You are intubating an hypoxic patient with a rapid sequence induction.
You are unable to visualise the cords during laryngoscopy. What is your plan to manage this problem
This question required a safe management plan that would cover the possible contingencies. The candidate should have mentioned that proper planning and assessment is the key but details of preparation were not specifically asked for.
Thus one approach is:
(a) If one is able to ventilate the patient:
• optimise laryngoscopy -extra pillow, McCoy blade, laryngeal manipulation etc.
• consider alternatives to laryngoscopy- fiberoptic laryngoscopy
• blind nasal, light wand
• call for expert help
• awaken patient
(b} If one is unable to ventilate the patient:
• call for expert help
• insert guedel airway and attempt ventilation with PEEP
• insert LMA and attempt ventilation
• if successful go to (a)
• if unsuccessful attempt to establish a transtracheal airway
- retrograde wire, cricothyrotomy, tracheostomy.
lt was assumed that suction. s .ECG, BP measurements were all preoptimised
Again, this is a question regarding the difficult intubation algorithm.
Nursing staff report that they are suctioning nasogastric feeds from the tracheostomy of a patient with cuffed tube in situ. How will you manage this problem?
A practical problem. It may be addressed thus:
(a) Sit the patient up if possible.
(b) Determine if the patient is actually aspirating NG feed by mixing food dye or methylene blue with feeds and repeat ETI suctioning intermittently.
(c) Check tracheal cuff pressures and absence of air leak. presence of seal. Ensure appropriate size tracheostomy in situ. Check tracheostomy tube position above carina and that cuff is at least 2 em below the cords.
(d) Check position of NG tube in stomach.
(e) If all the above conditions are satisfactory and the patient still appears to be aspirating, the feeds will have to be ceased and investigations for a trachco-oesophageal fistula may need to be instigated.
The causes of aspiration may numerous. One must identify which of the follwoing problems is present:
A practical approach would resemble the following sequence:
Elpern, Ellen H., et al. "Pulmonary aspiration in mechanically ventilated patients with tracheostomies." CHEST Journal 105.2 (1994): 563-566.
Bone, David K., et al. "Aspiration pneumonia: prevention of aspiration in patients with tracheostomies." The Annals of thoracic surgery 18.1 (1974): 30-37.
Thompson-Henry, Sheri, and Barbara Braddock. "The modified Evan's blue dye procedure fails to detect aspiration in the tracheostomized patient: five case reports." Dysphagia 10.3 (1995): 172-174.
Outline the role of monitoring in the management of upper airway obstruction.
Monitoring should be considered as either part of routine examination (clinical monitoring) or requiring additional equipment or investigations. Assumed in this case that the presence of an endotracheal tube or tracheostomy would prevent upper airway obstruction.
Clinical: essential part of monitoring. Clinical criteria more likely to lead to decision to intervene. Consider importance of assessment of level of consciousness, extent of obstruction (soft tissue iodrawing- suopraclivular, tracheal tug, intercostal muscles), and ability to cope with increased work of breathing (tachycardia, tachypnoea, sweating).
Equipment: pulse oximetry (limited information, better with lower FlO2),
ECG (rhythm, ischaemia), capnograph (respiratory rate, pattern of expiratory flow), invasive pressures (IA/CVP/PAWP - may help assess extent of intrathoracic pressure change and therefore work of breathing).
Investigations: arterial blood gases (direction of change may assist in decision to intervene eg. CO2/pH).
it is difficult to come up with a systematic answer to this weird question.
Upper airway obstruction ca potentially result in the loss of the whole airway, and this would manifest in a number of ways.
Physical examination findings (such as worsening stridor or tachypnoea) suggest that this patient should undergo serial examinations.
The earliest machine-monitored sign that the patient cannot breathe (or that the airway is closing) would be continuous capnometry.
Pulse oximetry would alert you to when it is already too late, and the patient is desperately hypoxic.
ABG analysis will tell you when the patient is tiring of breathing though their obstructed airway, and this may lead you to finally intubate them.
List the advantages and disadvantages of three commonly used techniques for percutaneous tracheostomy•
Commonly used techniques include: Ciaglia, Griggs (portex}, a combination of these, and the Translaryngeal approaches.
Ciaglia:
Advantages: initial technique, widely used, well known, well documented complication rate (low),
gradual dilatation, able to insert any type of tracheostomy tube
Disadvantages: need experienced operator and airway operator, endotracheal tube positioning may damage vocal cords or lose PEEP/minute ventilation/protection of airway, takes minutes to dilate
and spray of blood stained respiratory gases with each inspiration unless hole completely covered each time, damage to posterior wall of trachea with initial perforation and subsequent dilatations (? minimised by use of bronchoscope)
Griggs (Portex):
Advantages: less steps in technique, faster dilatation (may be used in emergency), able to insert any
type of tracheostomy tube
Disadvantages: need experienced operator and airway operator, needs sterilization of forceps if previously used, endotracheal tube positioning may damage vocal cords or lose PEEP/minute ventilation/protection of airway, more abrupt dilatation (may cause more tracheal damage), spray of blood stained respiratory gases with each inspiration unless hole completely covered, damage to posterior wall of trachea with initial perforation and subsequent dilatations (? minimised by use of bronchoscope), may want to insert different tracheostomy tube (wasting tube in pack)
Translaryngeal:
Advantages: well documented complication rate (very low, especially bleeding), has been safely used with marked coagulopathy, initial tracheal puncture under vision from inside trachea, avoids damage to posterior wall of trachea, allows ventilation (separate tube) throughout procedure, can be done as one person technique
Disadvantages: less widely known technique out of Europe, more fiddly technique, need experienced operator, requires Light sowce and scope (rigid or flexible), ventilation may be difficult
with small endotracheal tube, pulling through the tracheostomy tube may damage vocal cords, only able to insert one type of tracheostomy tube (not tube with inner cannula), need to use different technique to change type of tube
This answer, as a table:
|
Advantages |
Disadvantages |
Classical Ciaglia |
|
|
Ciaglia Blue Rhino |
|
|
Griggs forceps technique |
|
|
Cianchi balloon dilation technique |
|
|
Frova and Quintel (PercuTwist) technique |
|
|
Translaryngeal (Fantoni) |
|
|
Essentially, in the Ciaglia technique one dilates the trachea sequentially using a series of dilators, whereas in the Griggs technique one ends up dilating most of the trachea using forceps.
The Fantoni technique is different. in this one you use a Seldinger technique to pass a guidewire though the trachea and up through the mouth. Then, through the mouth the tracheostomy tube is advanced on an armoured trochar which is pushed to pierce though the wall of the trachea, and to emerge hideously out of the neck like the Alien. Weirdly, it seems to be the safest approach. The main benefit is that one is able to ventilate the patient thoughout this process by using the thin-walled ETT which comes with the set.
Byhahn, C., V. Lischke, and K. Westphal. "Translaryngeal tracheostomy in highly unstable patients." Anaesthesia 55.7 (2000): 678-683.
Ambesh, Sushil P., et al. "Percutaneous tracheostomy with single dilatation technique: a prospective, randomized comparison of Ciaglia Blue Rhino versus Griggs’ guidewire dilating forceps." Anesthesia & Analgesia 95.6 (2002): 1739-1745.
Antonelli, Massimo, et al. "Percutaneous translaryngeal versus surgical tracheostomy: A randomized trial with 1-yr double-blind follow-up*." Critical care medicine 33.5 (2005): 1015-1020.
Outline your plan of management for a rapidly deteriorating patient with severe airflow obstruction who is a known difficult intubation.
Initial management should ensure assessment and management of airway, breathing and circulation, as well as level of consciousness. Must be prepared for difficult intubation (essential equipment should be listed, checked and ready; adequate skilled assistance should be present; backup plans are essential). Specific plan should be elucidated with relation to reason for difficult intubation (eg. limited mouth opening, versus high anterior larynx etc.). Main difficulty is that bag-valve-mask ventilation or laryngeal mask ventilation may be impossible. The use of facemask CPAP may provide some time if not contraindicated by deteriorating neurologic state. Bronchoscopic or blind nasal intubation may be reasonable if operator adequately skilled in techniques. Paralysis may otherwise be essential. Early resort to surgical airway may be appropriate if problems develop.
This question is another one of those "how do you manage a difficult airway" questions.
The answer would need to be systematic.
History
Examination
Planning
Preparation of the staff
Preparation of the equipment
Specific equipment (the contents of the difficult intubaton trolley)
Preparation of the patient
ANZCA have a statement on the equipment which should be available to manage a difficult airway.
Nørskov, Anders Kehlet, et al. "Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database." Anaesthesia 70.3 (2015): 272-281.
Apfelbaum, Jeffrey L., et al. "Practice Guidelines for Management of the Difficult Airway An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway." The Journal of the American Society of Anesthesiologists 118.2 (2013): 251-270.
Frerk, C., et al. "Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults." British journal of anaesthesia 115.6 (2015): 827-848.
Heidegger, T. "The 2015 Difficult Airway Society guidelines: what about the anticipated difficult airway." Anaesthesia 71 (2016): 592-3.
Law, J. Adam, et al. "The difficult airway with recommendations for management–part 2–the anticipated difficult airway." Canadian Journal of Anesthesia/Journal canadien d'anesthésie 60.11 (2013): 1119-1138.
Walls, Ron M., and Michael Francis Murphy, eds. Manual of emergency airway management. Lippincott Williams & Wilkins, 2008.
Lim, M. S., and J. J. Hunt-Smith. "Difficult airway management in the intensive care unit: Practical guidelines." (2003): 43.
Caldiroli, D., and P. Cortellazzi. "A new difficult airway management algorithm based upon the El Ganzouri Risk Index and GlideScope® videolaryngoscope: a new look for intubation." Minerva Anestesiol 77.10 (2011): 1011-1017.
El-Ganzouri, Abdel Raouf, et al. "Preoperative airway assessment: predictive value of a multivariate risk index." Anesthesia & Analgesia 82.6 (1996): 1197-1204.
Zaouter, C., J. Calderon, and T. M. Hemmerling. "Videolaryngoscopy as a new standard of care." British journal of anaesthesia 114.2 (2015): 181-183.
Compare and contrast percutaneous and surgical tracheostomy.
