unit perawatan intensif, dibandingkan dengan pasien ruang operasi (P
<0,001; gambar. 1B).
Kesulitan intubasi trakea lebih besar pada pasien ICU daripada pada pasien ruang
operasi (P <0,001; gbr. 1C). Intubasi trakea di ICU memiliki peningkatan insiden
intubasi sedang dan sulit (33/208 [16%]), dibandingkan dengan ruang operasi
(18/208 [9%]; P <0,001). Penggunaan gum-elastic bougie lebih jarang dilakukan di
ruang operasi dibandingkan dengan di ICU (P = 0,002; tabel 2).

Komplikasi lebih sering terjadi selama intubasi trakea di ICU dibandingkan dengan
ruang operasi (76/208, 37% vs 13/208, 6%; P <0,001; tabel 2)
Ada hubungan antara jumlah upaya intubasi, kesulitan intubasi, dan tambahan
untuk mengarahkan
laringoskopi, dan pandangan laringoskopi sulit selama intubasi trakea di ICU.
Intubasi trakea lebih sulit, diperlukan lebih sering tambahan untuk mengarahkan
laringoskopi, dan membutuhkan lebih banyak upaya intubasi dari Cormack-Lehane
grade I ke IV (P <0,001; tabel 3)
Pembahasan

Dalam penelitian ini, kami telah membandingkan kondisi intubasi trakea pada
pasien yang sama dalam dua pengaturan klinis yang berbeda: ICU dan ruang
operasi. Kami mengamati bahwa intubasi trakea dengan laringoskopi langsung di
ICU dikaitkan dengan kondisi intubasi yang memburuk dan peningkatan
komplikasi dibandingkan dengan ruang operasi. Di ruang operasi, sebagian besar
intubasi trakea dilakukan di bawah elektif, kondisi terkontrol, pada pasien yang
dioptimalkan, dan oleh ahli anestesi yang ahli dalam manajemen jalan napas.
Tingkat kesulitan intubasi dan komplikasinya relatif rendah.15 Namun, risiko
1–7
kesulitan intubasi di ICU tinggi, dan keadaan di ICU dipertimbangkan oleh
banyak penulis3,8 sebagai faktor risiko independen dari sulitnya melakukan intubasi
dan komplikasi selama intubasi.
Tujuan utama dalam penelitian ini adalah membandingkan perbedaan dalam
visualisasi glotis antara operasi kamar dan ICU karena kami berhipotesis paparan
glotis yang buruk selama laringoskopi langsung dapat berpengaruh atas
peningkatan insiden intubasi yang sulit di ICU.

Untuk menggambarkan visualisasi glotis selama laringoskopi direk, kami

menggunakan klasifikasi Cormack-Lehane yang dimodifikasi. Ini adalah skala
yang sering digunakan dalam penelitian yang berhubungan dengan jalan nafas
untuk menggambarkan kondisi intubasi dan membandingkan visibilitas Untuk
menggambarkan visualisasi glotis selama laringoskopi direk, kami menggunakan
klasifikasi Cormack-Lehane yang dimodifikasi.
Di unit perawatan intensif, paparan glotis buruk selama laringoskopi langsung dapat
dipengaruhi oleh operator-, pasien-, dan / atau faktor-faktor yang berhubungan
dengan lingkungan.8 Karena pasiennya sama dan diintubasi dalam dua pengaturan
klinis yang berbeda oleh ahli anestesi dengan tingkat pengalaman yang sama,
visualisasi glotis yang memburuk diamati di unit perawatan intensif saat ini
diinvestigasi mungkin karena faktor fisiologis pasien sakit kritis, serta faktor
lingkungan. Faktor fisiologis termasuk hipoksemia, ketidakstabilan hemodinamik,
edema laring, adanya lambung penuh, dan penurunan cadangan fisiologis yang
membatasi durasi upaya laringoskopi. Faktor lingkungan termasuk yang terbatas
ruang, pencahayaan buruk, dan karakteristik tempat tidur kurang optimal di unit
perawatan intensif yang membatasi kemampuan untuk memposisikan atau
mengakses kepala dan jalan napas pasien dengan benar. Faktor-faktor ini bisa
mengganggu visualisasi glotis langsung saat menggunakan laringoskopi langsung,
karena itu meningkatkan kesulitan teknis intubasi. Kami mengamati bahwa pasien
dengan visualisasi glotis yang sebelumnya baik dan intubasi trakea mudah di ruang
operasi memiliki visualisasi glotis yang lebih buruk dengan peningkatan jumlah
upaya intubasi, dan kesulitan intubasi yang lebih besar pada pasien yang sama saat
diintubasi di unit perawatan intensif.
Menurut kami kesulitan dalam melihat glotis (Cormack-Lehane IIb, III, atau IV)
berhubungan dengan kesulitan intubasi. Dalam penyelidikan saat ini, kami
mengamati sejumlah besar upaya dan kesulitan intubasi trakea di unit perawatan
intensif, dari Cormack-Lehane grade I ke IV. Sesuai dengan penelitian kami,
6,10,19
penulis lain telah mengamati hubungan yang kuat antara kesulitan melihat
19
laringoskopi dan intubasi yang sulit. Soyunco et al. mengevaluasi 366 pasien
dalam study pengamatan prospektif dan mengamati bahwa intubasi trakea lebih
sulit dari Cormack-Lehane grade I ke IV (11 vs 25 vs 34 vs 81%). Martin et al.6
juga menunjukkan bahwa Cormack-Lehane kelas III dan IV adalah prediktor
independen dari komplikasi yag muncul selama intubasi. Semler et al. 10 mengamati
bahwa posisi Ramped menigkatkan insidensi Cormack-Lehane grade III atau IV,
dibandingkan dengan posisi sniffing di ICU (12 vs 5%). Pandangan laring yang
memburuk di posisi ramped meningkatkan insiden intubasi yang sulit dan jumlah
upaya yang diperlukan untuk intubasi.

Meskipun kami mengamati tingkat keberhasilan intubasi pertama kali kurang di

unit perawatan intensif dibandingkan dengan ruangan operasi, kami memiliki hasil
yang baik dengan hampir 90% pasien diintubasi pada upaya pertama di unit
perawatan intensif. Namun, penelitian lain menemukan tingkat keberhasilan
pertama kali antara 63 dan 75%.1–3,24 Banyak penulis menyarankan bahwa tujuan
dari intubasi di unit perawatan intensif harus menjadi keberhasilan upaya pertama
intubasi.8,24,25 Sebuah penelitian terbaru dari Sakles et al. 25
menunjukkan bahwa
risiko efek samping meningkat dengan setiap upaya intubasi dari 14 menjadi 47%
ketika upaya kedua diperlukan. Demikian pula, Simpson et al.,7 dalam studi
multicenter, diamati bahwa frekuensi hipoksemia berat meningkat 14 kali lipat pada
pasien yang membutuhkan lebih dari dua upaya intubasi trakea. Sesuai dengan
penelitian saat ini, 91% tingkat keberhasilan intubasi pertama kali dengan
laringoskopi direk. Tingginya tingkat keberhasilan intubasi pertama kali di ICU
diamati dalam penelitian kami dan dalam studi Simpson7 mungkin terjadi karena
pengalaman anestesi dari para intubator dan tingkat pengawasan residen yang
tinggi. Penelitian sebelumnya menemukan bahwa intubasi trakea dilakukan oleh
seorang ahli anestesi lebih mungkin berhasil, dengan upaya lebih sedikit, dan
dikaitkan dengan komplikasi lebih sedikit dan mortalitas yang lebih rendah
daripada intubasi yang dilakukan oleh nonexperts.2,6
Faktor lain yang mungkin mempengaruhi tingginya tingkat pertama kali
keberhasilan intubasi pada pasien di ICU dalam penelitian ini adalah tingginya
penggunaan blokade neuromuskuler untuk intubasi. Secara keseluruhan, 96% dari
pasien kami di unit perawatan intensif menerima blokade neuromuskuler,
dibandingkan dengan penelitian lain bahwa tingkat keberhasilan dari 5 hingga 72%
.1-3,6,9 Penggunaan blokade neuromuskuler di unit perawatan intensif telah
ditunjukkan untuk mengoptimalkan kondisi intubasi, 26 meningkatkan penampakan
27,28
glotis dan mengurangi upaya intubasi, dan dapat menurunkan tingkat
komplikasi. Di unit perawatan intensif, kami menggunakan suksinilkolin dengan
frekuensi lebih banyak, sesuai dengan investigasi lain, 6,7,9,28,29 karena durasi urutan
intubasi secara signifikan lebih pendek, dibandingkan dengan rocuronium pada
kondisi intubasi yang serupa.29 Pasien unit perawatan intensif kami sakit parah
sebelum intubasi. Untuk 83% pasien, alasannya untuk intubasi adalah gagal napas
akut, dan hampir 63% diperlukan ventilasi noninvasif sebelum intubasi trakea.
Dalam penelitian saat ini, kami mengamati peningkatan tingkat penggunaan jalan
nafas tambahan di unit perawatan intensif dibandingkan dengan ruang operasi. Ini
mungkin juga berkontribusi untuk tingkat keberhasilan intubasi pertama kali yang
tinggi yang diamati pada pasien kami di ICU. Data menunjukkan bahwa intubasi
trakea, terutama ketika laringoskopi direk menunjukan penampakan glotis yang
buruk, difasilitasi dengan penggunaan pengantar bougie.30 Laringoskopi yang
dipandu cahaya retrograde telah diusulkan baru-baru ini untuk memfasilitasi
intubasi trakea di ICU.18 Dalam beberapa tahun terakhir, beberapa studi telah
menilai apakah penggunaan laringoskopi video dapat meningkatkan keberhasilan
intubasi upaya pertama di ICU.15,17,31-38 Konflik hasil diperoleh. Dua meta-analisis
34,35
menunjukkan laringoskopi video meningkatkan keberhasilan upaya pertama,
visualisasi glotis, dan mengurangi trauma mukosa. Namun, Huang et al., 39 dalam
meta-analisis lain, melaporkan laringoskopi video tidak meningkatkan keberhasilan
upaya pertama, oleh karena itu, jangan mendukung penggunaan laringoskopi video
secara rutin selama intubasi trakea di unit perawatan intensif.
Akhirnya, kami menemukan bahwa tingkat komplikasi, seperti hipoksemia,
hipotensi, atau intubasi esofagus lebih sering di unit perawatan intensif
dibandingkan dengan ruang operasi. Komplikasi dapat terjadi hingga 40% dari
1-7,40
pasien sakit kritis. Hipoksemia dapat terjadi di sekitar 25%, dan hipotensi di
15 hingga 35% .1,2 De Jong et al.3 mengamati bahwa pada pasien obesitas, insiden
intubasi sulit dan komplikasi yang berkaitan dengan intubasi terjadi lebih sering di
unit perawatan intensif daripada di ruang operasi. Meskipun mereka
membandingkan pasien yang berbeda di dua pengaturan klinis ini, hasilnya sesuai
dengan penelitian kami.

Keterbatasan Penelitian
Penelitian kami memiliki keterbatasan. Pertama, ini adalah penelitian di unit
perawatan intensif dan ruang operasi di Rumah Sakit Pendidikan Santiago,
Spanyol. Hasil dari satu pusat, dan harus dipertimbangkan ketika mengekstrapolasi
hasil ke pengaturan klinis lainnya. Menggabungkan studi multicenter di masa depan
dapat lebih memvalidasi temuan ini.
Kedua, dalam penelitian kami semua intubasi di ruang operasi dan unit perawatan
intensif dilakukan oleh spesialis anesteso atau residen anestesi dengan pengalaman
anestesi intraoperative lebih banyak dari dua tahun. Tidak diketahui apakah hasil
yang serupa akan dicapai dengan operator dengan tingkat keterampilan yang
berbeda, atau tanpa pengawasan dokter yang merawat. Meski sudah tingkat
pelatihan yang serupa, intubator di ruang operasi tidak persis sama dengan di unit
perawatan intensif, jadi itu membatasi kesimpulan dari penelitian ini.
Ketiga, penelitian ini adalah observasional. Komplikasi prosedural dan rincian
prosedur intubasi dikumpulkan oleh ahli anestesi dan kemungkinan dokumentasi
yang tidak sempurna dan komplikasi yang dilaporkan harus dipertimbangkan.

Keempat, kami berkonsentrasi pada komplikasi hipoksemia, hipotensi, dan intubasi

esofagus. Komplikasi lain tidak didokumentasikan, dan dengan memasukan
komplikasi lai dalam inklusi mungkin dapat memperbaiki penelitian.
Terakhir, blokade neuromuskuler dan obat hipnotis digunakan untuk induksi
anestesi berbeda di ruang operasi dan di unit perawatan intensif. Durasi pendek aksi
suksinilkolin dapat menghambat intubasi trakea di ICU. Kami tidak berpikir bahwa
ini mempengaruhi hasil yang diperoleh dalam penetilian saat ini karena pada 99%
pasien unit perawatan intensif kami, intubasi trakea diperoleh pada percobaan
pertama atau kedua.

Terlepas dari keterbatasan ini, penelitian kami menawarkan wawasan manajemen

jalan napas di unit perawatan intensif dan operasi pengaturan ruangan.

