Guidelines for the management of tracheal intubation in critically ill adults.
Higgs A1, McGrath BA2, Goddard C3, Rangasami J4, Suntharalingam G5, Gale R6, Cook TM7; Difficult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists.
Author information
1
Anaesthesia and Intensive Care Medicine, Warrington and Halton Hospitals NHS Foundation Trust, Cheshire, UK(8). Electronic address: andyhiggs@doctors.org.uk.
2
Anaesthesia and Intensive Care Medicine, University Hospital South Manchester, Manchester, UK(9).
3
Anaesthesia & Intensive Care Medicine, Southport and Ormskirk Hospitals NHS Trust, Southport, UK(8).
4
Anaesthesia & Intensive Care Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK(8).
5
Intensive Care Medicine and Anaesthesia, London North West Healthcare NHS Trust, London, UK(10).
6
Anaesthesia & Intensive Care Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK(11).
7
Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK(12).
Abstract
These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel-bougie-tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.

Copyright © 2017 British Journal of Anaesthesia. All rights reserved.

KEYWORDS:
difficult airway; emergency medicine; intensive care; tracheal intubation; ‘Can't Intubate Can't Oxygenate’

Comment in
Surgical cricothyrotomy: the tracheal-tube dilemma. [Br J Anaesth. 2018]
A team approach to the difficult airway. [Br J Anaesth. 2018]
PMID: 29406182 DOI: 10.1016/j.bja.2017.10.021