Surgical tracheostomy is the time-honoured approach. Best operating conditions (coping with complexities of anatomy), best control of bleeding and airway. Requires operating time and staff, and transport to operating theatre. Lower incidence of peri-operative complications. Higher incidence of tracheal stenosis, postoperative bleeding and stomal infection.
Percutaneous tracheostomy refers to a number of different techniques. In particular the gradual dilatation [Ciaglia], forceps dilation [Griggs], Rhino and translaryngeal techniques. Most comparative data is for the Ciaglia technique. Blind external technique (which can be bronchoscopy assisted to improve visualization/placement) which seems to be significantly operator dependent. Some neck anatomy problems provide relative contraindications. Permits smaller incision, but lesser exposure and not usually performed with diathermy available. Only require intensive care staff, though airway maintenance is probably more critical, with respiratory acidosis and loss of airway more likely. No delays due to theatre requirements, no transport required, and takes less time to perform. Higher incidence of anterior tracheal wall injury and posterior wall perforation. Lower incidence of postoperative haemorrhage, infection and tracheal stenosis.
This question lends itself well to a tabulated answer.
|
Surgical tracheostomy |
Percutaneous tracheostomy |
Advantages |
|
|
Disadvantages |
|
|
Durbin, Charles G. "Indications for and timing of tracheostomy." Respiratory care 50.4 (2005): 483-487.
Kilic, Dalokay, et al. "Article When is Surgical Tracheostomy Indicated? Surgical “U-shaped” versus Percutaneous Tracheostomy." Ann Thorac Cardiovasc Surg 17.1 (2011): 29-32.
De Leyn, Paul, et al. "Tracheotomy: clinical review and guidelines." European Journal of Cardio-thoracic Surgery 32.3 (2007): 412-421.
Friedman, Yaakov, et al. "Comparison of percutaneous and surgical tracheostomies." CHEST Journal 110.2 (1996): 480-485.
Dulguerov, Pavel, et al. "Percutaneous or surgical tracheostomy: a meta-analysis." Critical care medicine 27.8 (1999): 1617-1625.
Duann, Chi‐Wei, et al. "Successful percutaneous tracheostomy via puncture through the thyroid isthmus." Respirology Case Reports 2.2 (2014): 57-60.
Friedman, Yaakov, et al. "Comparison of percutaneous and surgical tracheostomies." CHEST Journal 110.2 (1996): 480-485.
Dulguerov, Pavel, et al. "Percutaneous or surgical tracheostomy: a meta-analysis." Critical care medicine 27.8 (1999): 1617-1625.
Griffiths, John, et al. "Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation." Bmj 330.7502 (2005): 1243.
Johnson‐Obaseki, Stephanie, Andrea Veljkovic, and Hedyeh Javidnia. "Complication rates of open surgical versus percutaneous tracheostomy in critically ill patients." The Laryngoscope (2016).
Dempsey, Ged A., et al. "Long-Term Outcome Following Tracheostomy in Critical Care: A Systematic Review." Critical Care Medicine (2016).
Outline how you would assess a patient for potential difficulty with endotracheal intubation.
• History: of previous difficulty with intubation, infections/swelling affecting mouth or neck, problems with mouth opening or neck movement (arthritis, cervical spine injury), problems with teeth (especially caps/crowns, law wiring etc.).
• Examination (multiple components) consider:
o teeth (maxillary anterior to mandibular; length of upper incisors; ability to prognath mandible; inter-incisor distance [need > 3 cm])
o Pharynx (ability of visualise uvula and tonsillar pillars; height and narrowness of palate).
o Mandibular space (thyromental distance 2: 3 fingerbreadths [6 cm]; compliance and distensibility of submandibular space).
o Length of neck (qualitative: short neck more difficult eg. syndromes).
o Thickness of neck (qualitative: thick neck decreases ability to align planes).
o Range of motion (of head and neck: eg. sniffing position)
• Consider also the ability to assess potential difficulties by actually having a look with a laryngoscope.
This question was recycled as Question 11 in the first paper of 2006. To simplify revision, the answer to that SAQ is reproduced below.
Anaesthetic history:
Patient characteristics:
Specific pathologies associated with difficult intubation:
Physical examination: general features
Mouth, face and jaw examination
Neck and posture
LEMON is a nice short way of remembering what to look for. It certainly seems to be reliable in predicting difficult intubation.
Look:
Evaluate: 3:3:2 rule
Mallamati score
Obesity and obstruction
Neck mobility
Arne, J., et al. "Preoperative assessment for difficult intubation in general and ENT surgery: predictive value of a clinical multivariate risk index." British journal of anaesthesia 80.2 (1998): 140-146.
Wilson, M. E., et al. "Predicting difficult intubation." British Journal of Anaesthesia 61.2 (1988): 211-216.
Cattano, D., et al. "Anticipation of the difficult airway: preoperative airway assessment, an educational and quality improvement tool." British journal of anaesthesia 111.2 (2013): 276-285.
Reed, M. J., M. J. G. Dunn, and D. W. McKeown. "Can an airway assessment score predict difficulty at intubation in the emergency department?." Emergency medicine journal 22.2 (2005): 99-102.
Apfelbaum, Jeffrey L., et al. "Practice Guidelines for Management of the Difficult AirwayAn Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway." The Journal of the American Society of Anesthesiologists 118.2 (2013): 251-270.
Nørskov, Anders Kehlet, et al. "Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database." Anaesthesia 70.3 (2015): 272-281.
Williamson, Dominic, and Jerry Nolan. "Airway assessment." Emergency Airway Management (2015): 41.
Huitink, J. M., and R. A. Bouwman. "The myth of the difficult airway: airway management revisited." Anaesthesia 70.3 (2015): 244-249.
Gupta, Sunanda, Rajesh Sharma, and Dimpel Jain. "Airway assessment: predictors of difficult airway." Indian J Anaesth 49.4 (2005): 257-262.
A 60-year-old woman has a right hemi-hepatectomy for invasive cholangio-carcinoma. She has been admitted to your unit for postoperative care
c) On day 6 she has a massive melaena requiring urgent endoscopy in the Intensive Care Unit. She requires endotracheal intubation. How will you perform this?
There probably will be hypovolaemia, a potentially full stomach, hepatic, renal dysfunction and encephalopathy. The safest method of intubation is mandatory.
Consider: Preparation of intubation (what equipment, help, drugs,), what monitoring, description of probable rapid sequence induction with cricoid pressure.
This is another one of those "how would you prepare for intubation" questions.
Outline the potential advantages and disadvantages of a tracheostomy in the weaning of patients from mechanical ventilation.
Limited actual clinical trial data is available to support the performance of a tracheostomy over maintaining prolonged endotracheal intubation. Purported advantages include: less laryngeal pathology (not supported by the literature); improved patient comfort including reduced respiratory work of breathing and less sedation requirements for tube tolerance; improved communication (speech not possible with ETT), enhanced nursing care (including mouth care & mobility), ease of replacement of tracheal tube, ease of removal/reinstitution of ventilatory support, facilitate transfer to ward (with airway protection and ready airway access for suctioning).
Potential disadvantages include: requirement for surgical procedure and therefore associated peri-operative and post- operative procedural risks including haemorrhage, pneumothorax, tracheal perforation, and even death; increased aspiration risk, increased incidence of nosocomial pneumonia; increased risk of subglottic stenosis and granuloma formation; infection of stoma; occlusion of tracheostomy tube (posterior tracheal wall, granulomata, secretions [if not regular change of tube or inner cannula and/or problems with humidification]); problems associated with decannulation (either elective or emergent: including complicate emergency airway management).
Local resources for this topic:
Published literature:
Advantages of tracheostomy
Disadvantages of tracheostomy
Durbin, Charles G. "Indications for and timing of tracheostomy." Respiratory care 50.4 (2005): 483-487.
Sue, Richard D., and Irawan Susanto. "Long-term complications of artificial airways." Clinics in chest medicine 24.3 (2003): 457-471.
Davis, Kenneth, et al. "Changes in respiratory mechanics after tracheostomy." Archives of surgery 134.1 (1999): 59-62.
Pierson, David J. "Tracheostomy and weaning." Respiratory care 50.4 (2005): 526-533.
De Leyn, Paul, et al. "Tracheotomy: clinical review and guidelines." European journal of cardio-thoracic surgery 32.3 (2007): 412-421.
Clec’h, Christophe, et al. "Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: A propensity analysis*." Critical care medicine 35.1 (2007): 132-138.
Frutos-Vivar, Fernando, et al. "Outcome of mechanically ventilated patients who require a tracheostomy*." Critical care medicine 33.2 (2005): 290-298.
Manthous, Constantine A., and Gregory A. Schmidt. "Resistive pressure of a condenser humidifier in mechanically ventilated patients." Critical care medicine 22.11 (1994): 1792-1795.
A 45-year-old intellectually handicapped man is admitted to your Intensive Care Unit for airway management. He was nasally intubated for evacuation of a large dental abscess, which had caused airway compromise.
(a) Describe how you would assess him for extubation.
(a) Describe how you would assess him for extubation.
Readiness for extubation requires an assessment of factors that necessitated intubation in the first place, and standard criteria. Standard criteria would include:
· adequacy of oxygenation (usually on low level of FIO2 [eg. 0.4] and PEEP [eg. 5]),
· ventilation (minimal respiratory supports eg. low level of pressure support [eg. :: 10]
or tube compensation; some other ventilatory indices may be used [eg. VE < 10
L/min, tidal volume :respiratory rate ratio, maximal inspiratory force [negative pressure]),
· protection of airway (adequate cough ± gag),
· ability to clear secretions (sputum production and cough), and
· appropriate neurological state (usually/preferably obeys command, orientated). Specifics for this man would also include:
· an assessment of the airway swelling (supraglottic) via direct questioning (limited) and direct or indirect visualisation(laryngoscopy, endoscopy). Discussion with treating surgical team critical, especially with regard to timing, as swelling likely to increase over the first 48 hours. Uncommonly need more formal imaging.
· acceptable neurological state given his intellectual handicap (limited ability to understand and/or co-operate may alter threshold for the previously mentioned criteria).
This question closely resembles Question 11 from the second paper of 2011. In order to simplify revision, the answer to that question is duplicated below.
The normal criteria for extubation readiness are as follows:
Basic pre-conditions |
|
Airway protection assessment |
|
Gas exchange criteria |
|
Lung mechanics criteria |
|
... in the model answer, one may also want to mention that 30% of patients who DONT satisfy these criteria can still be successfully extubated.
