Question 27

A 54-year-old patient has a diagnosis of Ludwig’s angina confirmed on CT scan. They are admitted to
your ICU for observation.
a) Outline your approach to clinical assessment in order to help you determine the need for intubation.    (6 marks)
b) The patient deteriorates rapidly overnight and needs urgent intubation in ICU. Discuss the principles of managing the airway in this acute setting.
    (4 marks)
 

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College Answer

Syllabus topic/section:

2.1.19    Intensive Care Procedures.

Aim:
To allow the candidate to demonstrate the standard required for the assessment and management of a life- threatening airway condition.
Discussion:
Anticipating the difficult airway with challenging and dynamic clinical status is a core skill of Intensive Care practice.
This was a new approach of a core procedural skill, and some candidates did very well. These candidates had structured, detailed and relevant responses outlining features of difficult airway and Ludwig's angina. Detailing clinical assessment AND outlining how these features influence the determination of the need to intubate were a hallmark of these responses.
Failure to assess globally meant several candidates failed to achieve high marks despite having good airway plans. Candidates are reminded to read the glossary of terms as OUTLINE the approach to assessment to determines the need for intubation is not the same as LIST the features of the difficult airway.
Use of the glossary of terms to guide the answer would aid the candidate to improve their performance.

Part (B) – required a discussion of the principles of urgently managing an airway that is anticipated to be difficult. Discussions that did not address a plan for oxygenation (and the challenges that this may present in this clinical setting) and plans for progression to FONA in the event of failure/CICO were considered dangerous.

A)

Assessment of need for intubation

6 marks

Minimal history, little or no information regarding intubation

Minimal clinical examination

FONA not mentioned or in poor detail.

No investigations or irrelevant ones

Lack of structure to assessment

<1.5 marks

Limited History. Some omissions

Examination includes airway and assessment for FONA to a safe standard.

Some attempt to determine intubation need and judgement rationale.

Limited structure 2-4 marks

History covers most information with respect to intubation decision.

Clinical examination covering most points and include assessment for FONA.

Mentions some investigations with rationale.

Some structure to assessment

4.5-5 marks

Comprehensive structured history of patient and surroundings

Detailed clinical examination with rationale and justification for intubation timing etc,

Mentions investigations with detailed rationale.

6 marks

B)

Principles of emergency intubation

4 marks

No plan, or unsafe emergency plan.

No or minimal details around seniority of personnel or difficult intubation equipment.

No mention of FONA technique if failed intubation.

0-1 marks

Limited details of an emergency plan.

Minimal details around seniority of personnel or difficult intubation equipment

Mentions FONA technique if failed intubation but without relevant details.

1.5- 2.5 marks

Comprehensive emergency plan. Includes majority of the details around seniority of personnel and difficult intubation equipment required.

Appropriate FONA technique if failed intubation.

3-3.5 marks

Detailed and organised emergency plan with rationale +/- discussion.

Comprehensive details around seniority of personnel and difficult intubation equipment required.

Appropriate FONA technique if failed intubation.

4 marks

Discussion

The line "Outline your approach to clinical assessment in order to help you determine the need for intubation" contains about 75% verbal ballast, added presumably because "Outline your assessment of the airway" would have been too light and volatile. And it does seem like what they wanted, as the answer gives marks for not only "rationale and justification for intubation timing etc" but also 

"comprehensive structured history of patient and surroundings" and "airway and assessment for FONA to a safe standard" which would not normally form a part of the assessment of the need  for intubation, as it is possible to experience the need for intubation without being intubatable. Still, it is difficult to argue that the assessment of the anticipated difficulty of the airway plays a role in one;s decision of how and when to proceed, which is the spirit in which the following answer is written.

a) Assessment of the need for intubation is an "outline" and "assessment" question which therefore needs to have some structure beyond the usual unordered point-form list. Fortunately the "assessment" question framework calls for some predictable headings. Problem is, half of this answers the question "does this patient need to be intubated right now" and the other half is "is this patient going to be a difficult intubation". A table may actually be the best option, and point form is probably still the best form. What follows is only 113 words and 707 characters (for six marks, it would have had to be under 168 words, or 960 characters, which is around the maximum writing speed of a 1990s police detective jotting down the statements of a suspect.) 