Kesimpulan
Dibandingkan dengan ruang operasi, intubasi pasien yang sama di unit perawatan
intensif menggunakan laringoskopi langsung dikaitkan dengan memburuknya
pandangan glotis, penurunan tingkat keberhasilan pertama kali, dan peningkatan
kesulitan teknis intubasi dan timbulnya komplikasi
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 Comparison of Tracheal Intubation Conditions in
Operating Room and Intensive Care Unit
A Prospective, Observational Study
Manuel Taboada, M.D., Ph.D., Patricia Doldan, M.D., Andrea Calvo, M.D., Xavier Almeida, M.D.,
Esteban Ferreiroa, M.D., Aurora Baluja, M.D., Ph.D., Agustin Cariñena, M.D., Paula Otero, M.D.,
Valentin Caruezo, M.D., Alberto Naveira, M.D., Pablo Otero, M.D., Julian Alvarez, M.D., Ph.D.

ABSTRACT

Background: Tracheal intubation is a common intervention in the operating room and in the intensive care unit. The authors
hypothesized that tracheal intubation using direct laryngoscopy would be associated with worse intubation conditions and
more complications in the intensive care unit compared with the operating room.
Methods: The authors prospectively evaluated during 33 months patients who were tracheally intubated with direct laryngoscopy
in the operating room, and subsequently in the intensive care unit (within a 1-month time frame). The primary outcome was to
compare the difference in glottic visualization using the modified Cormack-Lehane grade between intubations performed on the
same patient in an intensive care unit and previously in an operating room. Secondary outcomes were to compare first-time success
rate, technical difficulty (number of attempts, operator-reported difficulty, need for adjuncts), and the incidence of complications.
Results: A total of 208 patients met inclusion criteria. Tracheal intubations in the intensive care unit were associated with
worse glottic visualization (Cormack-Lehane grade I/IIa/IIb/III/IV: 116/24/47/19/2) compared with the operating room
(Cormack-Lehane grade I/IIa/IIb/III/IV: 159/21/16/12/0; P < 0.001). First-time intubation success rate was lower in the
intensive care unit (185/208; 89%) compared with the operating room (201/208; 97%; P = 0.002). Tracheal intubations
in the intensive care unit had an increased incidence of moderate and difficult intubation (33/208 [16%] vs. 18/208 [9%];
P < 0.001), and need for adjuncts to direct laryngoscopy (40/208 [19%] vs. 21/208 [10%]; P = 0.002), compared with the
operating room. Complications were more common during tracheal intubations in the intensive care unit (76/208; 37%)
compared with the operating room (13/208; 6%; P < 0.001).
Conclusions: Compared with the operating room, tracheal intubations in the intensive care unit were associated with worse
intubation conditions and an increase of complications. (ANESTHESIOLOGY 2018; 129:321-8)

T RACHEAL intubation is a common and critical

intervention in the intensive care unit. This procedure
is associated with a high incidence of difficult intubation
and severe complications.1–7 In contrast, under elective
conditions in the operating room, the complication rate of
intubation is low.
The high incidence of difficult intubation in the intensive
care unit may be affected by operator-, patient-, and envi-
ronment-related factors.8,9 Operator-related factors include
the level of experience and training of the operator, and by
the use of pharmacologic agents that facilitate the procedure.
Patient-related factors include anatomic features that make
visualization of the glottic inlet or the ability to pass a tra-
cheal tube difficult, and physiologic factors that limit the
duration of the laryngoscopic attempt, such as hypoxemia
and hemodynamic instability of the critically ill patient.
Environmental factors include limited space, poor lighting,
and suboptimal bed characteristics that limit the ability to
properly position or access to the patient’s head and airway.
All of these factors can impair direct visualization of the
What We Already Know about This Topic
• Reported incidence rates of difficult trachea intubation are
higher outside of the operating room than in the operating
room
• The differences may be explained by operator-related, patient-
related, and environment-related factors
What This Article Tells Us That Is New
• In this observational study, 208 patients experienced direct
laryngoscopy both in the intensive care unit and operating
room during the perioperative period
• Tracheal intubation was associated with worse intubation
conditions and more complications in the intensive care unit
compared with the operating room
glottis using a direct laryngoscopy, therefore making tracheal
intubation difficult and increasing the rate of complications.
We hypothesized that tracheal intubation in the intensive
care unit using direct laryngoscopy would be associated with
worse intubation conditions and more complications com-
pared with tracheal intubation in the operating room. The

This article is featured in “This Month in Anesthesiology,” page 1A. This article has a video abstract. This article has an audio podcast.
This article has a visual abstract available in the online version.
Submitted for publication December 20, 2017. Accepted for publication April 26, 2018. Corrected on April 29, 2019. From the Department
of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Spain.
Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2018; 129:321-8

Anesthesiology, V 129 • No 2 321 August 2018

Downloaded from anesthesiology.pubs.asahq.org by guest on 01/28/2020

main endpoint of the study was to compare the difference
in glottic visualization using the modified Cormack–Lehane
grade between tracheal intubations performed by anesthe-
siologists on the same patient in the intensive care unit,
and previously in the operating room. Secondary endpoints
were to compare first-time success rate, technical difficult of
intubation, and the incidence of complications in these two
clinical settings.
Materials and Methods
We prospectively evaluated all patients admitted to the inten-
sive care unit at Clinical University Hospital of Santiago,
Spain, between March 1, 2015 and November 30, 2017, that
were tracheally intubated using a direct laryngoscopy in the
intensive care unit and in the previous month in the operat-
ing room. Exclusion criteria were pregnancy, aged younger
than 18 yr, or tracheal intubations utilizing a bronchoscope
or a video laryngoscopy. All intubations were performed by
attending anesthesiologists or anesthesia residents supervised
by attending anesthesiologists. All anesthesia residents had
at least 2 yr of intraoperative anesthesiology experience. The
study was approved by the ethics committee of Galicia (San-
tiago-Lugo, code No. 2015-012). Due to the observational,
noninterventional, and noninvasive design of this study, the
need for written consent was waived.
The sniffing position was routinely used as standard
head positioning for direct laryngoscopy and tracheal intu-
bation,10 however every anesthesiologist was free to vary
patients’ head positions, adapting to the clinical situation
(e.g., the ramped position for obese patients if necessary).
Both arterial blood pressure and oxygen saturation were reg-
istered before, during (between the anesthetic induction and
the tube insertion), and in the 30-min period after tracheal
intubation. Induction of anesthesia and failed attempts were
subsequently managed at the discretion of the attending
anesthesiologist. If the oxygen saturation decreased less than
90% during intubation attempts, the anesthesiologist with-
drew the laryngoscope and initiated mask ventilation.
After each tracheal intubation in the operating room, the
operator completed a data collection form, which included
the following information: patient demographics, Malla-
mpati classification score (I-IV), identification of the first
intubator (attending anesthesiologist vs. resident), type of
surgery, sedative agent, paralytic agent, the best modified
Cormack–Lehane glottic view, number of attempts of tra-
cheal intubation, the need for adjuncts to direct laryngos-
copy (gum-elastic bougie), operator-reported difficulty of
intubation, and complications during tracheal intubation.
After each tracheal intubation in the intensive care
unit, the operator completed a data collection form, which
included the following information: patient demographics,
reason for admission in intensive care unit, identification of
the first intubator (attending anesthesiologist vs. resident),
indication for intubation, use of noninvasive ventilation
prior to intubation, urgency of intubation, sedative agent,
Anesthesiology 2018; 129:321-8
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Intubation in Operating Room versus Intensive Care
paralytic agent, the best modified Cormack–Lehane glottic
view, number of attempts of tracheal intubation, the need
for adjuncts to direct laryngoscopy (gum-elastic bougie),
operator-reported difficulty of intubation, and complica-
tions during tracheal intubation.
Visualization of the laryngeal inlet was assessed according to
the modified classification of Cormack and Lehane11,12: I, full
view of the glottis; IIa, partial view of the glottis; IIb, arytenoid
or posterior part of the vocal cords just visible; III, only epiglot-
tis visible; IV, neither glottis nor epiglottis visible.
An intubation attempt was defined as insertion of the
laryngoscope blade into the oropharynx, regardless of whether
an attempt was made to pass the endotracheal tube. A laryn-
goscopic blade readjustment counted as a single attempt.
Successful intubation was defined as correct placement of
the endotracheal tube in the trachea. First-attempt success
was defined as successful tracheal intubation, as previously
defined, on the initial attempt. Operator-reported difficulty
of intubation was classified as: easy, mild, moderate, or severe.
Urgency of intubation was classified as: emergent, urgent
(within 30 min), or semi-elective (more of 30 min). Com-
plications during the intubation included esophageal intu-
bation, hypoxemia (oxygen saturation less than 80%), and
hypotension (systolic blood pressure lower than 80 mmHg)
during, or 30 min after, intubation. The choice of anesthetic
agents was left to the discretion of the anesthesiologist.
The primary outcome was to compare the difference in
glottic visualization using the modified Cormack–Lehane
grade between intubations performed on the same patient
in two different settings such as the operating room and the
intensive care unit. Secondary outcomes included first-time
success rate intubation, technical difficulty of intubation
(number of intubation attempts, operator-reported difficulty
of intubation, and the need for adjuncts to direct laryngos-
copy), and the incidence of complications during the proce-
dure (hypoxia, hypotension, esophageal intubation).
Statistical Analysis
This is an observational, prospective study of paired mea-
sures, in which patients are evaluated both in the operating
room and the intensive care unit. Data were collected during
a 33-month period. Summary statistics were calculated for
categories (frequency, percentage), and for numeric variables
(mean, median, SD).
Before data collection, sample size was calculated for the
McNemar test as 161 pairs of measurements to detect a 20%
minimum increase (from 5 to 25% of Cormack–Lehane IIb,
III, and IV) and a 5% maximum decrease (up to 5% of all
patients) in Cormack–Lehane grade, with an error alpha of
1%, and a 90% power (two-tailed).
Frequency changes from the operating room to the inten-
sive care unit were assessed using the McNemar chi-square
test for paired measurements, and the paired Wilcoxon test.
For McNemar tests, variables were recorded in binary cat-
egories, as follows:
322 Taboada et al.
 CRITICAL CARE MEDICINE

• Cormack–Lehane grade: Full range was I, IIa, IIb, Table 1. Specific Variables Recorded in Intubated Patients
III, IV; binary range was I+IIa, greater than IIa.
Patients
• Number of attempts: Full range was 1, 2, 3, 4, etc.; (N = 208)
binary range was 1, greater than 1.
• Subjective difficulty: Full range was 1-Easy, 2-Mild, Demographics
Age, mean ± SD, yr 70 ± 12
3-Moderate, 4-Severe; binary range was 1-Easy and Male sex, n (%) 61 (29)
Mild difficulty, 2-Moderate and Severe difficulty. Weight, mean ± SD, kg 75 ± 13
Variables with their full ranges were represented using Height, mean ± SD, cm 165 ± 9
BMI, mean ± SD, kg/m2 28 ± 5
dodged bar charts.13 All variables were either discrete or
BMI > 30 kg/m2, n (%) 62 (30)
nonparametric. Mallampati score, n (%)
To evaluate correlation between ordinal factors in a two- 1 41 (20)
way table, we used the nonparametric Goodman–Kruskal 2 98 (47)
gamma test with the corresponding 95% CI. The Fisher test 3 46 (22)
was used to assess statistical significance for single measure- 4 4 (2)
ments, either in the operating room or in the intensive care Not recorded 18 (9)
Reason for OR surgery, n (%)
unit. Multiple testing was penalized with the Bonferroni
Cardiac surgery 92 (44)
procedure. After multiple-testing penalization, only P values Abdominal surgery 39 (19)
larger than 0.0024 were considered statistically significant. Neurosurgery 27 (13)
The software used was R v.3 for all calculations, and the Vascular surgery 18 (9)
package Ggplot2 for the graphs (http://cran.r-project.org, Trauma surgery 12 (6)
accessed 2018).14 For McNemar sample size calculations, we Thorax surgery 10 (5)
wrote a custom web app using the Shiny package for R. Urology surgery 7 (3)
Others 3 (1)
Urgent surgery, n (%) 70 (34)
Results Reason for ICU admission, n (%)
During the 33-month study period, a total of 311 patients Postoperative surgery 138 (66)
were tracheally intubated in the intensive care unit. Of Acute respiratory failure 51 (25)
these, 208 patients were tracheally intubated previously Shock 10 (5)
Neurologic 6 (3)
(less than 1 month before) in the operating room, and met
Others 3 (1)
inclusion criteria. A total of 103 (33%) intubations were
Reason for ICU intubation, n (%)
excluded for the following reasons: 94 intubations were not Acute respiratory failure 172 (83)
intubated previously in the operating room, 4 were awake Shock 33 (16)
fiberoptic intubations, and 5 were video laryngoscopy intu- Neurologic 37 (18)
bations. Table  1 shows patient characteristics and their Unplanned extubation 7 (3)
surgical interventions. The reason for intensive care unit Failed trial of extubation 16 (8)
admission, reason for intensive care unit intubation, grade Elective (procedure) 7 (3)
Urgency of ICU intubation procedure, n (%)
of urgency of intensive care unit intubation procedure, and
Emergent 15 (7)
use of noninvasive ventilation before tracheal intubation are Urgent 117 (56)
shown in table 1. The most frequent indication for intuba- Semi-elective 76 (37)
tion in the intensive care unit was acute respiratory failure Noninvasive ventilation before intubation, n (%) 130 (63)
(83%), and 63% of patients needed noninvasive ventilation
Data presented as number (%) or mean ± SD.
before intubation. BMI = body mass index; ICU = intensive care unit; OR = operating room.
There was no statistically significant difference between
rank of the intubator in the operating room and in the inten-
sive care unit (table 2, P = 0.35). The type of hypnotic and rate intubation was 97% (201/208) in the operating room,
neuromuscular blockade used in the operating room, and higher than in the intensive care unit (185/208, 89%; P
intensive care unit tracheal intubations are shown in table 2. = 0.002). The number of attempts of tracheal intubation was
Tracheal intubation in the intensive care unit was associ- higher in intensive care unit patients, compared with operat-
ated with worsened glottic visualization (Cormack–Lehane ing room patients (P < 0.001; fig. 1B).
grade I/IIa/IIb/III/IV: 116/24/47/19/2), compared with the The difficulty of tracheal intubation was greater in inten-
operating room (Cormack–Lehane grade I/IIa/IIb/III/IV: sive care unit patients than in operating room patients
159/21/16/12/0, (P < 0.001; fig. 1A). Tracheal intubation in (P  <  0.001; fig.  1C). Tracheal intubations in the intensive
the intensive care unit worsened the visualization of the glot- care unit had an increased incidence of moderate and diffi-
tis in 69 patients (33%), and improved visualization of the cult intubation (33/208 [16%]), compared with the operat-
glottis in 14 patients (7%). The proportion of first-success ing room (18/208 [9%]; P < 0.001). The use of a gum-elastic