The Specific criteria for this patient
Things to consider before a difficult extubation:
Andrew D Bersen wrote chapter 27 of the Oh's Manual, which regards mechanical ventilation.
Table 27.3 on page 363 of the 6th edition of Ohs Manual is a nice list of the various indices meantioned above (eg. the rapid shallow breathing index).
On page 362, Bersen references this Chest article from 2001, where the evidence for extubation criteria is summarised.
MacIntyre NR (chairman), Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. CHEST December 2001 vol. 120 no. 6 suppl 375S-396S.
Recommendations regarding which conditions favour extubation has been put forward in a 2007 practice guidelines statement by the AARC:
AARC GUIDELINE: REMOVAL OF THE ENDOTRACHEAL TUBE; RESPIRATORY CARE •JANUARY 2007 VOL 52 NO 1
Karmarkar, Swati, and Seema Varshney. "Tracheal extubation." Continuing Education in Anaesthesia, Critical Care & Pain 8.6 (2008): 214-220.
Mitchell, V., et al. "Difficult Airway Society Guidelines for the management of tracheal extubation." Anaesthesia 67.3 (2012): 318-340.
Kriner, Eric J., Shirin Shafazand, and Gene L. Colice. "The endotracheal tube cuff-leak test as a predictor for postextubation stridor." Respiratory care 50.12 (2005): 1632-1638.
Loudermilk, Eric P., et al. "A prospective study of the safety of tracheal extubation using a pediatric airway exchange catheter for patients with a known difficult airway." CHEST Journal 111.6 (1997): 1660-1665.
Outline the role of the Laryngeal Mask Airway in the critically ill patient.
The Laryngeal Mask Airway has a number of potential roles in the ICU:
• Most important role is as part of the difficult airway algorithm (use to ventilate when cannot intubate; easily taught, good success rate, buys time)
• Can be used as a conduit for bronchoscopy and/or intubation in a patient who is difficult to intubate
• Could be considered as part of cardiac arrest management as an alternative in establishing airway and ventilation by practitioners not expert in the use of the endotracheal tube
• Can be used to maintain airway and ventilation during the performance of a percutaneous tracheotomy
• As an alternative airway during procedures in the ICU
Other variations have been developed (including the intubating laryngeal mask, which is one of the techniques that could be used for the patient who is difficult to intubate).
The above list is almost complete.
In summary, the ICU uses of the LMA are:
List the potential adverse effects of endotracheal intubation, and briefly outline how they can be minimised.
The answers provided by the candidates were very disappointing. Endotracheal intubation is so fundamental to Intensive Care practice that a high standard was expected in this question to obtain a pass mark. A list of the major complications and some suggestions regarding prevention were required. Very few candidates included myocardial ischemia, elevation of ICP, the potential for spinal cord injury in the presence of an unstable spine, or even failed intubation. Few candidates listed pre-oxygenation as potentially helpful in preventing hypoxia.
Potential adverse effects included:
Hypoxia, Failed intubation, Oesophageal intubation, Endobronchial intubation, Aspiration, Bronchospasm, Structural damage (including Cord injury/False passage), Foreign body aspiration, Bacteraemia, Hypertension/tachycardia/arrhythmias/myocardial ischaemia, Raised ICP, Hypotension/exacerbation of shock state, Other drug side-effects, Sputum retention / pneumonia, Sub-glottic stenosis, Tracheo-oesophageal fistula.
The candidate, who is preparing for their fellowship, does not need to hear how disappointing the college finds the previous candidates. Even among the genre of college feedback, which is notoriously unhelpful, such comments are especially pointless. Must we open a window on this? Sure, not one of the candidates achieved the "high standard" which the examiners considered a pass mark. But some might say that the candidates, all being senior ICU staff, by definition have a superlative understanding of intubation, and that the question was worded in such a profoundly stupid manner that this knowledge did not have a chance to spill out onto the answer booklet.
Perhaps one might have asked:
"What are the acute physiological consequences of a successful endotracheal intubation? How might these impact adversely on the critically ill patient?
What might be the adverse consequences of a failed intubation attempt?
"Describe some steps which might be taken to protect the patient from these consequences."
"You may tabulate your answer."
Complication |
Preventative measure |
Failure of intubation |
|
Oesophageal intubation |
|
Right main bronchus intubation |
|
Broncospasm |
|
Hypoxia |
|
Aspiration |
|
Pneumothorax and tension pneumothorax |
|
Cuff leak |
|
Myocardial ischaemia |
|
Spinal injury |
|
Increased intracranial pressure |
|
Increased intraocular pressure |
|
Structural damage: -lips |
|
Griesdale, Donald EG, et al. "Complications of endotracheal intubation in the critically ill." Intensive care medicine 34.10 (2008): 1835-1842.
Rashkin, Mitchell C., and Tern Davis. "Acute complications of endotracheal intubation. Relationship to reintubation, route, urgency, and duration." CHEST Journal 89.2 (1986): 165-167.
Divatia, J. V., and K. Bhowmick. "Complications of endotracheal intubation and other airway management procedures." Indian J Anaesth 49.4 (2005): 308-18.
Outline how you would assess a patient for potential difficulty with endotracheal intubation.
History: of previous difficulty with intubation, infections/swelling affecting mouth or neck, problems with mouth opening or neck movement (arthritis, cervical spine injury), problems with teeth (especially caps/crowns, jaw wiring etc.). Review of a previous anaesthetic chart.
Examination (multiple components) consider:
• Teeth (maxillary anterior to mandibular; length of upper incisors; ability to prognath mandible; inter-incisor distance [need > 3 cm])
• Pharynx (ability of visualise uvula and tonsillar pillars; height and narrowness of palate).
• Mandibular space (thyromental distance 2: 3 fingerbreadths [6 cm]; compliance and distensibility of submandibular space).
• Length of neck (qualitative: short neck more difficult eg. syndromes).
• Thickness of neck (qualitative: thick neck decreases ability to align planes).
• Range of motion (of head and neck: eg. sniffing position)
• Consider also the ability to assess potential difficulties by actually having a look with a laryngoscope. (10 marks)
In some situations specific investigations may also be indicated (eg. neck X-rays etc.)
There are numerous anatomical and historical features which predict difficult intubation.
Anaesthetic history:
Patient characteristics:
Specific pathologies associated with difficult intubation:
Physical examination: general features
Mouth, face and jaw examination
Neck and posture
LEMON is a nice short way of remembering what to look for. It certainly seems to be reliable in predicting difficult intubation:
Look:
Evaluate: 3:3:2 rule
Mallamati score
Obesity and obstruction
Neck mobility
Arne, J., et al. "Preoperative assessment for difficult intubation in general and ENT surgery: predictive value of a clinical multivariate risk index." British journal of anaesthesia 80.2 (1998): 140-146.
Wilson, M. E., et al. "Predicting difficult intubation." British Journal of Anaesthesia 61.2 (1988): 211-216.
Cattano, D., et al. "Anticipation of the difficult airway: preoperative airway assessment, an educational and quality improvement tool." British journal of anaesthesia 111.2 (2013): 276-285.
Reed, M. J., M. J. G. Dunn, and D. W. McKeown. "Can an airway assessment score predict difficulty at intubation in the emergency department?." Emergency medicine journal 22.2 (2005): 99-102.
Apfelbaum, Jeffrey L., et al. "Practice Guidelines for Management of the Difficult AirwayAn Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway." The Journal of the American Society of Anesthesiologists 118.2 (2013): 251-270.
Nørskov, Anders Kehlet, et al. "Diagnostic accuracy of anaesthesiologists’ prediction of difficult airway management in daily clinical practice: a cohort study of 188 064 patients registered in the Danish Anaesthesia Database." Anaesthesia 70.3 (2015): 272-281.
Williamson, Dominic, and Jerry Nolan. "Airway assessment." Emergency Airway Management (2015): 41.
Huitink, J. M., and R. A. Bouwman. "The myth of the difficult airway: airway management revisited." Anaesthesia 70.3 (2015): 244-249.
Gupta, Sunanda, Rajesh Sharma, and Dimpel Jain. "Airway assessment: predictors of difficult airway." Indian J Anaesth 49.4 (2005): 257-262.
Outline the anatomical relations of the cervical trachea relevant to performing a percutaneous tracheostomy.
• Trachea is attached superiorly to the cricoid cartilage, by the cricotracheal membrane
• Trachea is covered anteriorly by skin, superficial fascia, strap muscles
(sternohyoid, sternothyroid), and deep (pretracheal) fascia.
• 2nd to 4th rings of the trachea are covered by isthmus of the thyroid anteriorly.
• Branches of the superior thyroid artery run along the superior aspect of the thyroid isthmus, anterior to the trachea.
• Lateral lobes of the thyroid lie between the trachea and the carotid sheath and its contents.
• Oesophagus lies posterior to the trachea.
• Carotid sheath containing carotid artery, jugular vein, and vagus nerve lie posterolateral to the trachea.
• Recurrent laryngeal nerves lie posterolaterally in the grove between the trachea and the oesophagus.
• Anterior jugular veins are often connected by a vein that runs superficially across the lower neck.
• Inferior thyroid veins lie anterior to the lower part of the cervical trachea, posterior to the strap muscles.
A picture is worth a thousand words. Instant Anatomy does it best. However, if words are called for... Trauma.org has an excellent tutorial on this technique. ANZICS also has a position statement for percutaneous tracheostomy.
In short:
See?
Muhammad, Joseph Kamal, Edward Major, and David William Patton. "Evaluating the neck for percutaneous dilatational tracheostomy." Journal of Cranio-Maxillofacial Surgery 28.6 (2000): 336-342.
Epstein, Scott K. "Anatomy and physiology of tracheostomy." Respiratory care 50.4 (2005): 476-482.
What are the risk factors for the development of post-extubation stridor? Briefly outline the treatment of post extubation-stridor.
Risk factors:
1) Duration of IPPV > 5 days
2) Traumatic or difficult intubation
3) Prior history of self extubation
4) Trauma, surgery or infection of upper airways
5) History of agitation
6) Female sex
7) High BMI
8) Over inflated cuff
9) Older age group
10) Elevated APACHE
11) Low GCS
12) Large ETT size
Treatment:
1) Adrenaline nebs: constrict arterioles, reduce oedema, useful in acute stridor.
