2017-18 HSC Section 3 Green Book

Journal of Intensive Care Medicine

Table 5. Difficult Airway Management Team Activation Criteria Revised 2014.

procedure even when performed by competent operators. The lack of a dedicated airway registry did not allow us to provide an accurate measure of ESA frequency as a proportion of all intubations. However, we were able to confidently determine that there was a need for ESA in approximately 10 % of patients who were considered to be DAs by other trained personnel who activated the team for help in securing the airway. The lack of long-term follow-up in survivors of ESA precludes an under- standing of ESA-related complications such as tracheal steno- sis and quality of life. Finally, our data are only reflective of a singular academic institution’s experience and may not be gen- eralizable to institutions with dissimilar characteristics. Despite the obvious limitations of this study, we think that our study is informative and adds to the existing literature on ESA in that it is the first to characterize hospitalized critically ill patients undergoing ESA outside the OR, ED, or prehospital environments. Rather than depending on specific definitions of a DA, our cases are defined more practically and thus are likely to be more reflective of real-world experiences of trained air- way providers who encounter difficulty in airway management in critically ill patients. Corroborating our own experience, dedicated multidisciplinary airway teams similar to widely adopted RRTs are now emerging to address both routine and DA management in hospitalized patients. 47-53 Although the need for ESA may be relatively infrequent, institutions that care for critically ill patients or patients at risk for difficult or challenging airways should have or develop systems, person- nel, educational programs, and the necessary equipment that will allow for the timely performance of ESA by the most capable personnel available whenever the need arises. Conclusion The need for an ESA in critically ill patients is infrequent and occurs most commonly in patients who are in ICUs as well as in less favorable environments such as hospital wards and diag- nostic or treatment locations. Many of these patients had clin- ical features that are predictive of a DA, while others experienced unpredicted clinical deterioration such as CPA, bleeding from the upper aerodigestive tract, massive vomiting, or upper airway obstruction from angioedema. Even when per- formed by experienced operators, complications of ESA were frequent and associated with high mortality, especially in those who experienced CPA prior to or during the course of the air- way event. Secular trends indicating a reduction in the fre- quency of ESA and related mortality suggest a favorable impact of our DAMT and focused QI efforts in improving the process of care and patient safety. Authors’ Note Joseph M. Darby was responsible for the study design, review of cases, collection, analysis, and interpretation of data, and drafted the manuscript. Gregory Halenda participated in data interpretation, draft- ing the manuscript, and critical revision of the manuscript. Courtney Chou participated in the analysis and interpretation of the data and drafting of the manuscript. Joseph J. Quinlan contributed to the

DAMT Activation Recommended Prior to Airway Intervention

DAMT Activation Required

Can’t intubate: 3 failed attempts to intubate or failure to secure airway after a total of 10 minutes from the time of the first attempt to intubate. Can’t ventilate: ineffective manual ventilation. pulselessness or severe bradycardia occurring during attempts to secure an airway. Airway bleeding: massive hemoptysis or hematemesis with native airway. Artificial airway obstructed by blood clot. <90% and unresponsive to open airway maneuvers. Arrest or near arrest: Stridor: with SaO 2 Upper airway pathology: known mass or tumor involving upper airway, symptomatic angioedema, hematoma of neck, intermaxillary fixation. Surgical airway: any concern that patient may need immediate surgical airway. Age <13: any pediatric patient with need for emergency endotracheal intubation.

Difficult airway: known or suspected difficult airway anatomy.

Obesity: morbid or super-morbid (BMI > 50) obesity. Upper airway: massive emesis, macroglossia, micrognathia, small oral aperture, angioedema, prior head and neck surgery, prior radiation therapy, epiglottitis. Limited neck mobility: halo cervical fixation, unstable cervical spine fracture, kyphosis of cervical spine. Diseases and syndromes: rheumatoid arthritis, ankylosing spondylitis, scleroderma, Down syndrome, Klippel-Feil anomaly. Tracheostomy: dislodged or obstructed tracheostomy tube within 5 days of insertion, massive subcutaneous emphysema. Tracheal disease: tracheal stenosis, subglottic stenosis, tracheal stent, Montgomery T-tube.

Abbreviations: BMI, body mass index; DAMT, difficult airway management team, SaO 2 , arterial oxygen saturation.

their hospital-wide DA response team, there was a significant reduction in emergency surgical CRIC from 0.73 % to 0.21 % in a population of at-risk patients that looks to be similar to ours. 48 Our study has several important limitations, the most impor- tant of which is its retrospective descriptive design. Incomplete or inadequate documentation of clinical antecedents, airway anatomy, and the details of airway management may have obscured important variables, potentially contributing to the need for an ESA as well as related procedural complications. Another limitation in this study is the relatively small sample size and the lack of cohort comparisons that could have allowed us to define risk factors for ESA in the subset of hospitalized patients with complex or challenging airways. Despite the above limitations, we think that we have captured most of the relevant features of those patients who progressed to the point of needing an ESA and the most important complications of the

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