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 Intubation in Operating Room versus Intensive Care

Table 2. Comparison of Intubation Characteristics and

Procedural Complication Rate between Tracheal Intubation in
the OR and the ICU

OR ICU
(N = 208) (N = 208) P Value

Rank of intubator
Combined resident and 104 (50) 114 (55) 0.35
attending anesthesiologist
Attending anesthesiologist 104 (50) 94 (45)
Medications used for
intubation
Hypnotic drugs 208 (100) 200 (96) 0.013
Propofol 143 (69) 54 (26) < 0.001
Etomidate 65 (31) 139 (67) < 0.001
Midazolam 0 7 (3) NA
Neuromuscular blocking 208 (100) 201 (97) 0.023
drugs
Succinylcholine 32 (15) 187 (90) < 0.001
Rocuronium 61 (29) 10 (5) < 0.001
Cisatracurium 115 (55) 4 (2) < 0.001
Adjunct to direct laryngoscopy 21 (10) 40 (19.2) 0.0023
used (gum-elastic bougie)
Procedural complications 13 (6) 76 (37) < 0.001
Hypotension < 80 mmHg 9 (4) 58 (28) < 0.001
Hypoxia < 80% 4 (2) 29 (14) < 0.001
Esophageal intubation 0 4 (2) 1

Data presented as number (%).

ICU = intensive care unit; NA = not applicable; OR = operating room.

bougie was required less often in the operating room com-

pared with the intensive care unit (P = 0.002; table 2).
Complications were more common during tracheal intu-
bations in the intensive care unit compared with the operat-
ing room (76/208, 37% vs. 13/208, 6%; P < 0.001; table 2).
There was a relationship between number of intubation
attempts, difficulty of intubation, and adjuncts to direct
laryngoscopy used, and a difficult laryngoscopy view during
tracheal intubation in the intensive care unit. Tracheal intu-
bation was more difficult, required more frequently adjuncts
to direct laryngoscopy, and needed more intubation attempts
from Cormack–Lehane grade I to IV (P < 0.001; table 3).
Discussion
In this study, we have compared tracheal intubation condi-
tions in the same patient in two different clinical settings:
the intensive care unit and the operating room. We observed
that tracheal intubations with direct laryngoscopy in the
intensive care unit were associated with worsened intuba-
tion conditions and an increase of complications compared
with the operating room. In the operating room, most tra-
cheal intubations are performed under elective, controlled
conditions, in optimized patients, and by anesthesiologists
who are experts in airway management. The rate of difficult
intubation and complications is relatively low.15 However,
the risk of intubation difficulty in the intensive care unit is
high,1–7 and the intensive care unit setting is considered by
Fig. 1. (A) Percentage of patients according to the modified
classification of Cormack-Lehane in the intensive care unit
(ICU) and in the operating room (OR). Tracheal intubation in
the ICU was associated with worsened glottic visualization
compared to intubation in the OR (P < 0.001). (B) Percentage
of patients according to the number of laryngoscopy attempts
required for successful intubation in the ICU and in the OR. Tra-
cheal intubation in the ICU was associated with more attempts
to successfully intubate compared with the OR (P = 0.002). (C)
Percentage of patients according to the operator-reported dif-
ficulty of intubation in the ICU and in the OR. Tracheal intuba-
tion in the ICU was associated with worse reported difficulty of
intubation compared to intubation in the OR (P < 0.001).
many authors3,8 as an independent risk factor of difficult
intubation and complications during intubation.
The primary outcome in this investigation was to compare
the difference in glottic visualization between the operating
room and the intensive care unit because we hypothesized
that poor glottic exposure during direct laryngoscopy may
be responsible for increased incidence of difficult intubation
in the intensive care unit.
To describe glottic visualization during direct laryngos-
copy, we used the modified Cormack–Lehane classification.
This is a scale used frequently in airway-related research to
describe intubation conditions and compare visibility of

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 CRITICAL CARE MEDICINE

Table 3. Relationship between Number of Intubation Attempts, Difficulty of Intubation, Adjuncts to Direct Laryngoscopy Used, and
Procedural Complications with Laryngoscopic Grades Obtained during Tracheal Intubations in ICU (N = 208)

CL-I CL-IIa CL-IIb CL-III CL-IV

116 (56) 24 (12) 47 (23) 19 (9) 2 (1) P Value

Number of intubation attempts

1 attempt 114 (98) 22 (92) 39 (83) 10 (53) 0 < 0.001
2 attempts 2 (2) 2 (8) 8 (17) 8 (42) 1 (50)
3 attempts 0 0 0 1 (5) 1 (50)
Difficulty of intubation
No difficulty 101 (87) 18 (75) 3 (6) 1 (5) 0 < 0.001
Mild 13 (11) 5 (21) 29 (62) 5 (26) 0
Moderate 1 (1) 1 (4) 14 (30) 10 (52) 0
Severe 1 (1) 0 1 (2) 3 (16) 2 (100)
Adjunct to DL used (gum-elastic bougie) 6 (5) 1 (4) 18 (38) 13 (68) 2 (100) < 0.001

Data presented as number (%).

CL = Cormack–Lehane classification; DL = direct laryngoscopy; ICU = intensive care unit.

laryngeal structures.6,9,16–19 Though different authors have
questioned the validity of this scale,20 several studies have
addressed its reliability.14,21–23 In our institution, all anes-
thesiologists know and routinely use the Cormack–Lehane
classification associated with documenting relevant infor-
mation, such as number of intubation attempts, need of
adjuncts to intubate, and operator-reported difficulty. All
data were studied in the current investigation.
In the intensive care unit, poor glottic exposure during
direct laryngoscopy may be affected by operator-, patient-,
and/or environment-related factors.8 Because the same patient
was intubated in the two different clinical settings by anesthe-
siologists with similar levels of experience, the worsened glottic
visualization observed in the intensive care unit in the current
investigation was probably due to physiologic factors of the
critically ill patient, as well as environmental factors. Physi-
ologic factors included hypoxemia, hemodynamic instabil-
ity, laryngeal edema, presence of full stomach, and decreased
physiologic reserve that limit the duration of the laryngo-
scopic attempt. Environmental factors included the limited
space, poor lighting, and suboptimal bed characteristics in
the intensive care unit that limit the ability to properly posi-
tion or access the patient’s head and airway. These factors can
impair direct glottic visualization using a direct laryngoscopy,
therefore increasing the technical difficulty of intubation. We
observed that patients with previously good glottic visualiza-
tion and easy tracheal intubation in the operating room had
worse glottic visualization with increased number of intuba-
tion attempts, and greater difficulty of intubation when these
same patients were intubated in the intensive care unit. We
think that difficulty in viewing the glottis (Cormack–Lehane
IIb, III, or IV) is related to difficult intubation. In the cur-
rent investigation, we observed a greater number of attempts
and difficulty of tracheal intubation in the intensive care unit,
from Cormack–Lehane grade I to IV. Similar to our study,
other authors6,10,19 have observed a strong relationship between
difficult laryngoscopy view and difficult intubation. Soyunco
et al.19 evaluated 366 patients in a prospective observational
study and observed that tracheal intubation was more difficult
from Cormack–Lehane grade I to IV (11 vs. 25 vs. 34 vs. 81%).
Martin et al.6 also showed that Cormack–Lehane grades III and
IV were independent predictors of the complications during
emergent intubations. Semler et al.10 observed that a ramped
position increased the incidence of Cormack–Lehane grades
III or IV view, compared with the sniffing position in intensive
care unit patients (12 vs. 5%). The worsened laryngeal view in
the ramped position increased the incidence of difficult intuba-
tions and the number of attempts required for intubation.
Although we observed less first-time intubation success
rates in the intensive care unit compared with the operating
room, we had good results with nearly 90% of patients intu-
bated at the first attempt in the intensive care unit. However,
other studies have found first-time success rates between 63
and 75%.1–3,24 Many authors have suggested that the goal of
intubation in the intensive care unit should be first-attempt
success.8,24,25 A recent study from Sakles et al.25 shows that the
risk of adverse events increase with each successive attempt,
increasing from 14 to 47% when a second attempt is required.
Similarly, Simpson et al.,7 in a multicenter study, observed
that the frequency of severe hypoxemia increased 14-fold in
patients who required more than two attempts at tracheal intu-
bation. They had, similar to the current investigation, a 91%
first-time intubation success rate with direct laryngoscopy.
The high first-time intubation success rate in intensive
care unit observed in our study and in Simpson’s study7 may
be because of the anesthetic experience of the intubators and
the high level of supervision of residents. Previous investiga-
tions found that tracheal intubation performed by an expert
operator was more likely to be successful, took fewer attempts,
and was associated with fewer complications and lower mor-
tality than intubations performed by nonexperts.2,6 Similarly,
Schmidt et al.9 found that emergent intubation with supervi-
sion by attending anesthesiologists was associated with a statis-
tically significant decrease in complications (6 vs. 22%). Jaber
et al.1 also described having two operators as a protective factor
in reducing complications related to tracheal intubation.
Another factor that may explain the high rate of first-time
intubation success in intensive care unit patients in the current

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study was the high use of neuromuscular blockade for intuba-
tion. Overall, 96% of our patients in the intensive care unit
received neuromuscular blockade, compared with other studies
that document rates from 5 to 72%.1–3,6,9 The use of neuro-
muscular blockade in the intensive care unit has been shown
to optimize intubation conditions,26 improving glottic view
and reducing intubation attempts,27,28 and may contribute to
decreased complication rates. In the intensive care unit, we used
succinylcholine with more frequency, similar to other investiga-
tions,6,7,9,28,29 because the duration of the intubation sequence
is significantly shorter, compared with rocuronium in similar
intubation conditions.29 Our intensive care unit patients were
seriously ill before intubation. For 83% of patients, the reason
for intubation was acute respiratory failure, and nearly 63%
needed noninvasive ventilation before tracheal intubation.
In the current study, we observed an increase in the rate of
the use of airway adjunct in the intensive care unit compared
with the operating room. This probably has also contributed
to the high first-time intubation success rate observed in our
intensive care unit patients. Data suggest that tracheal intuba-
tion, particularly when direct laryngoscopy results in a poor
glottic view, is facilitated with the use of a bougie introductor.30
A retrograde light–guided laryngoscopy was proposed recently
to facilitate tracheal intubation in the intensive care unit.18
In recent years, several studies have assessed whether the
use of video laryngoscopy could increase first-attempt intu-
bation success in the intensive care unit.15,17,31–38 Conflicting
results were obtained. Two meta-analyses34,35 showed that
video laryngoscopy improves first-attempt success, the visu-
alization of the glottis, and reduces mucosal trauma. How-
ever, Huang et al.,39 in another meta-analysis, reported that
video laryngoscopy did not improve first-attempt success,
therefore, do not support routine use of video laryngoscopy
during tracheal intubation in the intensive care unit.
Finally, we found that the rates of complications, such as
hypoxemia, hypotension, or esophageal intubation, occurred
more frequently in the intensive care unit compared with
the operating room. Complications may occur in up to
40% of critically ill patients.1–7,40 Hypoxemia may occur
in around 25%, and hypotension in 15 to 35%.1,2 De Jong
et al.3 observed that in obese patients, difficult intubation
incidence and complications related to intubation occurred
more frequently in the intensive care unit than in the oper-
ating room. Although they compared different patients in
these two clinical settings, their results agree with ours.
Study Limitations
Our study has limitations. First, this was a study in the inten-
sive care unit and the operating room at Clinical University
Hospital of Santiago, Spain. Results are from a single center,
and this must be considered when extrapolating the results
to other clinical settings. Incorporating a multicenter study
in the future could further validate these findings.
Second, in our study all intubations in the operat-
ing room and the intensive care unit were performed by
Anesthesiology 2018; 129:321-8
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Intubation in Operating Room versus Intensive Care
attending anesthesiologists or anesthesia residents with more
than two years of intraoperative anesthesiology experience.
It is not known whether similar results would have been
achieved with operators with different skill levels, or without
the supervision of an attending physician. Although having
similar levels of training, intubators in the operating room
were not exactly the same as in the intensive care unit, so it
limits the conclusions from this study.
Third, the study was observational. Procedural complica-
tions and details of the intubation procedure were collected by
the anesthesiologists and the possibility of imperfect documen-
tation and underreporting of complications must be considered.
Four, we concentrated on the complications of hypox-
emia, hypotension, and esophageal intubation. Other com-
plications were not documented, and their inclusion may
have improved the study.
Last, the neuromuscular blockade and hypnotic drugs used
for induction of anesthesia were different in the operating room
and in the intensive care unit. The short duration of action of
succinylcholine could hamper tracheal intubation in the inten-
sive care unit if difficulty prolongs the attempt. We do not think
that this affects the results obtained in the current investigation
because in 99% of our intensive care unit patients, tracheal
intubation was obtained at first or second attempt.
Despite these limitations, our study offers insight into
airway management in intensive care unit and operating
room settings.
Conclusions
Compared with the operating room, intubation of the same
patient in the intensive care unit using a direct laryngoscopy
was associated with worsened glottic view, decreased first-
time success rate, and an increase in the technical difficulty
of intubation and incidence of complications.
Acknowledgments
The authors thank all physicians and residents of the De-
partment of Anesthesiology and Intensive Care Medicine,
Clinical University Hospital of Santiago, Spain.
Research Support
Support was provided solely from institutional and/or de-
partmental sources.
Competing Interests
The authors declare no competing interests.
Correspondence
Address correspondence to Dr. Taboada: Department of An-
esthesiology and Intensive Care Medicine, Servicio de Anes-
tesiología y Reanimación del Hospital Clínico Universitario
de Santiago de Compostela, Choupana sn, CP:15706, Santia-
go de Compostela (A Coruña), España. manutabo@yahoo.es.
This article may be accessed for personal use at no charge
through the Journal Web site, www.anesthesiology.org.
326 Taboada et al.
 CRITICAL CARE MEDICINE
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ANESTHESIOLOGY REFLECTIONS FROM THE WOOD LIBRARY-MUSEUM

