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Airway Management and Mechanical Ventilation John Angelo Perez St. Luke’s Medical Center International Institute of Neurosciences October 21, 2015

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Page 1: Airway management and Mechanical Ventilation

Airway Management andMechanical Ventilation

John Angelo PerezSt. Luke’s Medical Center

International Institute of NeurosciencesOctober 21, 2015

Page 2: Airway management and Mechanical Ventilation

Management of ICP is multi-modal

Increased ICP

Head Positioning

Osmotherapy

Sedation and Analgesia

Seizure ControlHypothermia

BP Control

Ventilation

Page 3: Airway management and Mechanical Ventilation

Questions for today

• What makes neurologic patients special?

Some considerations

• What are the steps for intubation?

Intubation as a life-saving intervention

• What is the role of ventilation in neurocritical care?

Ventilation in the NCCU

Page 4: Airway management and Mechanical Ventilation

Part 1: Some considerationsWhat makes neuro patients special?

Page 5: Airway management and Mechanical Ventilation

More patients require intubation in the NCCU

Bhardwaj and Mirski. Handbook of Neurocritical Care 2nd Ed. 2011

Page 6: Airway management and Mechanical Ventilation

The airway is divided into parts

Butterworth et al. Morgan and Mikhail's Clinical Anesthesiology 5th Edition. 2013

Page 7: Airway management and Mechanical Ventilation

Cranial nerves supply the airway

Butterworth et al. 2013

Page 8: Airway management and Mechanical Ventilation

Conditions Requiring Intubation

• Strokes• TBI• Status epilepticus• Encephalopathies• CNS Infections• Hydrocephalus• Cerebral Edema• Neuromuscular disorders

Bhardwaj and Mirski. Handbook of Neurocritical Care 2nd Ed. 2011

Page 9: Airway management and Mechanical Ventilation

Three principles guide intubation

Failure to Protect or Maintain Airway

Failure to Oxygenate or

Ventilate

Anticipate a deteriorating

course

Page 10: Airway management and Mechanical Ventilation

Conditions Requiring Intubation

• Strokes• TBI• Status epilepticus• Encephalopathies• CNS Infections• Hydrocephalus• Cerebral Edema• Neuromuscular disorders

Failure to Protect or Maintain Airway

Failure to Oxygenate or

Ventilate

Anticipate a deteriorating

course

Page 11: Airway management and Mechanical Ventilation

Part 2:A life-saving intervention

Page 12: Airway management and Mechanical Ventilation

RapidSequenceIntubation

Page 13: Airway management and Mechanical Ventilation

RapidSequenceIntubation

Page 14: Airway management and Mechanical Ventilation

PLAN: use LEMON to evaluate difficult airways

L – Look!E – Evaluate the 3-3-2 ruleM – Mallampati ScoreO - ObstructionsN – Neck mobility

Page 15: Airway management and Mechanical Ventilation
Page 16: Airway management and Mechanical Ventilation

Butterworth et al. 2013

Page 17: Airway management and Mechanical Ventilation

POSITION: Extend the neck to align the oro-pharyngo-tracheal axis

Page 18: Airway management and Mechanical Ventilation

PRE-OXYGENATE: An ill patient has 6 minutes to be intubated

Torbey, Michael. Neurocritical Care. 2010

Page 19: Airway management and Mechanical Ventilation

PREPARE: Keep everything within reach

Page 20: Airway management and Mechanical Ventilation

Patients must intubated within 60 seconds

Page 21: Airway management and Mechanical Ventilation

RapidSequenceIntubation

Page 22: Airway management and Mechanical Ventilation

RapidSequenceIntubation

Page 23: Airway management and Mechanical Ventilation

PARALYZE: three classes of drugs are used in RSI

Page 24: Airway management and Mechanical Ventilation
Page 25: Airway management and Mechanical Ventilation

Part 3:Ventilation in the NCCU

Page 26: Airway management and Mechanical Ventilation

Hyperventilation

Page 27: Airway management and Mechanical Ventilation

Hyperventilation induces hypocapnea

Page 28: Airway management and Mechanical Ventilation

Hypocapnea decreases CBF

30

Butterworth et al. . 2013

Page 29: Airway management and Mechanical Ventilation

Decreased CBF decreases ICP

Hyperventilation

Page 30: Airway management and Mechanical Ventilation

How long? How fast?How deep? Which diseases?

Page 31: Airway management and Mechanical Ventilation

Secondary infarction is the most important complication of hyperventilation

Normal: 50mL/100g/min

Stochetti et al. Hyperventilation in Head Injury: A Review. Chest 2012

Page 32: Airway management and Mechanical Ventilation
Page 33: Airway management and Mechanical Ventilation

The meta-analysis did not find sufficient evidence of improved outcomes

Page 34: Airway management and Mechanical Ventilation

What have we learned today?Failure to Protect or

Maintain Airway

Failure to Oxygenate or

Ventilate

Anticipate a deteriorating

course

Increased ICP

Head Positioning

Osmotherapy

Sedation and Analgesia

Seizure ControlHypothermia

BP Control

Ventilation

Page 35: Airway management and Mechanical Ventilation

Questions?Failure to Protect or

Maintain Airway

Failure to Oxygenate or

Ventilate

Anticipate a deteriorating

course

Increased ICP

Head Positioning

Osmotherapy

Sedation and Analgesia

Seizure ControlHypothermia

BP Control

Ventilation


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