2) Steroids: May be more useful in prevention rather than treatment, commenced 12 hr prior to extubation (recent Lancet paper). Also useful in children
3) CPAP – relief of symptoms, reduction in work of breathing (needs to be done with caution)
4) Heliox – improved patient comfort, shown to reduce need for intubation
5) If all above fail, endotracheal intubation and ventilation
A good article is available which details the predictors of stridor following intubation. Another specifically addresses the risk factors for laryngeal oedema and failure of extubation. The last one also contains a discussion of all the management strategies listed in the college answer.
Risk factors for post-extubation stridor
Management of post-extubation stridor
Jaber, Samir, et al. "Post-extubation stridor in intensive care unit patients."Intensive care medicine 29.1 (2003): 69-74.
Efferen, L. S., and A. Elsakr. "Post-extubation stridor: risk factors and outcome." Journal of the Association for Academic Minority Physicians: the official publication of the Association for Academic Minority Physicians 9.4 (1997): 65-68.
Wittekamp, B. H., et al. "Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients." Crit Care 13.6 (2009): 233.
Pluijms, Wouter A., et al. "Postextubation laryngeal edema and stridor resulting in respiratory failure in critically ill adult patients: updated review." Critical Care 19.1 (2015): 1-9.
This is an image of a 13 year old boy who rode his motorbike into a single strand of fencing wire, was thrown off and walked 500 metres for help. He now complains of difficulty in breathing. On examination he has stridor.
(a) How would you manage stridor in this boy?
(b) How will you secure his airway? Give reasons.
(a) How would you manage stridor in this boy?
• Oxygen
• Maintain spont vent in position of comfort until airway secure
• Nebulised adrenaline
• Heliox
• Prepare difficult airway equipment
• Call for assistance
(b) How will you secure his airway? Give reasons.
Options
• Awake fibreoptic intubation -may risk further laryngotracheal separation
• Tracheostomy under LA – the safest option available
• Gas induction with surgeon present for emergency tracheostomy
• Avoid cricothyroidotomy - risk of further damage
• RSI contraindicated – cricoid pressure may cause laryngotracheal separation
This boy has either an acute traumatic upper airway injury (eg. fracture of laryngeal cartilage or hyoid) or injury to the surrounding tissues which is now causing airway obstruction due to swelling. Either way, he needs to be intubated.
This question benefits from a systematic approach.
a)
Generic measures for the management of stridor may apply:
b)
Schaefer, Steven D. "Management of acute blunt and penetrating external laryngeal trauma." The Laryngoscope 124.1 (2014): 233-244.
This article is probably more useful:
Peady, "Initial Airway Management of Blunt Upper Airway Injuries: A Case Report and Literature Review" Australasian Anaesthesia 2005
A 40 year old man with a history of ankylosing spondylitis and known difficulty with intubation on previous elective surgery is admitted to your ICU for hypoxic respiratory failure. A decision to perform a semi-elective, awake fiberoptic intubation in the ICU has been made.
Describe how you will prepare for this procedure.
(a) Preparation of patient
• Consent/explanation of procedure
• Obtain history of previous airway difficulty, technique used, complications, etc. (from patient, letter from anaesthetist).H/o allergies-esp. to local anaesthetics. Fasting status. Other co-morbidities, eg. coagulopathy.
• Clinical assessment- of airway itself, mouth opening, nasal cavity/septum, range of neck movement, mental status including ability to understand and cooperate with proposed procedure, degree of hypoxia and ability to pre-oxygenate.
(b) Preparation of environment/personnel
• Appropriate lighting with ability to dim.
• Monitoring - ECG, pulse oximetry, arterial line, capnography set up.
• Adequate and working IV access
• Establish comfortable and adequate patient position, pillows, etc.
• Request help and ensure availability as appropriate- eg. Anaesthetist
• Ensure presence of adequate skilled assistants. Inform them in detail of steps of procedure and assign roles, as appropriate.(eg. observation of patient, administration of sedatives, optimisation of patient position, injection of LA, etc)
• Discuss a plan B, if technique were to fail.
• Keep resuscitation trolley easily available and ensure difficult airway equipment available.
(d) Preparation of drugs
• Systemic-
o Antisialagogue- eg. glycopyrrolate
o Consider proton pump inhibitor.
o Midazolam/Fentanyl as appropriate (small doses as patient should be able to cooperate)
• Local anaesthetics- Very important in order to achieve success. Ensure not to exceed recommended doses and allow adequate time to act.
o Nasal cavity and nasopharynx- 10% lignocaine spray with phenylephrine spray or cotton tipped pledgets soaked in 4% cocaine or nebuliser filled with
5ml of 4% lignocaine.
o Oral cavity and oropharynx- 10% lignocaine spray or 2% lignocaine viscous gargles.
• Extra local anaesthetic may be required to spray during advancement of bronchoscope.
This question separates the dual trainees in ICU and anaesthetics from those who don't routinely have their hands on a bronchoscope.
Walsh, Mary E., and G. D. Shorten. "Preparing to perform an awake fiberoptic intubation." The Yale journal of biology and medicine 71.6 (1998): 537.
A 45-year-old intellectually handicapped man is admitted to your Intensive Care Unit for airway management. He is currently nasally intubated following an evacuation of a large dental abscess that had caused airway compromise. Describe how you would assess his readiness for extubation.
Readiness for extubation requires an assessment of factors that necessitated intubation in the first place and standard criteria.
Standard criteria would include:
• Adequacy of oxygenation (usually on FiO2 ~ 0.4 and PEEP 5)
• Ventilation (minimal respiratory support eg low level of PS £ 10). Some other ventilatory indices may be used (eg rapid shallow breathing index, negative inspiratory force, P0.1, CROP, Vt 4-6 ml/kg, Vmin 10-15 L/min)
• Protection of airway (adequate cough ± gag)
• Ability to clear secretions
• Appropriate neurological state (obeys command, orientated)
• Stable haemodynamics not requiring support
• Sepsis controlled
• Metabolic / biochemical parameters normal
Specifics for this man would also include:
• Assessment of airway swelling with direct/indirect visualization
• Discussion with treating surgical team regarding timing and management of ongoing swelling
• Adjust criteria for neurological state given his intellectual handicap
This is a straightforward question about criteria for extubation. A curveball is thrown in the form of an intellectual handicap, but it is not anything too extraordinary.
The normal criteria for extubation readiness are outlined below.
Basic pre-conditions |
|
Airway protection assessment |
|
Gas exchange criteria |
|
Lung mechanics criteria |
|
... in the model answer, one may also want to mention that 30% of patients who DONT satisfy these criteria can still be successfully extubated.
The Specific criteria for this patient
Things to consider before a difficult extubation:
Andrew D Bersen wrote chapter 27 of the Oh's Manual, which regards mechanical ventilation.
Table 27.3 on page 363 of the 6th edition of Ohs Manual is a nice list of the various indices meantioned above (eg. the rapid shallow breathing index).
On page 362, Bersen references this Chest article from 2001, where the evidence for extubation criteria is summarised.
MacIntyre NR (chairman), Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. CHEST December 2001 vol. 120 no. 6 suppl 375S-396S.
Recommendations regarding which conditions favour extubation has been put forward in a 2007 practice guidelines statement by the AARC:
AARC GUIDELINE: REMOVAL OF THE ENDOTRACHEAL TUBE; RESPIRATORY CARE •JANUARY 2007 VOL 52 NO 1
Karmarkar, Swati, and Seema Varshney. "Tracheal extubation." Continuing Education in Anaesthesia, Critical Care & Pain 8.6 (2008): 214-220.
Mitchell, V., et al. "Difficult Airway Society Guidelines for the management of tracheal extubation." Anaesthesia 67.3 (2012): 318-340.
Kriner, Eric J., Shirin Shafazand, and Gene L. Colice. "The endotracheal tube cuff-leak test as a predictor for postextubation stridor." Respiratory care 50.12 (2005): 1632-1638.
Loudermilk, Eric P., et al. "A prospective study of the safety of tracheal extubation using a pediatric airway exchange catheter for patients with a known difficult airway." CHEST Journal 111.6 (1997): 1660-1665.
You are called urgently to the Emergency Department to review a 63-year-old male with chronic airflow limitation who is rapidly deteriorating. He is spontaneously breathing and a known difficult intubation.
Outline the priorities in this man’s management.
This is an emergency situation with the following key issues:
Rapid deterioration in a patient with airflow limitation
Preparation for a difficult intubation
Management comprises simultaneous resuscitation and assessment to diagnose the cause(s) of the rapid deterioration in this patient and initiation of supportive and definitive management and at the same time calling for help and preparing for a difficult intubation.
Prompt diagnosis and appropriate focussed management of the underlying cause(s) may obviate the need for intubation in this patient but should not delay intubation if this needs to be done.
Help should be sought from the most appropriate resources available (senior ED or anaesthetic colleague, ENT, skilled anaesthetic technician)
Diagnosis of underlying cause depends on history, examination and specific investigations. Possible causes of rapid deterioration in this patient include tension pneumothorax, worsening bronchospasm, pneumonia and septic shock, pulmonary embolus, myocardial ischaemia. Treatment measures may include thoracocentesis / insertion ICC, bronchodilators, fluid and vasopressor resuscitation and antibiotics, thrombolysis, reversal coronary ischaemia.
Consideration should be given to a trial of NIV but again this should not delay necessary intubation.
If the underlying problem is not readily reversible, proceed to securing the airway with preparation for difficult intubation.
Preparation for difficult intubation involves the following:
Location
Patient unsuitable for transfer to OT so use well-equipped resus bay in ED
Equipment
Standard intubation equipment plus difficult airway trolley including equipment for emergency surgical airway, resuscitation equipment and full monitoring and ETCO2
Drugs
Sedatives, muscle relaxants, resuscitation drugs and local anaesthetics
Personnel
Experienced assistants for airway equipment, drugs, cricoid pressure and general help Experienced colleague (ICU, anaesthesia, ED, ENT)
Technique
Assess patient’s airway and information regarding previous intubations and nature of difficulty and ease of bag-mask ventilation. It may be appropriate to perform immediate tracheostomy or cricothyroidotomy under local anaesthesia. Difficult to intubate BUT easy to ventilate increases options.