Planocaine: Procaine by May & Baker Ltd. of Dagenham

With John May (1809 to 1893) directing wholesale operations and William Garrad Baker (1815 to 1902) supervising
manufacturing and delivery, the pharmaceutical firm of May & Baker (M&B) was founded in 1839 in London. Three years
after M&B’s surviving founder had passed away, Germany’s Alfred Einhorn synthesized the local anesthetic procaine in
1905. Eventually, M&B became one of several non-German companies whose brands of procaine competed against
Novocaine, Germany’s leading procaine. The 5 ml ampoule (above) of 2% procaine solution was branded “Planocaine”
by May & Baker Ltd. and manufactured at Dagenham, East London. Planocaine was investigated in 1938 by F. R.
Ferguson and K. H. Watkins after cauda equina syndromes complicated 14 spinal anesthetics with “heavy duracaine,”
a mixture of planocaine and glycerine with either gliadin or gum acacia. (Copyright © the American Society of Anesthe-
siologists’ Wood Library-Museum of Anesthesiology.)
George S. Bause, M.D., M.P.H., Honorary Curator and Laureate of the History of Anesthesia, Wood Library-Museum
of Anesthesiology, Schaumburg, Illinois, and Clinical Associate Professor, Case Western Reserve University, Cleveland,
Ohio. UJYC@aol.com.

Anesthesiology 2018; 129:321-8 328 Taboada et al.

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Intubasi Trakeal yang Sulit pada Pasien dengan Penyakit Kritis
Armin Ahmed1* and Afzal Azim2

Abstrak
Latar belakang: Intubasi endotrakeal pada orang yang sakit kritis adalah sebuah
prosedur berisiko tinggi yang membutuhkan keahlian yang signifikan dalam
penanganan jalan napas serta pemahaman patofisiologi proses penyakit.

Bagian Utama: Pasien yang sakit kritis cenderung mengalami hipotensi dan
hipoksemia segera setelah intubasi karena dapat menumpulkan respons
kompensasi simpatik. Preoksigenasi tanpa NIV sering suboptimal, karena alveolar
yang terendam menyebabkan hilangnya permukaan kapiler alveolar pada banyak
pasien ini. Semua faktor ini, bersama dengan defisit cairan relatif, kelelahan
neuromuskuler, dan disfungsi organ yang hidup berdampingan menyebabkan
jalan napas sulit secara fisiologis. Jalan nafas di ICU dapat diklasifikasikan
sebagai sulit secara anatomis dan sulit secara fisiologis. Meskipun intubasi dengan
sekuens cepat adalah metode yang direkomendasikan untuk mengamankan jalan
napas, metode lain seperti intubasi dengan sekuens tertunda, intubasi pada pasien
sadar dan pendekatan pengaturan ganda dapat digunakan dalam subkelompok
tertentu. Penelitian lebih lanjut diperlukan dalam bidang ini untuk menetapkan
pedoman dan manajemen jalan nafas yang bagus untuk pasien dengan kegagalan
atau disfungsi organ tertentu.

Kesimpulan: Jalan napas di ICU harus dikelola sesuai dengan kelainan fisiologis
dan anatomi.

Kata kunci: Sakit kritis, Intubasi, jalan napas sulit secara fisiologis

Latar Belakang
Telah diketahui bahwa intubasi pada penyakit kritis adalah prosedur
berisiko tinggi dan berbeda dari ruang operasi karena berbagai alasan seperti
ketidakstabilan hemodinamik, hipoksia, asidosis metabolik, peningkatan tekanan
intrakranial, dan koagulopati. Peristiwa yang berhubungan dengan jalan nafas di
ICU berpotensi fatal, sehingga memberikan batas kesalahan minimal kepada
intensivist [1, 2]. Proyek audit nasional dari keempat perguruan tinggi ahli
anestesi dan kesulitan jalan nafas melaporkan bahwa 61% kejadian terkait jalan
nafas di ICU dikaitkan dengan kematian atau kerusakan neurologis permanen
dibandingkan dengan 14% kejadian di ruang operasi [3].
Terlepas dari faktor pasien, ada beberapa faktor termasuk lingkungan ICU
dan keterampilan operator dan asisten di ICU yang berbeda dari ruang operasi [4,
5].
Istilah jalan nafas yang sulit secara anatomis digunakan ketika ada kesulitan
dalam ventilation bag mask atau kesulitan dalam memasukkan alat jalan nafas
supraglotis atau kesulitan dalam visualisasi pembukaan glotis atau melewati
endotrakeal saat membuka. Jalan nafas yang sulit secara fisiologis adalah di mana
proses induksi dan intubasi dapat berpotensi mengancam jiwa karena
berkurangnya cadangan fisiologis yang berkaitan dengan proses penyakit [6].
Penting untuk membedakan antara jalan nafas yang sulit secara anatomis dan
fisiologis karena intubasi pada pasien sadar adalah standar baku dalam
memprediksi jalan nafas yang sulit secara anatomis sementara intubasi pada
pasien sadar dapat memperburuk fisiologi pasien yang sakit parah seperti
menumpulkan refleks saluran napas yang dapat menyebabkan peningkatan
tekanan intrakranial atau memperburuk iskemia jantung pada individu yang
memiliki kecenderungan.
Selain itu, gangguan fisiologis awal memburuk dengan meningkatnya
jumlah upaya intubasi [7]. Oleh karena itu, strategi jalan nafas dengan tingkat
keberhasilan pertama adalah penting dalam manajemen pasien ini. Mungkin ada
kelompok pasien lain yang memiliki jalan napas sulit secara anatomis dan
fisiologis (lihat Tabel 1). Orang dapat secara intuitif memahami bahwa
pendekatan umum induksi dan intubasi tidak dapat digunakan untuk semua jenis
kondisi dan subkelompok tertentu memerlukan modifikasi strategi spesifik.
Artikel saat ini berkaitan dengan komponen kunci dari manajemen jalan napas
pada pasien yang sakit kritis dan juga membahas perincian yang lebih baik dari
jalan napas yang sulit secara fisiologis.
Dasar-dasar manajemen jalan napas di ICU
Prediksi jalan napas sulit di ICU
Untuk mengatasi prediksi jalan nafas yang sulit pada pasien yang sakit
kritis, De Jong et al. mengembangkan dan memvalidasi skor (MACOCHA) dalam
penelitian multisenter yang meliputi 1000 intubasi pada 42 ICU [8]. Skor tersebut
termasuk tujuh parameter, di antaranya lima terkait dengan pasien (Mallampati >
III atau IV, Obstructive Sleep Apnoea (OSA), mobilitas C-spine berkurang,
pembukaan mulut < 3 cm), terkait dua parameter patologi (saturasi kurang dari
80% dan koma) dan satu parameter yang terkait operator (kehadiran non-
anestesiologis). Setiap parameter telah diberikan satu poin kecuali untuk
Mallampati dan OSA yang masing-masing memiliki 5 poin dan 2 poin. Kesulitan
intubasi meningkat ketika skor meningkat dari 0 menjadi 12.
Preoksigenasi adalah proses pembentukan reservoir oksigen di dalam paru-
paru yang dapat digunakan selama waktu apnea [9]. Reservoir ini dibuat dengan
menghilangkan nitrogen yang ada dalam kapasitas residual fungsional (FRC) dan
menggantinya dengan oksigen. Lebih besar FRC, lebih besar reservoir dan lebih
lama waktu untuk desaturasi selama apnea. Kecepatan desaturasi selama apnea
juga dipengaruhi oleh laju metabolisme. Pada tingkat metabolisme yang lebih
tinggi, oksigen akan dikeluarkan dengan cepat dari reservoir ini dan sebaliknya.
Konsumsi oksigen pada pasien yang dibius sekitar 250 ml / menit. Jumlah
oksigen di paru-paru selama pernapasan tidal normal sekitar 13% (290 ml; mis.
13% FRC). Untuk orang dewasa yang bernapas di udara ruangan dan konsumsi
oksigen normal, kandungan oksigen paru-paru akan dikonsumsi dalam 1 menit
setelah apnea. Denitrogenasi lengkap paru-paru akan memberikan reservoir
oksigen yang setara dengan FRC, yaitu sekitar 2000 hingga 2500 ml [10, 11].
Dengan kecepatan konsumsi oksigen 250 ml / menit, ini akan cukup untuk sampai
8 menit. Reservoir ini jauh lebih kecil pada pasien yang sakit kritis (terutama
obesitas) karena FRC berkurang.
Pra-oksigenasi umumnya dilakukan selama 3 sampai 5 menit di ruang
operasi untuk menghilangkan nitrogen paru-paru. Efektivitas preoksigenasi dapat
dipantau dengan mengukur fraksi oksigen dalam gas kadaluarsa (FeO2), yang
dianggap sebagai penanda pengganti kandungan oksigen alveolar. Ada data yang
terbatas pada durasi preoksigenasi untuk denitrogenasi yang memadai pada pasien
yang sakit kritis. Memperpanjang durasi preoksigenasi dari 4 hingga 8 menit telah
terbukti hanya sedikit efektif atau bahkan berbahaya dalam satu studi pada pasien
yang sakit kritis [12]. Pedoman saat ini merekomendasikan 3 menit preoksigenasi
pada pasien sakit kritis, yang harus dilakukan jika mungkin dengan menggunakan
ventilasi tekanan positif non-invasif (tekanan inspirasi 5 hingga 15 cm, PEEP 5
cm dan volume tidal target 6 hingga 8 ml / kg) dalam posisi kepala ke atas atau
dengan nasal kanul aliran tinggi dengan aliran oksigen pada 70 l per menit [4].
Terlepas dari denitrogenasi yang memadai, pasien yang sakit kritis
mengalami desaturasi lebih cepat karena FRC yang lebih kecil, tingkat konsumsi
oksigen yang lebih tinggi dan alveolar yang terendam luas (seperti yang terlihat
pada ARDS atau edema paru kardiogenik). Alveolar yang terendam dapat
mengurangi permukaan kapiler alveolar yang tersedia untuk pertukaran gas. Oleh
karena itu, jika reservoir oksigen ada di paru-paru, aliran oksigen dari reservoir ke
sirkulasi terhambat. Pasien-pasien ini telah meningkatkan grave arterial alveolar
(A-a) dan harus dioksigenasi terlebih dahulu menggunakan ventilasi tekanan
positif non-invasif (NIPPV), yang mengurangi fraksi shunt dengan merekrut
alveoli yang kolaps [13].
Oksigenasi / peroksigenasi apnoeik adalah oksigen yang diberikan dari
induksi apnea hingga awal ventilasi tekanan positif. Oksigenasi apnoeik
bergantung pada aliran massa oksigen melintasi gradien tekanan yang dibuat
antara saluran napas bagian atas dan alveoli karena pengambilan oksigen secara
konstan oleh kapiler. Kriteria yang paling penting untuk oksigenasi apnoeik yang
berhasil adalah pemeliharaan jalan napas paten sambil memberikan oksigen
selama upaya intubasi. Oksigenasi apnoeik dialirkan melalui nasal kanul aliran
tinggi (HFNC) yang mampu menghasilkan oksigen yang lembab dan hangat pada
40 hingga 60 l / menit. Dengan tidak adanya HFNC, nasal kanul standar pada 15 l
/ menit dapat digunakan setelah de-nitrogenasi yang adekuat. Komplikasi dari
oksidasi apnoeik yang berkepanjangan meliputi hypercarbia, asidosis,
hiperkalemia, peningkatan tekanan intrakranial dan hipertensi paru [11, 14].
Tinjauan sistematis dan metaanalisis pada dukungan pernapasan selama
intubasi pada pasien yang sakit kritis menunjukkan oksigenasi apnoeik (4 RCT,
358 pasien) dikaitkan dengan SpO2 minimum yang lebih tinggi dibandingkan
dengan mereka yang tidak menerima oksigenasi apnoeik [15]. Oksigenasi apnoeik
diberikan melalui nasal kanul aliran tinggi dalam 3 RCT dan melalui nasal kanul
standar dalam 1 RCT. Metaanalisis lain melaporkan peningkatan keberhasilan
pertama intubasi (mungkin karena lebih banyak waktu yang tersedia untuk
intubasi tanpa desaturasi), saturasi oksigen peri-intubasi yang lebih tinggi dan
penurunan tingkat hipoksemia dengan oksigenasi apnoeik [16].
Jaber et al. menggabungkan NIV untuk pra-oksigenasi dan HFNC untuk
oksigenasi apnoeik selama intubasi pasien hipoksemik dalam RCT termasuk 24
pasien dalam kelompok kontrol dan 25 pasien dalam kelompok intervensi. Nilai
SpO2 terendah secara signifikan lebih tinggi pada kelompok intervensi [17].
Jelas dari diskusi di atas bahwa pra-oksigenasi dan oksigenasi apnoeik
adalah dua strategi kunci untuk meningkatkan keamanan intubasi pada orang yang
sakit kritis. Harus diingat bahwa pada pasien dengan hipoksemia berat, strategi ini
mungkin tidak berfungsi karena kerusakan luas pada permukaan alveolar-kapiler.
Pasien yang tidak mempertahankan saturasi pada NIV membentuk subkelompok
di mana pra-oksigenasi dan oksigenasi apnoeik cenderung tidak efektif. Oleh
karena itu, uji coba NIV yang berkepanjangan pada pasien hipoksemia berat tidak
dianjurkan dan pasien ini harus diintubasi tepat waktu menggunakan bundel
perawatan intubasi ICU. Jaber et al. menunjukkan sepuluh pendekatan bundel
berbasis komponen yang dikaitkan dengan pengurangan yang signifikan dalam
kedua nyawa yang mengancam serta komplikasi lain dalam intubasi ICU [18].
Bundel intubasi mereka termasuk pra-oksigenasi dengan ventilasi tekanan positif
non-invasif, induksi urutan cepat, dua operator, tekanan cricoids, kapnografi,
cairan, sedasi dan vapor sesuai kebutuhan.
Kapnografi adalah pemantauan terus menerus dari tekanan parsial karbon
dioksida dalam gas yang dihembuskan. Bentuk gelombang kapnografi dicapai
dengan memplot tekanan parsial CO2 yang kedaluwarsa pada sumbu Y dan waktu
pada sumbu X. Metode pengukuran kapnografi meliputi penganalisis aliran
samping dan penganalisa arus utama. Kapnografi banyak digunakan untuk
berbagai indikasi mulai dari konfirmasi intubasi trakea, pemantauan kecukupan
ventilasi, estimasi curah jantung, dan pemantauan kecukupan resusitasi
kardiopulmoner. Lebih dari 70% kematian jalan napas terkait ICU dalam studi
NAP4 dikaitkan dengan kegagalan untuk menggunakan kapnografi pada pasien
yang bergantung pada jalan napas buatan [3]. Oleh karena itu, pedoman saat ini
merekomendasikan penggunaan kapnografi terus menerus selama intubasi dan
trakeostomi untuk konfirmasi penempatan endotracheal tube atau trakeostomi
yang benar serta untuk pemantauan pada semua pasien yang dibius dan pasien
yang membutuhkan dukungan hidup terlepas dari lokasi mereka [4, 5].
Videolaryngoscope digunakan untuk manajemen jalan nafas yang sulit di ruang
operasi, unit perawatan intensif dan darurat, sebagai teknik penyelamatan ketika
laringoskopi langsung gagal. Perangkat ini terdiri dari fiberoptic indirect rigid
laryngoscope dengan kamera video terpasang di satu ujung. Intubasi dilakukan
berdasarkan gambar video dari inlet yang diperbesar dan membutuhkan lebih
sedikit tekanan suspensi untuk mencapai tampilan laring yang memadai.
Videolaryngoskopi tersedia dalam desain blade Macintosh standar dan desain
acute angle blade. Desain acute angle blade membutuhkan sedikit manipulasi
leher, tetapi stylet diperlukan untuk memfasilitasi pemasangan tube. Sebuah
tinjauan sistematis yang baru-baru ini diterbitkan termasuk 64 uji coba terkontrol
secara acak tentang penggunaan videolaringoskopi vs laringoskopi langsung
untuk intubasi pada orang dewasa ditemukan berkurangnya kegagalan intubasi
dengan lingkup videolaringoskopi terutama ketika mengelola jalan napas yang
sulit [19]. Kinerja diferensial dilaporkan dengan desain yang berbeda. Bukti saat
ini tidak menunjukkan penggunaan efek videolaringoskopi dengan jumlah upaya
intubasi, durasi yang diperlukan untuk intubasi atau kejadian komplikasi hipoksia.
Mode induksi (Tabel 2)
Induksi dan intubasi urutan cepat (RSII)
Ini adalah metode induksi pada pasien dengan perut yang penuh dan
peningkatan risiko muntah dan aspirasi. RSII digunakan untuk meminimalkan
durasi antara hilangnya refleks jalan nafas dan pembentukan jalan nafas definitif
dengan inflasi cuff. RSII adalah induksi pilihan pada pasien ICU karena bahkan
jika mereka adalah nil oral untuk durasi yang signifikan, perubahan elektrolit dan
lingkungan metabolik dapat menyebabkan berkurangnya motilitas usus dan
peningkatan risiko aspirasi. Lebih baik untuk berhenti memberi makan enteral dan
mengeluarkan isi lambung dengan hisap lembut bila memungkinkan sebelum
RSII.

