Thread by @critconcepts

Sam Galvagno on airway management in obesity (#SCCM2023)

oxygenation normal, but poor reserve - low compliance, compression of small airways at bases. ERV, TLC, FRC reduced.

P's of airways in obesity: Prediction, Positioning, Preox, Performance, Postintubation management

Prediction: obesity = difficult mask, but less clear association with difficult intubation.

Position: sniffing position helps everyone. Ramped position helps the obese - also makes it easier to insert laryngoscope handle.

Modified ramped position can be done with a pyramid-shaped pillow.

Fastest method is just put them in reverse Trendelenburg - better than just elevating head.

Preox: end-tidal oxygen is the best marker of nitrogen washout. Time to desat is usually < 3 minutes in the obese due to low FRC.

Nasal CPAP: allows continuous oxygen and positive pressure during intubation. Reduces aspiration risk versus face mask.
Or: NPA + regular nasal cannula at 15L. Lowest sat in experiment group 4% higher, adds 1.5 minutes safe apnea time.

HFNC for apneic ox: Not good data; most is from non-critically-ill. Does NOT denitrogenate, esp with mouth open. Wu 2022 did show utility. Safe apnea time may be similar to using regular cannula at around 10L.

Should you use video? Probably. Overall higher likelihood glottic visualization, higher first pass success, lower likelihood trauma/sore throat, lower intubation time. Plus good for QA/training and situational awareness; everyone sees what you see.

Post-intubation management: Individualized tools like manometry may decrease mortality, could guide you to things like higher PEEP. Extubating? Low threshold to extubate to NIPPV; may decrease failure ~16%.