Whenever one is asked to "outline the priorities", one shoud probably begin with attention to the immediate ABCs of management.
After that, the priorities here are firstly the management of acute respiratory failure, and secondly the preparation for a difficult intubation.
Immediate attention to ABCs:
Management of respiratory failure:
Preparation for a difficult intubation:
A generic list of difficult airway equipment to have ready:
Hyperglycemic Comas by P. VERNON VAN HEERDEN from Vincent, Jean-Louis, et al. Textbook of Critical Care: Expert Consult Premium. Elsevier Health Sciences, 2011.
Oh's Intensive Care manual: Chapter 58 (pp. 629) Diabetic emergencies by Richard Keays
Umpierrez, Guillermo E., Mary Beth Murphy, and Abbas E. Kitabchi. "Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome." Diabetes Spectrum15.1 (2002): 28-36.
ARIEFF, ALLEN I., and HUGH J. CARROLL. "Nonketotic hyperosmolar coma with hyperglycemia: clinical features, pathophysiology, renal function, acid-base balance, plasma-cerebrospinal fluid equilibria and the effects of theraphy in 37 cases." Medicine 51.2 (1972): 73-94.
Gerich, John E., Malcolm M. Martin, and Lillian Recant. "Clinical and metabolic characteristics of hyperosmolar nonketotic coma." Diabetes 20.4 (1971): 228-238.
Kitabchi, Abbas E., et al. "Hyperglycemic crises in adult patients with diabetes." Diabetes care 32.7 (2009): 1335-1343.
Kitabchi, Abbas E., et al. "Hyperglycemic crises in adult patients with diabetes a consensus statement from the American Diabetes Association." Diabetes care 29.12 (2006): 2739-2748.
Ellis, E. N. "Concepts of fluid therapy in diabetic ketoacidosis and hyperosmolar hyperglycemic nonketotic coma." Pediatric clinics of North America 37.2 (1990): 313-321.
Pinies, J. A., et al. "Course and prognosis of 132 patients with diabetic non ketotic hyperosmolar state." Diabete & metabolisme 20.1 (1993): 43-48.
Critically evaluate the timing of elective tracheostomy in adult Intensive Care patients.
Introduction
Tracheostomy is performed in critically ill adults requiring prolonged invasive ventilation as a strategy to reduce respiratory tract injury, improve patient confort and/or to facilitate weaning. Timing of tracheostomy has been a subject of debate and may be considered as “early” at <10 days or “late” >10 days although these definitions may vary.
Rationale
There has been debate as to whether “early” trache may confer advantages of reduced morbidity and mortality Disadvantages of tracheostomy include airway trauma, bleeding and death and this may be increased by doing an “ early” tracheostomy in patients who may otherwise die or be extubated before 10 days.
Early tracheostomy is a consideration in patients with neurological issues (brain injury, GBS, CVA etc.) and shortens time on ventilator and time in ICU.
Evidence
Many studies and meta-analyses of variable quality have evaluated this issue. Methodological issues include differences in “early” and “late” timing, prediction of which patients will require “long-term” ventilation, exclusion/inclusion of specific patient groups and diagnosis of end-points such as VAP.
Cochrane Review 2012 considered 4 studies (latest 2010) to meet inclusion criteria. Conclusions were that quality of evidence to date was poor and results conflicting. Recent RCT Tracman Study from UK – tracheostomy at 1-4 days v >10 days invasive ventilation. Early tracheostomy associated with shorter duration of sedation but increased number of procedures and associated complications with no beneficial effect on overall mortality not ICU/hospital LOS.
Studies have evaluated patients with respiratory failure and not those intubated for neurological injury.
Own Practice
Any reasonable approach acceptable.
Summary
Lack of evidence to support early v late trache overall. Selected patients eg neurotrauma, GBS, stroke may benefit from early.
Probably best decided on case by case basis.
Involves invasive procedure with attendant risks and complications and needs appropriate expertise.
The timing of tracheostomy is well discussed in a recent meta-analysis. Sure, its PLOS, and sometimes people only value the advice they have to pay for, but I think it is of a high quality. The model answer makes reference to TracMan, a trial which had not yet been published at the time of the exam, and so could not have been expected as a part of an answer to this question. If this question were repeated in future papers (eg. Question 13 from the second paper of 2017) modern data expected of the candidates would probably come from the 2015 meta-analysis article by Andriolo et al and Szakmany et al, which arrived at essentially the same conclusions (in three words, early vs late tracheostomy makes no difference to any parameters of interest when you homogenise the ICU population).
Introduction:
Rationale for early tracheostomy:
Rationale for delaying tracheostomy:
Evidence:
Cochrane review by Andriolo et al (2015):
Own practice:
Summary:
Huang, Huibin, et al. "Timing of Tracheostomy in Critically Ill Patients: A Meta-Analysis." PloS one 9.3 (2014): e92981.
Young, Duncan, et al. "Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial." Jama 309.20 (2013): 2121-2129.
Longworth, Aisling, et al. "Tracheostomy in special groups of critically ill patients: Who, when, and where?." Indian Journal of Critical Care Medicine 20.5 (2016): 280.
Baron, David Marek, et al. "Tracheostomy is associated with decreased hospital mortality after moderate or severe isolated traumatic brain injury." Wiener klinische Wochenschrift (2016): 1-7.
Hosokawa, Koji, et al. "Timing of tracheotomy in ICU patients: a systematic review of randomized controlled trials." Critical Care 19.1 (2015): 1-12.
Gomes Silva, Brenda Nazaré, et al. "Early versus late tracheostomy for critically ill patients." Cochrane Database Syst Rev 3 (2012).
Andriolo, B. N., et al. "Early versus late tracheostomy for critically ill patients." Cochrane Database Syst Rev 1 (2015).
Szakmany, T., et al. "Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials." British journal of anaesthesia 114.3 (2015): 396-405.
An 18-year-old male presents following a bicycle crash with obvious facial injuries. He has profuse bleeding from the mouth and nose and insists on sitting up at 90 degrees. He has bruising under both eyes, his face is significantly swollen and his mid-face is mobile. His breathing is “noisy”.
His vital signs are as follows:
His GCS is 15. He has no cervical spine injury and no other significant injuries.
List the possible techniques for securing the airway in this patient, and the pros and cons of each.
Rapid Sequence Induction:
Pro:
Rapid technique - may be only option if patient peri – arrest No special expertise required
May be best technique with ENT/Surgical backup at bedside to perform immediate tracheostomy if intubation fails.
Con:
Obscured / absent landmarks (potential to lose airway with RSI)
Co-existing upper airway / tracheal injuries Patient unable to lie flat
Left lateral position may be preferred but increases degree of difficulty Limited respiratory reserve
Pre-oxygenation, bag-mask ventilation problematic
Likely to become haemodynamically unstable with sedation
Cricothyroidotomy / Awake tracheostomy:
Pro:
Safe – no risk of losing airway
Patient breathing throughout
Con:
May be difficult without sedation Positioning may be problematic
May be technically challenging in the setting of local tissue damage and haemorrhage
Fibreoptic intubation:
Pro:
No risk of losing airway
Patient breathing throughout
Con:
Likely to be extremely challenging in the setting of ongoing haemorrhage
Attempted nasotracheal intubation could result in nasocranial passage of tube and/or severe nasal haemorrhage
Need expert/experienced airway assistance
Awake direct laryngoscopy / intubation:
Pro:
Quick – no time wastage
Reduced risk of losing airway
Patient breathing throughout
Uses standard intubating equipment
May be method of choice with senior operator
Allows easy transition to a back-up technique
Con:
Technically challenging
Needs adequate local anaesthesia
Positioning patient problematic
Credit given to discussion of any sensible technique and any relevant introductory or concluding statement giving a summary of the issues.
This patient is suffering from fractures of the mid-face.
There are several options for securing the airway in this patient.
Firstly, does he need intubation? It seems he does, as his respiratory rate is rapid, and his oxygenation is poor. Likely, he has inhaled some blood. And NIV is absolutely contraindicated in such people. So yes, he does need intubation - largely for airway protection, to prevent vast quantities of blood and snot from seeping into his lungs.
And the savvy candidate will have arrived at this conclusion without a half a page of introductory gibberish.
So, the question asked by the college really is "how do you intubate a hypoxic patient with facial injuries".
They ask for pros and cons, which lends itself well to a tabulated answer.
Technique | Advantages | Disadvantages |
Rapid sequence induction |
|
|
Fibreoptic intubation |
|
|
Percutaneous cricothyroidotomy |
|
|
Then, the college asks for a sensible concluding statement, without demonstrating what one should look like.
In summary, this patient requires intubation by skilled technicians, with backup equipment available. If the patient is peri-arrest, there is not time for any technique other than RSI. Ideally, a videolaryngoscope should be available. Otherwise, the first attempt should be an awake fiberoptic orotracheal intubation, with the opportunity to convert to RSI. In the event that both techniques fail, a percutaneous cricothyroidotomy should be the approach of last resort.
In addition to this "model answer" (pfft) I have also found unusual trivia around the medical literature. There are many ways to approach intubation in the patient with midfacial injuries.
For instance, a submental approach is a well-recognised approach. Retrograde intubation may be attempted, which might be even bloodier than the cricothyroidotomy. These techniques and others are discussed in a good 2009 review article of airway management in facial trauma.
Caron, Guy, et al. "Submental endotracheal intubation: an alternative to tracheotomy in patients with midfacial and panfacial fractures." Journal of Trauma and Acute Care Surgery 48.2 (2000): 235-240.
Barriot, P. A. T. R. I. C. K., and B. R. U. N. O. Riou. "Retrograde technique for tracheal intubation in trauma patients." Critical care medicine 16.7 (1988): 712-713.
Mohan, Raja, Rajiv Iyer, and Seth Thaller. "Airway management in patients with facial trauma." Journal of Craniofacial Surgery 20.1 (2009): 21-23.
A 67-year-old male has been intubated and ventilated in your ICU for the last 15 days following an upper GI bleed and banding of oesophageal varices. He is obese (BMI 31), has alcoholic liver disease and smokes heavily. He has been assessed as unsuitable for transplantation. His ICU stay has been complicated by aspiration pneumonia, acute kidney injury and ongoing encephalopathy.
Discuss the potential benefits and risks of percutaneous dilatational tracheostomy (PDT) in this patient.