RSII pertama kali diperkenalkan oleh Stept dan Safar pada tahun 1970 [20].
Sejak itu, teknik ini semakin populer dalam manajemen jalan napas darurat pasien
dengan perut yang penuh di seluruh dunia. Langkah-langkah induksi dengan
sekuens cepat termasuk pemberian agen penginduksi, penggunaan pelemas otot
dengan onset yang cepat (suksinilkolin atau rocuronium) bersama dengan
penerapan tekanan krikoid. Bukti saat ini menunjukkan variasi dan modifikasi
yang signifikan dalam teknik RSII [21, 22]. Institusi harus mengembangkan
protokol RSII mereka sendiri sesuai kebutuhan dan populasi pasien:
• Posisi optimal pasien harus dicapai (secara rutin Sniffing position / jalan
dalam kegemukan / head up selama preoksigenasi untuk meningkatkan FRC
/ miring lateral kiri pada pasien hamil untuk menghindari kompresi
aortokaval oleh uterus gravid)
• Preoksigenasi dan per-oksigenasi menggunakan ventilasi non-invasif atau
kanula hidung aliran tinggi
• Agen penginduksi (pilihan ditentukan oleh status hemodinamik; ketamin
lebih disukai karena secara hemodinamik tidak stabil; dosis agen
penginduksi dapat ditetapkan sebelumnya atau dititrasi sesuai respon)
• Opioid tambahan yang bekerja cepat untuk menumpulkan refleks
laringoskopi
• Penerapan tekanan krikoid (10 N pada saat induksi, yang meningkat
menjadi 30 N setelah kehilangan kesadaran). Tekanan krikoid harus
dihilangkan jika ada muntah aktif, kesulitan dalam laringoskopi atau
lewatnya tabung endotrakeal. Penempatan perangkat saluran napas
supraglotis membutuhkan pengangkatan tekanan krikoid. Ada perbedaan
pendapat mengenai kegunaan tekanan krikoid dalam mencegah regurgitasi.
Bukti saat ini tidak mendukung atau membantah penggunaannya
• Relaksan otot (suksinilkolin / rocuronium)
• Ventilasi manual (meskipun bukan komponen standar RSII, ventilasi
manual yang lembut dapat digunakan jika saturasi oksigen turun antara
induksi dan onset kelumpuhan). Risiko insuflasi lambung selama ventilasi
manual dapat diminimalkan dengan menggunakan posisi yang tepat,
tekanan inflasi yang lembut dan aplikasi tekanan krikoid.
• Memaksimalkan pass pertama (tambahan bougie dan stylets)
• Pendekatan pusaran (langkah-langkah yang jelas dan transisi cepat dari satu
rencana ke rencana berikutnya dalam situasi krisis tanpa menyia-
nyiakanwaktu dengan melakukan beberapa upaya dengan peralatan yang
sama dan teknik yang sama). Pendekatan pusaran memungkinkan tiga upaya
masing-masing dengan ventilasi sungkup muka, intubasi dan penyisipan
perangkat supraglottic. Pedoman Inggris juga memungkinkan tiga upaya
intubasi. Namun, ada data yang menunjukkan bahwa lebih dari dua upaya
 intubasi di luar ruang operasi dikaitkan dengan tingkat komplikasi yang
tinggi.

Induksi sekuens tertunda (DSI)

Ini adalah metode induksi pada pasien yang gelisah dan sulit dilakukan pra-
oksigenasi [23, 24]. Dosis ketamin atau benzodiazepine dalam jumlah kecil dapat
digunakan untuk menenangkan pasien sehingga dapat mentoleransi pra-
oksigenasi. Titrasi dosis dilakukan dengan cara tidak menumpulkan refleks jalan
napas atau pernapasan spontan. Dosis lebih lanjut dari agen penginduksi diberikan
setelah pra-oksigenasi telah dicapai dengan memuaskan. Ketamin dapat
menyebabkan takikardia dan hipertensi karena efek simpatomimetiknya. Dex-
medetomidine (alpha 2 antagonist) adalah alternatif pada pasien pada pasien yang
takikardiak atau hipertensi. Metode sedasi prosedural ini telah lama digunakan
tetapi istilah intubasi urutan tertunda baru-baru ini diciptakan oleh Weingart et al.
dalam penelitian observasional yang melibatkan 62 pasien yang membutuhkan
manajemen jalan napas darurat tetapi sulit untuk melakukan pra-oksigenasi karena
status mental yang berubah [25]. Penelitian ini telah menerima kritik untuk desain
dan ukuran sampelnya tetapi DSI tetap merupakan strategi penting dalam populasi
pasien yang mengigau. DSI harus dilakukan oleh ahli anestesi berpengalaman
karena ada laporan kasus apnea bahkan dengan dosis kecil agen penginduksi.

Intubasi secara sadar

Ini adalah metode induksi di mana respirasi spontan dipertahankan selama
mengamankan jalan napas [26]. Intubasi secara sadar adalah metode yang lebih
disukai dari manajemen jalan nafas yang diprediksi sulit di kamar operasi yang
merupakan saluran udara yang sulit secara anomali. Telah dikemukakan oleh
beberapa penulis bahwa “intubasi secara sadar” harus menjadi metode
pengamanan jalan napas pada pasien kritis untuk mencegah penumpulan respon
kompensasi fisiologis [27].
Topikalisasi jalan napas, premedikasi dengan anti-sialogogues, H2 blocker
dan metoclopramide adalah komponen kunci dari intubasi sadar. Menumpulkan
refleks jalan nafas yang tidak adekuat dapat memicu laringospasme, takikardia,
hipertensi, dll. Intubasi ruang lingkup yang fleksibel, video-laringoskopi, tongkat
cahaya, laringoskopi langsung, intubasi buta, dll. Adalah beberapa metode untuk
intubasi secara sadar. Keahlian yang signifikan diperlukan untuk melakukan
intubasi secara sadar pada pasien yang sakit kritis dengan aman.

Pendekatan pengaturan ganda

Ini adalah strategi mempersiapkan dua pendekatan secara bersamaan pada
pasien dengan antisipasi gagal intubasi [28]. Membran krikothyroid dapat
diidentifikasi melalui ultrasound atau secara klinis sebelum menginduksi pasien
untuk RSII. Demikian pula, persiapan bedah trakeostomi dapat dilakukan sebelum
mendorong pasien berisiko tinggi.
Studi NAP 4 melaporkan tingkat kegagalan needle cricothyroidotomy yang
tinggi dan tidak terduga. Kegagalan untuk mengidentifikasi membran krikotiroid
dalam situasi darurat yang penuh tekanan adalah salah satu penyebabnya [3]. Juga
telah ditemukan bahwa ketika tidak dapat intubasi tidak dapat terjadi situasi
oksigenasi, jalan napas diamankan tetapi sebagian besar sudah terlambat untuk
mencegah kerusakan otak yang tidak dapat diperbaiki. Pendekatan pemasangan
ganda meningkatkan margin keselamatan dan membantu mengatasi kegagalan
kognitif dalam situasi darurat.

Persiapan untuk kehilangan pasca induksi dan kompensasi fisiologis pasca

induksi
Pasien ICU berada di bawah tekanan fisiologis karena penyakit yang
mendasarinya. Banyak dari mereka berada dalam kondisi kompensasi dari
kekacauan fisiologis mereka. Penggunaan agen induksi pada pasien ini mengarah
pada "kompensasi fisiologis tumpul atau kegagalan". Akibatnya, pasien dapat
mengalami perubahan akut pada hemodinamik dan lingkungan metabolik pada
saat induksi dan intubasi [29]. Faktor-faktor lain yang berkontribusi terhadap
dekompensasi termasuk kurang tidur, hipovolemia relatif karena asupan yang
buruk dan peningkatan kerja pernapasan yang menyebabkan kelelahan diafragma.
Saluran arteri harus diamankan sebelum induksi dan intubasi pasien berisiko
tinggi. Jika pemantauan tekanan darah non-invasif sedang dilakukan, siklus
pengukuran harus ditetapkan pada interval 1 hingga 2 menit selama induksi dan
periode pasca intubasi segera. Perubahan cepat dalam status metabolisme harus
dipantau melalui analisis gas darah secara teratur. Terlihat bahwa masalah jalan
nafas terkait ICU terjadi terutama pada fase pasca intubasi. Memahami
patofisiologi yang mendasari proses penyakit tertentu dan mempersiapkan respons
pasca induksi pasien dapat membantu meringankan masalah tersebut (mis.
Pemuatan cairan pada pasien hipovolemik, infus vasopresor untuk hipotensi, infus
bikarbonat untuk asidosis metabolik yang parah). Gambar 1 menggambarkan
berbagai tahap ventilasi mekanik pada pasien yang sakit kritis.

