Thread by @virenkaul

Live at 1400 ET: chestmeeting2021.junolive.co/live/mainstage…

"Airway management in the era of severe pneumonia" with #CHESTairways experts from the Airway Domain Task Force.

Will live tweet this talk on this #CHEST2021 thread.

Speakers:
@Chaeface @KDoerschug @J_Mendelson_MD and yours truly!

Let's get started with WHY our session is important:
🔥 Appx. 10% emergent intubations may result in failed airway
🔥 It's not just anatomical challenges, but physiological ones that have to be considered, esp with severe pneumonia
🔥 Lessons from the pandemic

#CHEST2021

* Let's talk about the vicious cycle of injury that occurs in acute resp failure (pic 1)
* Clinical course of disease imp for decision to intubate (pic 2)
* Ideal timing related to worsening work of breathing (pic 3)

PMID: 32747391
PMID: 27626833

#CHEST2021 #CHESTairways

Prediction scores:
* Pic 1: Cabrini Strain Scale: PMID: 32521584
* Pic 2: ROX Index: PMID: 30576221
* Pic 3: HACOR Score: PMID: 31565779

ROX & HACOR may correlate w/ failure or success of therapy in resp failure

#CHEST2021 #CHESTairways

How can we clinically assess the work of breathing?

Tulaimat (PMID: 27288621) studied this: Check out the sensitivity and specificity of exam findings. More signs of inc WOB, more sens/spec the decision usually

Pic 2: From Apigo et al (PMID:  32736637)

#CHEST2021 #CHESTairways

Now we have thought about WHEN we need to intubate, let's look at the other side: How long can we safely tolerate apnea?

This classic graph from Benumof (PMID: 9357902) from 1997 says it all!

Worsening illness and higher weight narrows the apnea time #CHEST2021 #CHESTairways

Ergo, with increasing risk of desaturation, the pre and intraprocedural interventions should get more appropriately aggressive as Moser describes

#CHEST2021 #CHESTairways

Let's talk pre-oxygenation:
PaO2 only increases a little bit with #PreOx in critically ill patients --> reflects the marginal reserve these patients have, as we have all seen with #COVID19Vic

Pic PMID: 16276196

#CHEST2021 #CHESTairways

As Casey showed in 2019: BVM improves the degree of hypoxemia during #ApneicOxygenation vs. no ventilation. This is a CORE skill for airway operators!

PMID: 30779528

#CHEST2021 #CHESTairways

Patient positioning matters:
Sniffing pos: Aligns airways
Ramped pos: Helpful in low FRC conditions (obesity, ascites, pregnancy)

Data is split, see pic here.
Optimize to the patient!

PMID: 28487139
PMID: 26866753
PMID: 31895986

#CHEST2021 #CHESTairways

Let's talk holding technique for BVM ventilation.

This 2017 study showed better ventilation (Vt) with V-E technique vs. C-E technique (PMID:  28403406)

To reiterate, positioning, BVM technique, #ApOx and #PreOx are all important considerations.

#CHEST2021 #CHESTairways

Ah! Now the classic debate: To use paralytics or not?

In this observational trial of 566 emergent intubations (>200 by trainees), use of NMBs:
* Fewer attempts
* Better views
* Fever complications

PMID: 22610185

#CHEST2021 #CHESTairways

What causes failed airways and leads to issues with management?

* Not being recognized
* Unstructured approach
* Training and preparation
* Inadequate support/equipment

Amongst other reasons, as described by Cook and team (NAP4 study, PMID: 21447488 )

#CHEST2021 #CHESTairways

Having a solid APPROACH to ICU intubations is key for preventing adverse outcomes

Here is the APPROACH strategy advised by @accpchest airway course universal ICU intubation management algorithm

#CHEST2021 #CHESTairways

🛑Know the failed attempt criteria
🛑 Failed airway? -> CALL FOR HELP!!!
🛑Follow a pathway that you as well as your team knows well and have prepared/practiced for
🛑 Here's the non-emergent @accpchest pathway

#CHEST2021 #CHESTairways

There are other algorithms/pathways such as @dasairway pathways and @VortexApproach

🔑 points:
🔺Prepare, prepare, prepare
🔺Systematic APPROACH
🔺Recognize failed airway ASAP
🔺Ask for help early
🔺Follow practiced interdisciplinary pathway

#TeamApproach
#CHEST2021

fin/