PDT is a common procedure in Australasian ICUs to facilitate airway management and/or weaning from MV. PDT in this man may be helpful in this regard, but presents significant problems related to body habitus and acute and chronic comorbidities.
Benefits:
May help facilitate ventilatory weaning
Increased patient comfort
Improved management of secretions
May facilitate mobilisation during weaning
Potentially reduced sedation requirements
Provide a secure airway in the setting of a fluctuating conscious state
Risks:
Difficult placement / maintenance:
o Should mention potentially difficult airway
o May have difficult neck anatomy as obese/increased risk of malposition or tracheal injury
o High risk of dislodgement later on if standard trache tube used
Bleeding risk
Likely coagulopathy secondary to CLD
Likely thrombocytopenia secondary to portal hypertension / hypersplenism.
May have systemic venous hypertension (portosystemic shunting, alcoholic cardiomyopathy etc.)
Infection risk
Increased in setting of chronic liver disease
Increased in obesity
Poor wound healing in heavy smoker
General risks
Loss of airway
Pneumothorax
Hypoxaemia (defer if FiO2 > 0.6 and PEEP > 10)
Cardiac arrest
Death
Wisdom issues
Prognosis guarded at best even with tracheostomy; long-term outlook is poor and it will not treat any of this man's underlying issues: therefore requires due consideration / deliberation.
Number of prior presentations for the same problem are also a factor
Patient's previously expressed wishes a consideration but ultimately a medical decision
Risk/benefit ratio may not be favourable: ongoing aggressive treatment of encephalopathy with view to primary extubation may be better.
If deemed appropriate to proceed, surgical tracheostomy may be a safer alternative
Examiners' comments: Some candidates discussed PDT in general rather than issues as they related to this patient.
Local resources for this topic:
Published literature:
Advantages of "PDT in general" are offered below:
Advantages of tracheostomy in general
|
Disadvantages of tracheostomy in general
Arguments against tracheostomy in this specific patient:
|
Durbin, Charles G. "Indications for and timing of tracheostomy." Respiratory care 50.4 (2005): 483-487.
Sue, Richard D., and Irawan Susanto. "Long-term complications of artificial airways." Clinics in chest medicine 24.3 (2003): 457-471.
Davis, Kenneth, et al. "Changes in respiratory mechanics after tracheostomy." Archives of surgery 134.1 (1999): 59-62.
Pierson, David J. "Tracheostomy and weaning." Respiratory care 50.4 (2005): 526-533.
De Leyn, Paul, et al. "Tracheotomy: clinical review and guidelines." European journal of cardio-thoracic surgery 32.3 (2007): 412-421.
Clec’h, Christophe, et al. "Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: A propensity analysis*." Critical care medicine 35.1 (2007): 132-138.
Frutos-Vivar, Fernando, et al. "Outcome of mechanically ventilated patients who require a tracheostomy*." Critical care medicine 33.2 (2005): 290-298.
Manthous, Constantine A., and Gregory A. Schmidt. "Resistive pressure of a condenser humidifier in mechanically ventilated patients." Critical care medicine 22.11 (1994): 1792-1795.
A 40-year-old male with a history of ankylosing spondylitis and known difficulty with intubation with previous elective surgery is admitted to your ICU for hypoxic respiratory failure. A decision to perform a semi-elective, awake fibre-optic intubation in the ICU has been made.
Describe how you will prepare for this procedure.
Preparation of patient
Preparation of environment/personnel
Preparation of equipment
Preparation of drugs
This question is identical to Question 21 from the first paper of 2011. The answer offered here is also identical.
Walsh, Mary E., and G. D. Shorten. "Preparing to perform an awake fiberoptic intubation." The Yale journal of biology and medicine 71.6 (1998): 537.
Describe your management of a patient who develops neck swelling with palpable crepitus, difficulty in ventilation and rapid desaturation immediately following a percutaneous tracheostomy.
Immediate assessment and resuscitation
Reintubation
Further management:
Assess for other related damage:
Re-evaluate need for tracheostomy
Thorough answer should consider –
Additional Examiners‟ Comments:
A significant number of candidates described removal of the tracheostomy tube without checking position/patency and/or did not mention use of capnograph or bronchoscope.
Important differentials:
Immediate management:
If the bag ventilation is easy and the patient improves with it:
If the bag ventilation is difficult and the patient is still unwell:
If the tracheostomy being dislodged is a real possibility:
Options for reinserting an "older" tracheostomy
Collateral damage:
Wisdom issues
HUTCHINSON, ROBERT CHARLES, and RODNEY DICKSON MITCHELL. "Life-threatening complications from percutaneous dilational tracheostomy." Critical care medicine 19.1 (1991): 118-119.
Eisenhauer, Brenda. "DISLODGED TRACHEOSTOMY TUBE." Nursing2015 26.6 (1996): 25.
Seay, Shirley Jordan, Sonja L. Gay, and Melvin Strauss. "Tracheostomy Emergencies: Correcting accidental decannulation or displaced tracheostomy tube." AJN The American Journal of Nursing 102.3 (2002): 59-63.
Pattanong, Paradorn. "Dislodged tracheostomy." The Journal of Prapokklao Hospital Clinical Medical Education Center-วารสาร ศูนย์ การ ศึกษา แพทยศาสตร์ คลินิก รพ. พระ ปก เกล้าฯ 24.4 (2012): 304-308.
Chew, John Y., and Robert W. Cantrell. "Tracheostomy: complications and their management." Archives of Otolaryngology 96.6 (1972): 538-545.
Casserly, P., et al. "Assessment of healthcare professionals' knowledge of managing emergency complications in patients with a tracheostomy." British journal of anaesthesia 99.3 (2007): 380-383.
An 18-year-old male presents following a fight in a bar with obvious facial injuries. He has profuse bleeding from the mouth and nose and insists on sitting up at 90°. He has bruising under both eyes, his face is significantly swollen and his mid-face is mobile. His breathing is "noisy".
His vital signs are as follows:
He has no cervical spine injury and no other significant injuries.
List the possible techniques for securing the airway in this patient and the pros and cons of each.
Rapid Sequence Induction:
Pro:
Rapid technique - may be only option should patient‟s condition deteriorate to peri-arrest
No special expertise required
May be best technique with ENT/Surgical backup at bedside to perform immediate tracheostomy if intubation fails.
Con:
Obscured / absent landmarks (potential to lose airway with RSI)
• Airway swelling
• Haematomata and ongoing haemorrhage
• Bony and soft tissue trauma
Co-existing upper airway / tracheal injuries
Patient unable to lie flat
Left lateral position may be preferred but increases degree of difficulty
Limited respiratory reserve
Pre-oxygenation, bag-mask ventilation problematic
Likely to become haemodynamically unstable with sedation
Cricothyroidotomy / Awake tracheostomy
Pro:
Safe – no risk of losing airway
Patient breathing throughout
Con:
May be difficult without sedation
Positioning may be problematic
May be technically challenging in the setting of local tissue damage and haemorrhage
Fibreoptic intubation
Pro:
No risk of losing airway
Patient breathing throughout
Con:
Likely to be extremely challenging in the setting of ongoing haemorrhage
Attempted nasotracheal intubation could result in nasocranial passage of tube and/or severe nasal haemorrhage
Need expert/experienced airway assistance
Awake direct laryngoscopy / intubation
Pro:
Quick – no time wastage
Reduced risk of losing airway
Patient breathing throughout
Uses standard intubating equipment
May be method of choice with senior operator
Allows easy transition to a back-up technique
Con:
Technically challenging
Needs adequate local anaesthesia
Positioning patient problematic
Credit was given to discussion of any sensible technique and any relevant introductory or concluding statement giving a summary of the issues.
Additional Examiners‟ Comments:
In general, well-answered, using a good structure.
Apart from certain cosmetic differences (bar fight vs bicycle crash) this question is identical to Question 24 from the first paper of 2013.
The discussion section from 2013 is reproduced below, with minimal modification.
Thus:
This patient is suffering from fractures of the mid-face.
There are several options for securing the airway in this patient.
Firstly, does he need intubation? It seems he does, as his respiratory rate is rapid, and his oxygenation is poor. Likely, he has inhaled some blood. And NIV is absolutely contraindicated in such people. So yes, he does need intubation - largely for airway protection, to prevent vast quantities of blood and snot from seeping into his lungs.
And the savvy candidate will have arrived at this conclusion without a half a page of introductory gibberish.
So, the question asked by the college really is "how do you intubate a hypoxic patient with facial injuries".
They ask for pros and cons, which lends itself well to a tabulated answer.
Technique | Advantages | Disadvantages |
Rapid sequence induction |
|
|
Fibreoptic intubation |
|
|
Percutaneous cricothyroidotomy |
|
|
Then, the college asks for a sensible concluding statement, without demonstrating what one should look like.
In summary, this patient requires intubation by skilled technicians, with backup equipment available. If the patient is peri-arrest, there is not time for any technique other than RSI. Ideally, a videolaryngoscope should be available. Otherwise, the first attempt should be an awake fiberoptic orotracheal intubation, with the opportunity to convert to RSI. In the event that both techniques fail, a percutaneous cricothyroidotomy should be the approach of last resort.
In addition to this "model answer" (pfft) I have also found unusual trivia around the medical literature. There are many ways to approach intubation in the patient with midfacial injuries.
For instance, a submental approach is a well-recognised approach. Retrograde intubation may be attempted, which might be even bloodier than the cricothyroidotomy. These techniques and others are discussed in a good 2009 review article of airway management in facial trauma.
Caron, Guy, et al. "Submental endotracheal intubation: an alternative to tracheotomy in patients with midfacial and panfacial fractures." Journal of Trauma and Acute Care Surgery 48.2 (2000): 235-240.
Barriot, P. A. T. R. I. C. K., and B. R. U. N. O. Riou. "Retrograde technique for tracheal intubation in trauma patients." Critical care medicine 16.7 (1988): 712-713.
Mohan, Raja, Rajiv Iyer, and Seth Thaller. "Airway management in patients with facial trauma." Journal of Craniofacial Surgery 20.1 (2009): 21-23.
Describe the advantages and disadvantages of the available methods for allowing speech in a patient with a tracheostomy tube in situ.
1. Cuff deflation
Simple cuff deflation may allow patients to speak.