Jalan napas yang sulit karena gangguan neurofisiologis

Cidera otak traumatis dan pasien stroke yang memerlukan intubasi dan
ventilasi mekanis membentuk subkelompok khusus di mana tekanan intrakranial
yang meningkat adalah gangguan fisiologis utama. Pasien-pasien ini juga
menunjukkan fluktuasi luas tekanan darah selama induksi urutan cepat dan
intubasi [30]. Tabel 3 menunjukkan komponen perlindungan saraf yang penulis
gunakan di ICU mereka saat mengintubasi pasien tersebut.
• Monitoring Pemantauan tekanan darah invasif lebih baik sebelum induksi
karena fluktuasi tekanan darah dapat menyebabkan peningkatan ICP dan
herniasi. Status cairan dan elektrolit harus dievaluasi dengan cermat
sebelum induksi karena pasien-pasien ini secara rutin mendapatkan manitol
untuk mengurangi edema serebral. Induksi dalam volume pasien yang
berkurang dapat menyebabkan penurunan tekanan darah yang drastis.
 • Premedikasi dengan fentanyl / remifentanil digunakan untuk menumpulkan
respons stres akibat laringoskopi dan peningkatan ICP yang terkait.
Penggunaan lidokain sebagai tindakan kontrol ICP lemah didukung oleh
bukti [31, 32]. Injeksi lidokain bolus yang cepat dapat menyebabkan
hipotensi, terutama bila digunakan dengan propofol atau thiopentone.
• Ketamin tidak lagi dianggap kontraindikasi pada pasien cedera kepala
karena studi prospektif baru belum menunjukkan hubungan antara
peningkatan tekanan intrakranial dan penggunaan ketamin [33, 34]. Agen
penginduksi lain seperti propofol atau thiopentone dapat menyebabkan
penurunan tekanan darah yang signifikan dan harus digunakan dengan hati-
hati.
• Fasikulasi yang disebabkan oleh suksinilkolin dapat menyebabkan
peningkatan tekanan intrakranial. Dosis de-fasikulasi dengan blocker non-
depolarisasi harus diberikan sebelum digunakan.

Jalan nafas yang sulit karena kekacauan kardiovaskular

Intubasi pada pasien jantung membutuhkan preload, afterload, denyut
jantung dan optimalisasi kontraktilitas. Tampon jantung membentuk subkelompok
spesifik di mana intubasi harus ditunda sampai manajemen definitif tamponade
jantung tercapai. Pemutaran samping tempat tidur ECHO sangat membantu dalam
penilaian preload, afterload, dan kontraktilitas.
Tujuan manajemen pada pasien yang berisiko tinggi untuk iskemia miokard
adalah menghindari peningkatan denyut jantung dan faktor-faktor yang
menyebabkan peningkatan ekstrim dalam tekanan dinding, yaitu inotropi dan
afterload [35]. Etomidate adalah agen penginduksi kardio paling stabil tetapi tidak
menumpulkan stres laringoskopi [36]. Ia dapat dikombinasikan dengan opioid
onset cepat untuk intubasi. Pasien dengan hipertrofi ventrikel kiri memiliki
kepatuhan diastolik yang buruk dan bergantung pada tendangan atrium untuk
pengisian ventrikel. Pasien-pasien ini harus dikelola dengan strategi berdasarkan
penghindaran aritmia atrium, hipotensi dan iskemia miokard. Pasien dengan lesi
regurgitasi (regurgitasi aorta / mitral) dikelola dengan mempertahankan denyut
jantung sedikit lebih tinggi, rendah setelah beban, preload yang memadai dan
dukungan kontraktilitas jika terganggu.
Pasien dengan lesi stenotik paling sulit ditangani. Tujuan hemodinamik
dalam penatalaksanaan stenosis mitral termasuk pencegahan peningkatan tekanan
arteri pulmonalis, denyut jantung dan pengurangan afterload yang nyata. Stenosis
aorta membutuhkan kontrol detak jantung, preload yang adekuat, dan
penghindaran iskemia miokard.

Jalan nafas yang sulit karena gangguan pernapasan

Pra-oksigenasi dengan NIV adalah komponen paling penting dari strategi
manajemen jalan nafas dalam kegagalan pernafasan karena ARDS. Pasien-pasien
ini cenderung untuk rekrutmen cepat sehingga memberikan banyak tekanan waktu
pada intensivist. Ventilasi bag mask tidak dapat diandalkan sebagai strategi
penyelamatan pada pasien ini karena ARDS paru-paru yang parah sulit untuk
mengembang dengan mask bag. Upaya-upaya untuk menutupi topeng dapat
menyebabkan buang-buang waktu yang tidak perlu. Masker tas harus diganti
dengan NIV. Oksigenasi apnoeic dan juga pra-oksigenasi merupakan komponen
penting dari manajemen jalan napas pada pasien ARDS, tetapi perlu dicatat bahwa
ini adalah pasien yang sangat di mana pre-oksigenasi dan oksigenasi apnoeic
cenderung paling tidak efektif.
Pasien ARDS rentan disfungsi ventrikel kanan akut. Jika waktu
memungkinkan skrining, ECHO samping tempat tidur harus dilakukan untuk
mengevaluasi ventrikel kanan. Pemantauan hemodinamik invasif lebih disukai
pada saat induksi pada pasien dengan gagal jantung dan pernapasan bersamaan.
Intubasi pada pasien dengan kegagalan ventrikel kanan sangat berisiko karena
tidak seperti fungsi ventrikel kiri, deterio- fungsi ventrikel kanan dengan
peningkatan tekanan intra-toraks yang disebabkan oleh ventilasi tekanan positif.
Preload ventrikel kanan dan optimalisasi afterload diperlukan sebelum intubasi
untuk mencegah kolaps kardiovaskular. Metode optimalisasi afterload ventrikel
kanan termasuk vasodilator paru inhalasi seperti nitrat oksida atau epoprostenol,
koreksi vasokonstriksi paru hipoksik dengan suplementasi oksigen dan penurunan
atelektasis melalui dukungan ventilator non-invasif. Untuk detail lebih lanjut, lihat
ulasan oleh Hrymak et al. dan Krishnan et al. [37, 38]. Jalan nafas yang sulit
karena gangguan hati
Pasien gagal hati telah meningkatkan ICP karena ensefalopati hepatik. Mereka
harus diintubasi dengan strategi protektif saraf. Selain itu, mereka memiliki
koagulopati dan seringkali trombositopenik. Kondisi intubasi suboptimal dapat
menyebabkan trauma jalan napas dan perdarahan, sehingga membuat jalan napas
menjadi sulit secara fisiologis dan juga secara anatomis sulit.
Intubasi hidung tidak boleh digunakan pada pasien ini dalam melihat
kecenderungan perdarahan. Transfusi produk darah harus dipertimbangkan pada
pasien dengan risiko perdarahan tinggi.

Jalan nafas yang sulit karena gangguan ginjal

Pasien gagal ginjal mungkin memerlukan intubasi karena peningkatan kerja
pernapasan yang disebabkan oleh asidosis metabolik yang parah. Pasien-pasien
ini mempertahankan pH mereka dalam kisaran normal dengan meningkatkan
ventilasi dan menghilangkan karbon dioksida. Induksi anestesi menyebabkan
penurunan ventilasi dan hilangnya respons kompensasi. Menggunakan obat
penghambat neuromuskuler selanjutnya dapat menurunkan pH dan menyebabkan
penurunan tekanan darah yang cepat dan peningkatan konsentrasi kalium yang
berbahaya. Pasien-pasien ini harus diintubasi dengan mempertimbangkan
perubahan yang cepat dalam lingkungan metabolik.
• Suksinilkolin menyebabkan hiperkalemia dan harus dihindari pada pasien
dengan gagal ginjal [39]. Rocuronium adalah obat pilihan saat mengintubasi
subkelompok ini.
• Vasopressor harus dihubungkan melalui kanula yang besar pada saat
induksi.
• Infus Sodabicarbonate dapat dipertimbangkan pada pasien dengan pH < 7,2
sebelum induksi.

Jalan nafas sulit karena sepsis

Pasien sepsis cenderung mengalami syok distributif. Ketidakstabilan
hemodinamik, asidosis laktat, dan koagulopati sering menjadi masalah. Resusitasi
volume dan vasopressor merupakan komponen kunci dari strategi manajemen
jalan napas. Akses vena yang optimal harus diamankan sebelum induksi pada
pasien ini.
Pemantauan hemodinamik invasif lebih disukai pada pasien yang
membutuhkan noradrenalin dosis tinggi. Etomidate dapat menyebabkan
kekurangan kortisol. Ketamin adalah agen yang ditunjuk untuk induksi.

Kesimpulan
• Penting untuk mengetahui bahwa intubasi di ICU berbeda dari ruang
operasi. Strategi intubasi pada sakit kritis memerlukan modifikasi sesuai
kekacauan fisiologis.
• Jalan napas di ICU dapat diklasifikasikan sebagai sulit secara anatomis, sulit
secara fisiologis dan keduanya
• Meskipun induksi dengan sekuens cepat adalah strategi inti untuk induksi
jalan napas yang sulit secara fisiologis, modifikasi strategi seperti intubasi
terjaga dengan videolaryngoscope atau intubasi flexiblescope dan intubasi
dengan sekuens tertunda dapat digunakan oleh para ahli di subkelompok
risiko tinggi tertentu.
• Gen Preoksigenasi dan oksigenasi apnoeic melalui NIV dan kanula nasal
aliran tinggi adalah metode yang berguna untuk meningkatkan waktu apnea
yang aman.
• Pilihan agen penginduksi dan pelemas otot ditentukan oleh patofisiologi
pasien.

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Ahmed and Azim Journal of Intensive Care (2018) 6:49
https://doi.org/10.1186/s40560-018-0318-4

REVIEW Open Access

Difficult tracheal intubation in critically ill

Armin Ahmed1* and Afzal Azim2

Abstract
Background: Endotracheal intubation in critically ill is a high-risk procedure requiring significant expertise in airway
handling as well as understanding of pathophysiology of the disease process.
Main body: Critically ill patients are prone for hypotension and hypoxemia in the immediate post-intubation phase
due to blunting of compensatory sympathetic response. Preoxygenation without NIV is frequently suboptimal, as
alveolar flooding cause loss of alveolar capillary interface in many of these patients. All these factors, along with
relative fluid deficit, neuromuscular fatigue and coexistent organ dysfunction lead to physiologically difficult airway.
Airway in ICU can be classified as anatomically difficult, physiologically difficult and anatomically as well as
physiologically difficult. Though rapid sequence intubation is the recommended method for securing airway
in these patients, other methods like delayed sequence intubation awake intubation and double setup approach can
be used in specific subgroups. Further research is needed in this field to set guidelines and fine tune airway
management for patients with specific organ failure or dysfunction.
Conclusion: Airway in ICU should be managed according to the physiological as well as the anatomical
abnormalities.
Keywords: Critically ill, Intubation, Physiologically difficult airway

Background tube through the opening. Physiologically difficult airway

It is well known that intubation in critically ill is a
high-risk procedure and different from operating room
for various reasons like hemodynamic instability, hypox-
emia, metabolic acidosis, raised intracranial pressure,
and coagulopathy. Airway-related events in ICU are
potentially fatal, thus giving minimal margin of error to
the intensivist [1, 2]. Fourth national audit project of the
royal college of anaesthetists and the difficult airway so-
ciety reported that 61% of airway-related events in ICU
were associated with death or permanent neurological
damage compared with 14% in operating room [3].
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].
The term anatomically difficult airway is used when
there is difficulty in bag mask ventilation or difficulty in
inserting supraglottic airway device or difficulty in visu-
alisation of glottic opening or passing of endotracheal
* Correspondence: drarminahmed@gmail.com
1
Department of Critical Care Medicine, King George Medical University,
Lucknow 226003, India
Full list of author information is available at the end of the article
is the one where the process of induction and intubation
can be potentially life threatening due to reduced
physiological reserves pertaining to disease process [6].
It is important to differentiate between anatomically and
physiologically difficult airway because awake intubation
is the gold standard in predicted anatomically difficult
airway while awake intubation can worsen already
deranged physiology of a critically ill patient such as
inadequate blunting of airway reflexes can cause rise in
intracranial pressure or worsen cardiac ischemia in the
predisposed individuals.
Moreover, baseline physiological derangements worsen
with increased number of attempts to intubate [7]. There-
fore, airway strategy with highest rate of first pass success
is important in management of these patients. There can
be another group of patients who have anatomically as
well as physiologically difficult airway (see Table 1). One
can intuitively understand that a common approach of
induction and intubation cannot be used for all types of
conditions and specific subgroups require specific strategy
modification. Current article deals with key components
of airway management in critically ill patients and also
address the finer details of physiologically difficult airway.