Need for intubation Expected difficulty
History
  • Speed of onset
  • Progression of swelling
  • Planned procedures
  • History of premorbid airway difficulty
  • Previous neck surgery/radiotherapy
Examination
  • Stridor
  • Hypoxia, cyanosis
  • Respiratory rate and effort
  • Quality of speech
  • Ability to control own secretions
  • Level of consciousness, anxiety, degree of cooperation
  • Sitting posture, drooling
  • Rate of deterioration in the abovementioned signs
  • Neck extension
  • Mouth opening
  • Nasal access
  • Distortion of anterior surface structures (predicting the need for FONA)
Investigations
  • ABG to track hypercapnia/hypoxia
  • CT to assess the extent of the airway narrowing and oedema

CT of the neck can:

  • help plan FONA and assess the depth of soft tissue
  • Assess the displacement of airway structures to inform laryngoscopy

"Planned procedures" in the above is an attempt to introduce into this answer the pragmatic concern that the patient is likely to require incision and drainage, and the question "does this patient need to be intubated right now in my ICU, or can they wait until they are in theatre where all the sharp objects and FONA experts are".

b) Principles of emergency intubation for this difficult airway is 

Detailed and organised emergency plan with rationale +/- discussion.

Comprehensive details around seniority of personnel and difficult intubation equipment required.

Appropriate FONA technique if failed intubation.

4 marks

Planning

  • Decide a priori what the best first attempt option should be.
    Options include:
    • Awake fibreoptic (oral or nasal) laryngoscopy
    • Videolaryngoscopy
    • Awake tracheostomy
    • Inhalational induction followed by intubation
  • Prepare for FONA by
    • identifying the anterior neck anatomy
    • setting up the equipment
    • prepping and draping the anterior neck
    • applying the local anaesthetic
  • Caveats:
    •  Awake nasal fiberoptic intubation, though ideal, may not be an option in this acute deterioration
    • The patient may not have a sufficiently patent airway to allow safe preoxygenation
    • Anaesthetic equipment may not be available for a gas induction

Preparation of the staff

  • Ideally the most senior staff available, including:
    • Anaesthetics 
    • ENT/oral surgery or ICU staff to scrub for FONA
    • Enough ICU staff to act as resuscitation team (chance of cardiac arrest is not zero)
  • Discuss the plan with the team to ensure everyone is aware of what is going to happen
  • Ask FONA staff to scrub and stanby

Preparation of the equipment

  • Plan A equipment should be ready for use
  • Plan B equipment should be available within 60 seconds (which means, in the room, within arm’s reach, and wherever possible unwrapped and lubricated).
  • Drugs should be drawn up, including a couple of adrenaline ampoules in case CPR becomes a part of the rapid sequence induction.
  • An end-tidal CO2 monitor should be within reach

Preparation of the patient

  • Explain to the patient what the plan is (if they are conscious and capable of processing this information, it would be helpful to have them on your side).
  • Commence high flow oxygen
  • Give an adrenaline neb
  • Administer glycopyrrolate or similar anticholinergic agent to dry secretions
  • Preoxygenate for a minimum of 3 minutes. 
  • During this time, either position the patient for intubation, or (if they cannot tolerate that position) prepare equipment and assistants to put them into that position as soon as the induction is commenced.

In terms of the literature to guide this answer, it appears that everything we know about acutely intubating the patient with Ludwig's angina is mostly derived from case reports, where an anaestetist has a terrible experience and then writes about it for a medical journal.

References

Hardcastle, R. A., and C. J. Matthews. "Speed of writing." Journal of the Forensic Science Society 31.1 (1991): 21-29.

Kulkarni, Anand H., et al. "Ludwig's angina and airway considerations: a case report." Cases journal 1 (2008): 1-4.

Neff, S. P. W., A. F. Merry, and B. Anderson. "Airway management in Ludwig's angina." Anaesthesia and intensive care 27.3 (1999): 659-661.

Candamourty, Ramesh, et al. "Ludwig's Angina–An emergency: A case report with literature review." Journal of natural science, biology, and medicine 3.2 (2012): 206.

Fellini, Roberto Taboada, et al. "Airway management in Ludwig's angina-a challenge: case report." Revista Brasileira de Anestesiologia 67 (2017): 637-640.

Mehmood, R., Z. Mansoor, and S. Mehmood. "Anaesthetic management in a patient presenting with Ludwig's angina." Anaesthesia (2022): 46-46.