2. Capping tube
Cuff is deflated and patient or caregiver places finger over tracheostomy tube.
3. Speaking valve e.g. Passy Muir
One-way valve attached to tracheostomy tube.
Gas enters tracheostomy during inspiration but is directed through larynx in expiration.
4. Sub glottis air insufflation e.g. Pitt tube/Speaking
Tube Gas line with an outlet above the cuff and a thumb port. Patient or caregiver can occlude the port which directs gas through the larynx allowing speech.
5. Fenestrated tube
Specialised tube with fenestration and inner cannula that allows gas to pass to larynx when tube occluded.
6. Electronic larynx
Specialised equipment that is held to patient's neck and vibrates when activated and mechanically resonates when words or sounds are mouthed. Uncommon in ICU but has been described.
Additional Examiner Comments:
This was answered poorly. Several candidates failed to mention that the cuff must be delated prior to use of a speaking valve; this omission could lead to serious clinical consequences.
Discussion of advantages and disadvantages always benefits from a table-like structure. This table was composed using the excellent 2005 article by Dean R Hess.
Method | Advantages | Disadvantages |
Cuff up, fenestrated tube: |
|
|
Cuff down, speaking valve: Gas only exits through the upper airway during exhalation (one way valve) |
|
|
Cuff down, no speaking valve i.e. gas freely exists via both the tracheostomy and the upper airway |
|
|
Cuff down, finger occlusion - i.e. the patient blocks the tracheostomy and exhales using the upper airway instead |
|
|
Hess, Dean R. "Facilitating speech in the patient with a tracheostomy."Respiratory care 50.4 (2005): 519-525.
Morris, Linda L., et al. "Restoring speech to tracheostomy patients." Critical care nurse 35.6 (2015): 13-28.
You are preparing to intubate a morbidly obese patient for respiratory failure.
Describe the strategies for minimising hypoxaemia in the period immediately pre- and post-intubation.
Ensure optimal treatment of the underlying cause of respiratory failure where possible, e.g.
• Diuretics and CPAP for acute pulmonary oedema
• Bronchodilators for asthma
1. Optimise pre-oxygenation/ intra procedure oxygenation
• Longer time of pre-oxygenation
• Use of PSV or CPAP pre-intubation (peak Pi not >15 cmH2O recommended)
• Nasal prong and/or high-flow oxygenation during intubation (e.g. THRIVE or simple prongs at 15l/min)
• Monitoring end tidal oxygen; target FeO2 >80%
2. Minimising time to first breath
• Positioning (essential point to mention)
• Ramping (or similar) achieving tragus-sternal angle in horizontal plane Important in obese patient
• Experienced operator
• Equipment ready (expect candidate to have fall-back equipment such as VL, bougies, second generation LMA. No specific right or wrong re which device they should use first)
• Use of rapidly acting skeletal muscle relaxant (or use of spontaneously breathing technique e.g. LA) • Monitoring for intra-tracheal placement of ETT; capnography
• Ventilator set up with appropriate settings for immediate use including FiO2 1.0 and appropriate level PEEP, Vt and inspiratory airway pressure
• Teamwork management – clear roles in primary and backup plans
• NB: Delay with use of video-laryngoscopy
3. Rescue strategies
• Plan A, Plan B, Plan C
• Preparations for supraglottic and infraglottic rescue (more credit if specific algorithm is mentioned e.g. Vortex, DAS)
4. Optimise cardiac output for improved V/Q matching
• Judicious fluid loading
• Vasopressors (e.g. Nor-adrenaline, metaraminol)
• Awareness of fall in output with induction of anaesthesia and institution of IPPV
• Invasive arterial pressure monitoring
The details of this answer are explored in the chapter on the prevention of hypoxia during airway management. For a proper literature reference, the time-poor candidate is directed to "Preoxygenation and prevention of desaturation during emergency airway management" by Weingart and Levitan (2011).
Positioning
Denitrogenation
Positive pressure
Minimisation of metabolic demands
Anticipation of hypoxia
Apnoeic oxygenation
Preparation for failure
Weingart, Scott D., and Richard M. Levitan. "Preoxygenation and prevention of desaturation during emergency airway management." Annals of emergency medicine 59.3 (2012): 165-175.
Heller, Morris L., and T. Richard Watson Jr. "Polarographic study of arterial oxygenation during apnea in man." New England Journal of Medicine 264.7 (1961): 326-330.
Cherniack, NEIL S., and G. S. Longobardo. "Oxygen and carbon dioxide gas stores of the body." Physiological reviews 50.2 (1970): 196-243.
Enghoff, H., and L. RISHOLM. "Diffusion respiration in man." Nature 168.4280 (1951): 830-830.
Draper, William B., and Richard W. Whitehead. "The Phenomenon of Diffusion Respiration.." Anesthesia & Analgesia 28.6 (1949): 307-318.
Lane, S., et al. "A prospective, randomised controlled trial comparing the efficacy of pre‐oxygenation in the 20° head‐up vs supine position." Anaesthesia 60.11 (2005): 1064-1067.
Ramkumar, Venkateswaran, Goneppanavar Umesh, and Frenny Ann Philip. "Preoxygenation with 20º head-up tilt provides longer duration of non-hypoxic apnea than conventional preoxygenation in non-obese healthy adults." Journal of anesthesia 25.2 (2011): 189-194.
Mort, Thomas C. "Preoxygenation in critically ill patients requiring emergency tracheal intubation." Critical care medicine 33.11 (2005): 2672-2675.
Mort, Thomas C., Barbara H. Waberski, and Jonathan Clive. "Extending the preoxygenation period from 4 to 8 mins in critically ill patients undergoing emergency intubation." Critical care medicine 37.1 (2009): 68-71.
Nielsen, Niels D., et al. "Apneic oxygenation combined with extracorporeal arteriovenous carbon dioxide removal provides sufficient gas exchange in experimental lung injury." ASAIO journal 54.4 (2008): 401-405.
Eger, E. I., and J. W. Severinghaus. "The rate of rise of PaCO2 in the apneic anesthetized patient." Anesthesiology 22.3 (1961): 419-425.
Russotto, Vincenzo, et al. "Respiratory support techniques to avoid desaturation in critically ill patients requiring endotracheal intubation: A systematic review and meta-analysis." Journal of Critical Care (2017).
Altermatt, F. R., et al. "Pre-oxygenation in the obese patient: effects of position on tolerance to apnoea." British journal of anaesthesia 95.5 (2005): 706-709.
Dixon, Benjamin J., et al. "Preoxygenation Is More Effective in the 25° Head-up Position Than in the Supine Position in Severely Obese PatientsA Randomized Controlled Study." The Journal of the American Society of Anesthesiologists 102.6 (2005): 1110-1115.
Duggan, Michelle, and Brian P. Kavanagh. "Atelectasis in the perioperative patient." Current Opinion in Anesthesiology 20.1 (2007): 37-42.
Baillard, Christophe, et al. "Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients." American journal of respiratory and critical care medicine 174.2 (2006): 171-177.
Tang, L., et al. "Desaturation following rapid sequence induction using succinylcholine vs. rocuronium in overweight patients." Acta Anaesthesiologica Scandinavica 55.2 (2011): 203-208.
Critically evaluate the timing of elective tracheostomy in ICU patients.
Introduction
Tracheostomy is performed in critically ill adults requiring prolonged invasive ventilation as a strategy to reduce respiratory tract injury, improve patient comfort and/or to facilitate weaning. Timing of tracheostomy has been a subject of debate and may be considered as “early” at <10 days or “late” >10 days although these definitions may vary
Rationale There has been debate as to whether “early” trache may confer advantages of reduced morbidity and mortality Disadvantages of tracheostomy include airway trauma, bleeding and death and this may be increased by doing an “early” tracheostomy in patients who may otherwise die or be extubated before 10 days
Early tracheostomy is a consideration in patients with neurological issues (brain injury, GBS, CVA etc.) and shorten time on ventilator
Evidence
Many studies and meta-analyses of variable quality have evaluated this issue. Methodological issues include differences in “early” and “late” timing, prediction of which patients will require “long-term” ventilation, exclusion/inclusion of specific patient groups and diagnosis of end-points such as VAP Cochrane Review 2012 considered 4 studies (latest 2010) to meet inclusion criteria. Conclusions were that quality of evidence to date was poor and results conflicting. Recent RCT TracMan Study from UK 2013 – tracheostomy at 1-4 days v >10 days invasive ventilation. Early tracheostomy associated with shorter duration of sedation but increased number of procedures and associated complications with no beneficial effect on overall mortality not ICU/hospital LOS
Studies have evaluated patients with respiratory failure and not those intubated for neurological injury
Own Practice
Any reasonable approach acceptable
Summary
Lack of evidence to support early v late trache overall. Selected patients e.g. neurotrauma, GBS, stroke may benefit from early.
Probably best decided on case by case basis
Involves invasive procedure with attendant risks and complications and needs appropriate expertise
This question is identical to Question 13 from the first paper of 2013, with the exception that in 2013 they specifically asked about adult Intensive Care patients. The discussion section for that question is reproduced below with minimal modification, in keeping with the college's own complete verbatim replication of their 2013 model answer, complete even with their reference to the "recent RCT Trac Man", a 2013 publication which in early 2013 was not yet published and in late 2017 is no longer recent.
The timing of tracheostomy is well discussed in a recent meta-analysis. Sure, its PLOS, and sometimes people only value the advice they have to pay for, but I think it is of a high quality. The 2013 model answer makes reference to TracMan, a trial which had not yet been published at the time of the exam, and so could not have been expected as a part of an answer to this question. If this question were repeated in future papers, modern data expected of the candidates would probably come from the 2015 meta-analysis article by Andriolo et al and Szakmany et al, or the 2016 meta-analysis by Meng et al. All of them arrived at essentially the same conclusions (in three words, early vs late tracheostomy makes no difference to any parameters of interest when you homogenise the ICU population),
Introduction:
Rationale for early tracheostomy:
Rationale for delaying tracheostomy:
Evidence:
Cochrane review by Andriolo et al (2015):
Own practice:
Summary:
Huang, Huibin, et al. "Timing of Tracheostomy in Critically Ill Patients: A Meta-Analysis." PloS one 9.3 (2014): e92981.
Young, Duncan, et al. "Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial." Jama 309.20 (2013): 2121-2129.