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Ahmed and Azim Journal of Intensive Care (2018) 6:49 Page 2 of 9

Table 1 Classification of airway in ICU

Anatomically difficult airway
A. Difficult bag mask ventilation
B. Difficult supraglottic device placement
C. Difficult intubation
D. Difficult surgical airway
Physiologically difficult airway Anatomically as well as physiologically
difficult airway
1. Neurophysiologic derangement (raised intracranial • A + (any of physiological derangement 1....8)
pressure)
2. Cardiovascular derangement (derangements of • B + (any of physiological derangement 1....8)
preload, afterload, contractility or rhythm)
3. Respiratory derangement (hypoxemia and • C + (any of physiological derangement 1....8)
hypercarbia)
4. Hepatic derangement (raised intracranial pressure • D + (any of physiological derangement 1....8)
and coagulopathy)
5. Renal derangement (encephalopathy, pulmonary
oedema, hyperkalemia and metabolic acidosis)
6. Gut derangement (raised intra-abdominal pressure,
abdominal compartment syndrome)
7. Severe sepsis (lactic acidosis, distributive shock
multiple organ dysfunction)

Basics of airway management in ICU
Prediction of difficult airway in ICU
In order to address the prediction of difficult airway in
critically ill patients, De Jong et al. developed and vali-
dated a score (MACOCHA) in a multicentre study in-
cluding 1000 intubations in 42 ICUs [8].The score
included seven parameters, out of which five were
patient related (Mallampati >III or IV, obstructive sleep
apnoea (OSA), reduced C-spine mobility, mouth open-
ing < 3 cm), two parameters pathology related (satur-
ation less than 80% and coma) and one parameter
operator related (presence of non-anaesthesiologist).
Each parameter has been given one point except for
Mallampati and OSA which have 5 points and 2 points
each respectively. The difficulty of intubation increases
as the score increases from 0 to 12.
Preoxygenation is the process of creating an oxygen
reservoir inside the lung which can be used during the
apnoea time [9].This reservoir is created by removing ni-
trogen present in functional residual capacity (FRC) and
replacing it with oxygen. Larger is the FRC, larger will
be the reservoir and longer is the time to desaturate dur-
ing apnoea. Rapidity of desaturation during apnoea is
also affected by metabolic rate. At higher metabolic rate,
oxygen will be removed rapidly from this reservoir and
vice versa.
Oxygen consumption in an anaesthetised patient is
around 250 ml/min. Amount of oxygen in lungs dur-
ing normal tidal breathing is roughly 13% (290 ml;
i.e. 13% of FRC). For an adult breathing at room air
and normal oxygen consumption, the oxygen content
of the lung will be consumed in 1 min after apnoea.
Complete de-nitrogenation of the lung will give an
oxygen reservoir equivalent to FRC, i.e. around 2000
to 2500 ml [10, 11].With oxygen consumption at the
rate of 250 ml/min, this will be sufficient for up to
8 min. This reservoir is much smaller in critically ill
(especially obese) patients due to reduced FRC.
Pre-oxygenation is generally done for 3 to 5 min in
operating room to de-nitrogenate the lungs. Effective-
ness of preoxygenation can be monitored by measuring
fraction of oxygen in the expired gas (FeO2), which is
considered a surrogate marker of alveolar oxygen con-
tent. There is limited data on duration of preoxygenation
for adequate de-nitrogenation in critically ill patients.
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 preoxygena-
tion in critically ill patients, which should be done if
possible by using non-invasive positive pressure venti-
lation (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].
In spite of adequate de-nitrogenation, critically ill
patients desaturate more rapidly due to smaller FRC,
higher rate of oxygen consumption and extensive alveolar
flooding (as seen in ARDS or cardiogenic pulmonary
oedema). Alveolar flooding reduces the alveolar capillary
interface available for gas exchange. Therefore, even if
the oxygen reservoir is there in the lungs, passage of
oxygen from the reservoir into circulation is hampered.
These patients have increased alveolar arterial (A-a) gra-
dient and should be pre-oxygenated using non-invasive
positive pressure ventilation (NIPPV), which decreases
shunt fraction by recruitment of collapsed alveoli [13].
Apnoeic oxygenation/peroxygenation is the oxygen
given from induction of apnoea till beginning of positive
pressure ventilation. Apnoeic oxygenation relies on mass
flow of oxygen across the pressure gradient created be-
tween upper airway and alveoli due to constant uptake of
Ahmed and Azim Journal of Intensive Care (2018) 6:49
oxygen by capillaries. Most essential criteria for successful
apnoeic oxygenation are maintenance of patent airway
while delivering oxygen during attempts to intubate.
Apnoeic oxygenation is delivered via high-flow nasal can-
nula (HFNC) capable of delivering warm humidified oxy-
gen at 40 to 60 l/min. In the absence of HFNC, standard
nasal cannula at 15 l/min can be used after adequate
de-nitrogenation. Complications of prolonged apnoeic oxy-
genation include hypercarbia, acidosis, hyperkalemia, raised
intracranial pressure and pulmonary hypertension [11, 14].
A systematic review and meta-analysis on respiratory
support during intubation in critically ill patients showed
apnoeic oxygenation (4 RCTs, 358 patients) was associated
with higher minimum SpO2 as compared to those who
did not receive apnoeic oxygenation [15]. Apnoeic oxy-
genation was delivered via high-flow nasal cannula in 3
RCTs and via standard nasal cannula in 1 RCT. Another
meta-analysis reported increased first pass success rate of
intubation (probably due to more time available for intub-
ation without desaturation), higher peri-intubation oxygen
saturation and decreased rates of hypoxemia with apnoeic
oxygenation [16].
Jaber et al. combined NIV for pre-oxygenation and
HFNC for apnoeic oxygenation during intubation of
hypoxemic patients in a RCT including 24 patients in
the control group and 25 patients in the intervention
group. Lowest SpO2 values were significantly higher in
the intervention group [17].
It is clear from the above discussion that pre-oxygenation
and apnoeic oxygenation are two key strategies for increas-
ing safety of intubation in critically ill. It should be remem-
bered that in patients with severe hypoxemia, these
strategies might not work due to widespread damage to
alveolar-capillary interface. Patients not maintaining satur-
ation on NIV form a subgroup where pre-oxygenation and
apnoeic oxygenation are likely to be ineffective. Therefore,
prolonged NIV trials in severely hypoxemic patients are
discouraged and these patients should be timely intubated
using an ICU intubation care bundle. In their landmark
paper, Jaber et al. showed a ten component-based
intubation bundle approach was associated with significant
reduction in both life threatening as well as other complica-
tions in ICU intubations [18]. Their intubation bundle
included pre-oxygenation with non-invasive positive pres-
sure ventilation, rapid sequence induction, two operators,
cricoids pressure, capnography, fluids, sedation and vaso-
pressors as per need.
Capnography is the continuous monitoring of partial
pressure of carbon dioxide in the exhaled gases. The
capnography waveform is achieved by plotting expired
partial pressure of CO2 on the Y axis and time on the X
axis. Methods of capnography measurement include side
stream analyser and mainstream analyser. Capnography
is widely used for various indications ranging from
Page 3 of 9
confirmation of tracheal intubation, monitoring ad-
equacy of ventilation, estimation of cardiac output and
monitoring of adequacy of cardiopulmonary resuscita-
tion. More than 70% of ICU-related airway deaths in
NAP4 study were associated with failure to use capnogra-
phy in patients dependent on artificial airway [3]. There-
fore, current guidelines recommend use of continuous
capnography during intubation and tracheostomy for con-
firmation of correct placement of endotracheal or tracheos-
tomy tube as well as for monitoring in all anaesthetised
patients and patients requiring life support irrespective of
their location [4, 5].
Videolaryngoscopes are used for management of diffi-
cult airway in operation theatre, intensive care units and
emergency, as a rescue technique when direct laryngos-
copy fails. These devices consist of fiberoptic indirect
rigid laryngoscope with video camera mounted at one
end. Intubation is done based on the video image of the
laryngeal inlet which is magnified and requires less
amount of suspension pressure to achieve adequate
laryngeal view. Videolaryngoscopes are available in
standard Macintosh blade design and acute angled blade
designs. The acute angled blade design requires less neck
manipulation, but stylet is needed for facilitation of tube
insertion. A recently published systematic review includ-
ing 64 randomised controlled trials on use of videolaryn-
goscopes vs. direct laryngoscopy for intubation in adults
found reduced failed intubations with videolaryngo-
scopes especially while managing difficult airway [19].
Differential performance was reported with different
designs. Current evidence does not show use of
videolaryngoscope effects number of intubation at-
tempts, duration required for intubation or incidence
of hypoxic complications.
Mode of induction (Table 2)
Rapid sequence induction and intubation (RSII)
It is the method of induction in patients who are full
stomach and at increased risk of vomiting and aspir-
ation. RSII is used to minimise the duration between loss
of airway reflexes and establishment of definitive airway
with cuff inflation. RSII is the induction of choice in
ICU patients because even if they are nil oral for signifi-
cant duration, changes in electrolytes and metabolic
milieu can lead to diminished gut motility and increased
risk of aspiration. It is preferable to stop enteral feeding
and remove gastric contents by gentle suction whenever
possible before RSII.
RSII was first introduced by Stept and Safar in 1970
[20]. Since then, the technique gained popularity in
emergency airway management of full stomach patients
across the globe. Steps of rapid sequence induction
include administration of inducing agent, use of muscle
relaxant with rapid onset of action (succinylcholine or
Ahmed and Azim Journal of Intensive Care (2018) 6:49 Page 4 of 9

Table 2 Modes of induction

Rapid sequence induction and
intubation (RSII)
Delayed sequence intubation
(DSI
Awake intubation
Double setup approach
Salient features
• Use of rapidly acting inducing
agent (ketamine and etomidate
preferred agents in critically ill)
• Short acting muscle relaxant
(succinylcholine or rocuronium)
• Cricoid pressure
• Preoxygenation done after
judicious use of sedation in
delirious patients
• Intubation is done without use
of muscle relaxant (spontaneous
respiration is remains intact)
• Flexiblescope intubation and
videolaryngoscopy are used to
aid awake intubation
• Two approaches are prepared
simultaneously in anticipated
failed intubation.eg. RSII and
surgical airway
Advantages
• Key strategy for patients at high
risk for aspiration
• Key strategy in patients difficult
to pre-oxygenate due to agitation
• Key strategy in anatomically as
well as physiologically difficult
airway
• Spontaneous respiration remains
intact
• Physiological compensatory
response remains relatively intact
• Increased safety and reduced
time required for switching from
one approach to other
Disadvantages
• In inexperienced hands RSII can
lead to CICO situation (cannot
intubate, cannot oxygenate)
• FONA (front of airway) techniques
should be available as backup plan
• Even low doses of sedation can
cause blunting of airway reflexes
and apnoea in critically ill patients
• Significant expertise and skill is
required to perform awake intubation
safely
• Attempts to intubate without proper
blunting of airway reflexes can
precipitate laryngospasm and severe
hypoxemia
• Failed attempts can cause vomiting,
aspiration, local injury and bleeding.
• Critically ill patients can develop toxicity
of local anaesthetics at very low doses
due to compromised hepatic and renal
function
• May increase the cost of care

rocuronium) along with application of cricoid pressure. ! Muscle relaxant (succinylcholine/rocuronium)

Current evidence shows significant variation and modifi-
cation in RSII technique [21, 22]. Institutions should
develop their own RSII protocols as per their require-
ments and patient population:
! Optimal positioning of the patient should be
achieved (routinely sniffing position/ramp in obese/
head up during preoxygenation to increase FRC/left
lateral tilt in pregnant patients to avoid aortocaval
compression by gravid uterus)
! Preoxygenation and per-oxygenation using non-
invasive ventilation or high-flow nasal cannula
! Inducing agent (choice is dictated by hemodynamic
status; ketamine preferred in hemodynamically
unstable; dose of inducing agent can be pre-fixed or
titrated as per response)
! Rapidly acting adjunct opioid to blunt laryngoscopy
reflexes
! Application of cricoid pressure (10 N at the time of
induction, which is increased to 30 N after loss of
consciousness). Cricoid pressure should be removed
if there is active vomiting, difficulty in laryngoscopy
or passing of endotracheal tube. Supraglottic airway
device placement requires removal of cricoid
pressure. There is difference of opinion regarding
the utility of cricoid pressure in preventing
regurgitation. Current evidence neither favours nor
refutes it use.
! Manual ventilation (though not a component of
standard RSII, gentle manual ventilation can be used
if oxygen saturation falls between induction and
onset of paralysis). Risk of gastric insufflation during
manual ventilation can be minimised by using
proper positioning, gentle inflation pressure and
cricoid pressure application.
! Maximising first pass (adjuncts bougie and stylets)
! Vortex approach (well-defined steps and swift transition
from one plan to next in crisis situation without wasting
time by performing multiple attempts with the same
equipment and same technique). The vortex approach
allows three attempts each with facemask ventilation,
intubation and supraglottic device insertion. British
guidelines also allow three attempts at intubation.
However, there are data to suggest that more than two
attempts at intubation outside the operation theatre are
associated with high rate of complications.
Delayed sequence induction (DSI)
It is the method of induction in patients who are
agitated and difficult to pre-oxygenation [23, 24]. Small
doses of ketamine or benzodiazepine can be used to
calm the patient enough to tolerate pre-oxygenation.
Dose titration is done in a way not to blunt airway
reflexes or spontaneous respiration. Further doses of
inducing agent are given after pre-oxygenation has been
satisfactorily achieved. Ketamine can cause tachycardia
Ahmed and Azim Journal of Intensive Care (2018) 6:49
and hypertension due to its sympathomimetic effect. Dex-
medetomidine (alpha 2 antagonist) is an alternative in
patients in patients who are tachycardiac or hypertensive.
This method of procedural sedation has long been in use
but the term delayed sequence intubation has been only
recently coined by Weingart et al. in an observational
study involving 62 patients requiring emergency airway
management but difficult to pre-oxygenate due to altered
mental status [25]. The study has received criticism for its
design and sample size but DSI remains an important
strategy in delirious patient population. DSI should be
done by experienced anaesthetist as there are case reports
of apnoea even with small doses of inducing agent.
Awake intubation
It is the method of induction in which spontaneous respir-
ation is preserved during securing the airway [26]. Awake
intubation is the preferred method of predicted difficult
airway management in operating rooms which are ana-
tomically difficult airways. It has been advocated by some
authors that “awake intubation” should be the method of
securing airway in critically patients to prevent blunting of
physiological compensatory response [27].
Topicalization of the airway, premedication with anti-
sialogogues, H2 blocker and metoclopramide are the key
components of awake intubation. Inadequate blunting of
airway reflexes can precipitate laryngospasm, tachycar-
dia, hypertension, etc. Flexible scope intubation, video-
laryngoscopy, light wand, direct laryngoscopy, blind
intubation, etc. are some of the methods for awake
intubation. Significant expertise is required to perform
awake intubation in critically ill patients safely.
Double setup approach
It is a strategy of preparing for two approaches simultan-
eously in patients with anticipated failed intubation [28].
Cricothyroid membrane may be identified via ultrasound
or clinically before inducing the patient for RSII. Simi-
larly, preparation of surgical tracheostomy can be done
before inducing a high-risk patient.
NAP 4 study reported an unexpected high failure rate
of needle cricothyroidotomy. Failure to identify the
cricothyroid membrane in stressful emergency situation
was one of the causes [3]. It has also been found that
when cannot intubate cannot oxygenate situation occurs,
surgical airway is secured but mostly it is too late to pre-
vent irreversible brain damage. Double setup approach
increases the safety margin and helps overcome cogni-
tive failure in emergency situation.
Preparation for post induction loss of sympathetic
drive and physiological compensation
ICU patients are under physiological stress due to their
underlying disease. Many of them are in compensated
Page 5 of 9
state of their physiological derangement. Use of induc-
tion agents in these patients lead to “physiological com-
pensation blunting or failure”. As a result, patient may
undergo acute changes in hemodynamics and metabolic
milieu at the time of induction and intubation [29].
Other factors contributing to the decompensation
include lack of sleep, relative hypovolemia due to poor
intake and increased work of breathing leading to
diaphragmatic fatigue.
Arterial line should be secured before induction and
intubation of high-risk patients. If non-invasive blood
pressure monitoring is being done, measurement cycle
should be set at 1 to 2 min interval during induction
and immediate post intubation period. Rapid changes in
metabolic status should be monitored via regular blood
gas analysis. It was shown that ICU-related airway
problems occurred mainly in the post intubation phase.
Understanding the underlying pathophysiology of par-
ticular disease process and preparing for post induction
response of the patient can help alleviate such problems
(e.g. fluid loading in hypovolemic patients, vasopressors
infusion for hypotension, bicarbonate infusion for severe
metabolic acidosis). Figure 1 describes the various stages
of mechanical ventilation in critically ill patients.
Difficult airway due to neurophysiologic
derangement
Traumatic brain injury and stroke patients requiring
intubation and mechanical ventilation form a specific
subgroup where raised intracranial pressure is the key
physiological derangement. These patients also show wide
fluctuation of blood pressure during rapid sequence
induction and intubation [30]. Table 3 shows the compo-
nents of neuroprotection which authors use in their ICU
while intubating such patients.
! Invasive blood pressure monitoring is preferable
before induction as fluctuation in blood pressure can
lead to increase in ICP and herniation. Fluid and
electrolyte status should be evaluated meticulously
before induction as these patients routinely get
mannitol for decreasing cerebral oedema. Induction
in volume depleted patients can lead to precipitous
fall in blood pressure.
! Premedication with fentanyl/remifentanil is used to
blunt the stress response due to laryngoscopy and
associated increase in ICP. Use of lidocaine as an
ICP control measure is weakly supported by
evidence [31, 32]. Rapid bolus injection of lidocaine
can cause hypotension, especially when used with
propofol or thiopentone.
! Ketamine is no more considered contraindicated in
head injury patients as newer prospective studies
have not shown any association between increase
Ahmed and Azim Journal of Intensive Care (2018) 6:49
Stages of Mechanical Ventilation in ICU
Initiation of Mechanical ventilation
Pre-intubation assessment of airway
and optimization
CORE strategy;
CORE strategy;
Classification of airway
(physiologically vs. anatomically Rapid sequence vs. Delayed sequence vs. Awake
difficult vs. both) intubation
Preparing an AIRWAY PLAN Vortex approach (for airway crisis management)
Preparing a RESCUE strategy
Fig. 1 Stages of mechanical ventilation in ICU
intracranial pressure and ketamine use [33, 34].
Other inducing agents like propofol or thiopentone
can cause significant drop in blood pressure and
should be used with caution.
! Fasciculations caused by succinylcholine can cause
rise in intracranial pressure. De-fasciculation dose
with non-depolarising blocker should be given
before its use.
Difficult airway due to cardiovascular
derangement
Intubation in cardiac patients requires preload, afterload,
heart rate and contractility optimization. Cardiac tampon-
ade forms a specific subgroup where intubation should be
delayed till definitive management of cardiac tamponade
is achieved. Screening bedside ECHO is helpful in assess-
ment of preload, afterload and contractility.
Management goals in patients at high risk for myocar-
dial ischemia are avoiding increase in heart rate and
factors that cause extreme increase in wall stress, i.e.
inotropy and afterload [35]. Etomidate is the most cardio
stable inducing agent but it does not blunt the stress of
laryngoscopy [36].It can be combined with rapid onset
opioids for intubation. Patients with left ventricular
hypertrophy have poor diastolic compliance and depend
on atrial kick for ventricular filling. These patients
should be managed with strategy based on avoidance of
Page 6 of 9
Maintenance of Mechanical ventilation Weaning
CORE Strategy; Lung protection CORE Strategy; Spontaneous breathing trails
Post-intubation optimization of acute physiological derangement
CORE strategy;
Optimization of hemodynamics and metabolic
parameters (including pH)
May require deviation from standard lung protective
strategy during initial phase in some case scenarios
Low threshold for dialysis (early optimization of
metabolic parameters)
atrial arrhythmias, hypotension and myocardial ische-
mia. Patients with regurgitant lesions (aortic/mitral
regurgitation) are managed by maintaining slightly
higher heart rate, low after load, adequate preload and
support of contractility if impaired.
Patients with stenotic lesions are most challenging
to manage. Hemodynamic goals in management of
mitral stenosis include prevention of increase in
pulmonary artery pressures, heart rate and marked
afterload reduction. Aortic stenosis requires heart rate
control, adequate preload and avoidance of myocar-
dial ischemia.
Difficult airway due to respiratory derangement
Pre-oxygenation with NIV is the most important com-
ponent of airway management strategy in respiratory
failure due to ARDS. These patients are prone for rapid
recruitment thus putting lot of time pressure on the
intensivist. Bag mask ventilation cannot be relied upon
as a rescue strategy in these patients as severe ARDS
lung is difficult to inflate with bag mask. Attempts to
bag mask may cause unnecessary waste of time. Bag
mask should be replaced with NIV. Apnoeic oxygenation
as well as pre-oxygenation are important components of
airway management in ARDS patients, but it should be
noted that these are the very patients where
Ahmed and Azim Journal of Intensive Care (2018) 6:49
Table 3 Neuroprotective strategy in ICU
• Head neutral
• Head up
• No compression on internal jugular veins
• Maintain normal intrathoracic pressure, avoid airway obstruction,
brochospasm, straining, coughing
• Premedication before intubation with
◦ Fentanyl 2 mcg/kg (caution for bradypnea, bradycardia and respiratory arrest)
• Rapid sequence induction with ketamine and midazolam or
ketamine and propofol or etomidate
• Muscle relaxant
◦ Rocuronium preferable
◦ Succinylcholine (fasciculations can cause increase in ICP; hyperkalemia in
patients with extrajunctional receptors)
• Hemodynamic and metabolic targets
➢Mean arterial pressure MAPs 90 to 100 mmHg (titrate according to baseline
MAP± 20%)
➢PaO2 80 to 100 mmHg
➢PaCO2 30 to 35 mmHg
➢pH 7.35 to 7.45
➢Normoglycemia
➢Normothermia
➢Adequate sedation/analgesia
• Potential cerebrovasodilators should not be used
➢Vasopressin
➢Calcium channel blockers
➢NTG
➢Nitroprusside
• For acute rise in intracranial pressure
➢Hyper ventilate to achieve PaCO2 25 to 30 mmHg
➢Hypertonic saline OR mannitol bolus
➢Deepen sedation (boluses of midazolam)
pre-oxygenation and apnoeic oxygenation are likely to
be least effective.
ARDS patients are prone of acute right ventricular
dysfunction. If time permits screening, bedside ECHO
should be done to evaluate right ventricle. Invasive
hemodynamic monitoring is preferable at the time of
induction in patients with concomitant cardiac and
respiratory failure. Intubation in patients with right
ventricular failure is extremely risky because unlike left
ventricular function, right ventricular function deterio-
rates with increased intra-thoracic pressure caused by
positive pressure ventilation. Right ventricular preload
and afterload optimization is needed before intubation
in order to prevent cardiovascular collapse. Methods of
right ventricular afterload optimization include inhaled
pulmonary vasodilators like nitric oxide or epoprostenol,
correction of hypoxic pulmonary vasoconstriction by
oxygen supplementation and decreasing atelectasis via
non-invasive ventilator support. For further details, see
reviews by Hrymak et al. and Krishnan et al. [37, 38].
Page 7 of 9
Difficult airway due to hepatic derangement
Hepatic failure patients have raised ICP due to hepatic
encephalopathy. They should be intubated with neuro-
protective strategy. Moreover, they have coagulopathy
and are frequently thrombocytopenic. Suboptimal intub-
ating conditions can lead airway trauma and bleeding,
thus making physiologically difficult airway also anatom-
ically difficult.
Nasal intubation should not be used in these patients
in view bleeding tendency. Blood product transfusion
should be considered in patients with high risk of
bleeding.
Difficult airway due to renal derangement
Renal failure patients may require intubation due to in-
creased work of breathing caused by severe metabolic
acidosis. These patients maintain their pH within normal
range by increasing minute ventilation and washing out
carbon dioxide. Induction of anaesthesia causes fall in
minute ventilation and loss of compensatory response.
Using neuromuscular blocking drug can further bring
down the pH and cause precipitous fall in blood pres-
sure and dangerous rise in potassium concentration.
These patients should be intubated keeping rapid
changes in metabolic milieu in mind.
! Succinylcholine causes hyperkalemia and should be
avoided in patients with renal failure [39].
Rocuronium is the drug of choice while intubating
this subgroup.
! Vasopressor should be connected via large bore
cannula in the time of induction.
! Sodabicarbonate infusion can be considered in
patients with pH < 7.2 before induction.
Difficult airway due to gut dysfunction
ICU patients may suffer from paralytic ileus, ascites,
pseudo-obstruction and raised intra-abdominal pressure.
All these factors predispose for vomiting and aspiration
till the airway is secured with cuff inflation. Rapid
sequence induction is the preferred mode. Fluid shifts in
patients in paralytic ileus, pancreatitis and intestinal ob-
struction predispose for hypotension during induction.
Difficult airway due to sepsis
Sepsis patients are prone for distributive shock.
Hemodynamic instability, lactic acidosis and coagulopathy
are frequent issues. Volume resuscitation and vasopressor
form the key components of airway management strategy.
Optimal venous access should be secured before induction
in these patients.
Invasive hemodynamic monitoring is preferable in
patients requiring high-dose noradrenaline. Etomidate
Ahmed and Azim Journal of Intensive Care (2018) 6:49
can cause cortisol insufficiency. Ketamine is the pre-
ferred agent for induction.
Conclusion
! It is important to recognise that intubation in the
ICU is different from the operating room. Intubation
strategy in critically ill requires modification as per
the physiological derangement.
! Airway in the ICU can be classified as anatomically
difficult, physiologically difficult and anatomically as
well as physiologically difficult.
! Though rapid sequence induction is the core
strategy for induction of physiologically difficult
airway, strategy modification like awake intubation
with videolaryngoscope or flexiblescope intubation
and delayed sequence intubation can be used by
experts in certain high-risk subgroups.
! Preoxygenation and apnoeic oxygenation via NIV
and high-flow nasal cannula are useful methods to
increase safe apnoea time.
! Choice of inducing agent and muscle relaxant is
dictated by patient’s pathophysiology.
Abbreviations
A-a gradient: Alveolar arterial gradient; ARDS: Adult respiratory distress
syndrome; DSI: Delayed sequence induction; FeO2: Fraction of oxygen in the
expired gas; FRC: Functional residual capacity; HFNC: High-flow nasal
cannula; ICP: Intracranial pressure; ICU: Intensive care unit; NAP4: National
audit project 4; NIPPV: Non-invasive positive pressure ventilation;
OSA: Obstructive sleep apnoea; PEEP: Positive end-expiratory pressure;
RCT: Randomised controlled trial; RSII: Rapid sequence induction and
intubation
Acknowledgements
We would like to thank Dr. Afzal Azim for his valuable contributions.
Authors’ contributions
AAh did the literature search and wrote the manuscript. AAz supervised the
manuscript preparation and gave intellectual inputs. Both authors read and
approved the final manuscript.
Ethics approval and consent to participate
No approval is required.
Consent for publication
No consent is required.
Competing interests
The authors declare that they have no competing interests.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Author details
1
Department of Critical Care Medicine, King George Medical University,
Lucknow 226003, India. 2Department of Critical Care Medicine, Sanjay Gandhi
Postgraduate Institute of Medical Sciences, Lucknow 226014, India.
Page 8 of 9
Received: 7 April 2018 Accepted: 2 August 2018
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