Longworth, Aisling, et al. "Tracheostomy in special groups of critically ill patients: Who, when, and where?." Indian Journal of Critical Care Medicine 20.5 (2016): 280.
Baron, David Marek, et al. "Tracheostomy is associated with decreased hospital mortality after moderate or severe isolated traumatic brain injury." Wiener klinische Wochenschrift (2016): 1-7.
Hosokawa, Koji, et al. "Timing of tracheotomy in ICU patients: a systematic review of randomized controlled trials." Critical Care 19.1 (2015): 1-12.
Gomes Silva, Brenda Nazaré, et al. "Early versus late tracheostomy for critically ill patients." Cochrane Database Syst Rev 3 (2012).
Andriolo, B. N., et al. "Early versus late tracheostomy for critically ill patients." Cochrane Database Syst Rev 1 (2015).
Szakmany, T., et al. "Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials." British journal of anaesthesia 114.3 (2015): 396-405.
Meng, Liang, et al. "Early vs late tracheostomy in critically ill patients: a systematic review and meta‐analysis." The clinical respiratory journal 10.6 (2016): 684-692.
A 47-year-old female patient is in your ICU having had a prolonged wean from mechanical ventilation following severe head and chest injuries sustained in a motor vehicle collision. She has a tracheostomy and has been breathing spontaneously, free from ventilatory support, on an FiO2 of 0.3 via a tracheostomy mask for 24 hours.
Describe how you will assess whether the tracheostomy tube can be safely removed.
Assessment will involve history, examination and targeted investigations and may involve a trial period with the tracheostomy “capped” or occluded (with the cuff deflated!) to ensure that it can be safely removed.
The tracheostomy can be safely removed if the patient:
• Has a patent upper airway
• Has a protected upper airway
• Can adequately clear her secretions
• No longer requires mechanical ventilation
Patent upper airway
• History
o Upper airway trauma
o Duration of translaryngeal intubation
o Indication for tracheostomy (was it placed for upper airway obstruction)
o Known grade of intubation or difficulty with intubation
• Examination
o Facial or airway trauma or recent surgery
• Investigations (if indicated, not routine)
o Direct or fibreoptic laryngoscopy
o CT scans if available may offer some information
Protected upper airway
• History
o Severity of brain injury
o Focal brainstem injury
• Examination
o Current neurological status
Level of consciousness
Lower cranial nerves including cough and gag reflex
• Investigations
o Neurological imaging inc CT and MRI
o Barium swallow or fibreoptic assessment for aspiration
Adequate clearance of secretions
History
o Injuries that may impair cough
Spinal cord injury
Multiple rib fractures with flail segment
Diaphragmatic injury
Severe lung trauma
Recurrent pneumonia or lung abscess
o Co-morbidity
Lung disease e.g., bronchietcasis
Neuromuscular weakness
Sleep apnoea
Examination
o Respiratory
Frequency of suctioning
Nature and volume of secretions
Presence of flail segment
o Neurological assessment
Peripheral neuromuscular function
Cough assessment (strength, ability to cough secretions past tube)
Investigation
o Ultrasound of diaphragm (if problem suspected)
o Fibreoptic examination of vocal cord function
No requirement for mechanical ventilation
• History
o Background and co-morbidities (OSA, smoking, lung or heart disease….)
o Nature and extent of chest injury and other injuries
o Requirement for any ongoing surgery
o Pattern and duration of weaning from ventilation (24hours of spontaneous ventilation would be a minimum for trache removal)
• Examination
o Respiratory and cardiovascular examination
o Tertiary survey
• Investigations
o CXR
o CT chest
o ABG off ventilation
o Spirometry
Notes
The answer template is not exhaustive, merely indicative and this level of detail in this template was not required. To pass the candidate needed to demonstrate awareness of the requirement for all of:
1. Patent upper airway
2. Ability to clear secretions with a mention of cuff deflation
3. Adequate level of consciousness
4. Adequacy of spontaneous ventilation
Examiners Comments:
Superficial approach. Lack of systematic approach to a common procedure done in ICU. Cuff deflation missed most often.
This college answer has left little room for improvement. One may only try to rearrange the points into something which is not specific to a trauma patient with head and chest injuries, i.e. a more generic approach to anybody with a tracheostomy. One must caution against this formulaic templated approach in the actual exam, as the examiners often complain about how the trainees have not read their carefully worded question text. It would be always important to include case-specific details in one's answer to demonstrate one's engagement with the question.
Heffner, J. E. "The technique of weaning from tracheostomy. Criteria for weaning; practical measures to prevent failure." The Journal of critical illness 10.10 (1995): 729-733.
Christopher, Kent L. "Tracheostomy decannulation." Respiratory Care 50.4 (2005): 538-541.
O'Connor, Heidi H., and Alexander C. White. "Tracheostomy decannulation." Respiratory Care 55.8 (2010): 1076-1081.
Singh, Ratender Kumar, Sai Saran, and Arvind K. Baronia. "The practice of tracheostomy decannulation—a systematic review." Journal of intensive care 5.1 (2017): 38.
Clini, Enrico, et al. "Long-term tracheostomy in severe COPD patients weaned from mechanical ventilation." Respiratory care 44.4 (1999): 415-420.
Chadda, Karim, et al. "Physiological effects of decannulation in tracheostomized patients." Intensive care medicine 28.12 (2002): 1761-1767.
Epstein, Scott K. "Anatomy and physiology of tracheostomy." Respiratory care 50.4 (2005): 476-482.
Ceriana, Piero, et al. "Weaning from tracheotomy in long-term mechanically ventilated patients: feasibility of a decisional flowchart and clinical outcome." Intensive care medicine 29.5 (2003): 845-848.
Enrichi, Claudia, et al. "Clinical criteria for tracheostomy decannulation in subjects with acquired brain injury." Respiratory care 62.10 (2017): 1255-1263.
Rumbak, Mark J., et al. "Tracheostomy tube occlusion protocol predicts significant tracheal obstruction to air flow in patients requiring prolonged mechanical ventilation." Critical care medicine 25.3 (1997): 413-417.
Donzelli, Joseph, Susan Brady, and Michele Wesling. "Using Modified Evan's Blue Dye Test to predict aspiration." The Laryngoscope 114.9 (2004): 1680.
Belafsky, Peter C., et al. "The accuracy of the modified Evan's blue dye test in predicting aspiration." The Laryngoscope113.11 (2003): 1969-1972.
Cameron, John L., J. Reynolds, and G. D. Zuidema. "Aspiration in patients with tracheostomies." Surg Gynecol Obstet 136.1 (1973): 68-70.
Shen, K. Robert, and Douglas J. Mathisen. "Management of persistent tracheal stoma." Chest surgery clinics of North America 13.2 (2003): 369-73.
Bach, John R., and Louis R. Saporito. "Indications and criteria for decannulation and transition from invasive to noninvasive long-term ventilatory support." Respiratory care 39.5 (1994): 515.
A tracheo-innominate artery fistula (TIF) is a rare but life-threatening complication of tracheostomy.
a) What are the contributing factors for TIF formation? (30% marks)
b) What are the clinical features that make you suspect a TIF and how would you confirm the diagnosis? (30% marks)
c) What is your management of a TIF? (40% marks)
Examiners Comments:
This was not well answered overall with a poor knowledge of this complication demonstrated.
Contributing factors to the formation of tracho-innominate fistula:
Clinical features of tracheo-innominate fistula
Management of tracheo-innominate fistula
Grant, C. A., et al. "Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review." British journal of anaesthesia 96.1 (2006): 127-131.
Goldenberg, David, et al. "Tracheotomy complications: a retrospective study of 1130 cases." Otolaryngology—Head and Neck Surgery 123.4 (2000): 495-500.
Chew, John Y., and Robert W. Cantrell. "Tracheostomy: complications and their management." Archives of Otolaryngology 96.6 (1972): 538-545.
Allan, James S., and Cameron D. Wright. "Tracheoinnominate fistula: diagnosis and management." Chest Surgery Clinics 13.2 (2003): 331-341.
Schlaepfer, Karl. "Fatal hemorrhage following tracheotomy for laryngeal diphtheria." Journal of the American Medical Association 82.20 (1924): 1581-1583.
Utley, Joseph R., et al. "Definitive management of innominate artery hemorrhage complicating tracheostomy." Jama 220.4 (1972): 577-579.
You are asked to review a 46-year-old female on the surgical ward who has stridor 4 hours after a total thyroidectomy.
a) List six possible causes for this. (30% marks)
b) You determine intubation is necessary. Outline your approach to securing her airway and justify it.
(70% marks)
Causes
Approach:
Immediate oxygenation measures:
Administer High flow Oxygen / Hudson mask with rebreath bag at 15L. Sitting up position better tolerated than lying flat
Can try Heliox – though to be effective will need 79% Helium, 21% Oxygen mix which may be inadequate if patient has poor gas exchange / pulmonary oedema
Declare Airway emergency – get help: Surgeon, Anaesthetist, Nursing staff
Decide on location for intubation: In ward, theatre or ICU – depending on distance to be moved and patient stability
Decide on and communicate plan of airway intervention including plan for failure: Plans A,B,C highlighting each approach
Ensure Team members are aware of roles & sequence of events and emergency responses
Check Equipment for familiarity and correct function
Be clear about pros and cons of approaches for airway management (Must justify one)
Outline plan for failure: then front of neck access:
Possible causes of stridor in a patient returning from thyroidectomy are more than likely going to be related to the thyroidectomy, or less likely to the drugs which have been given around the time of the thyroidectomy. In any case, it is still probably worthwhile reasoning through this as if it were an exercise in generating differentials:
To throw a coat of peer-review varnish over this unprofessional gibberish, one could point to an excellent article by Ayandipo et al (2016), which discusses a case series of airway complications from a high-volume ENT service in Nigeria. The most common reason for the reintubation was tracheomalacia, which was observed in something like 5% of the total cases.
Approach to securing the airway is an exercise in demonstrating a level of caution and anxiety to the examiners, so as to give the appearance of a safe practitioner. Specific noises which one needs to make to generate this impression are:
So, the ideal approach here would be:
However, the college asked for "your approach to securing her airway", not "your approach to avoiding having to handle her airway". Frequently, this scenario plays out after-hours. Consider that a complex total thyroidectomy may take all day, finish at 8pm, and then stridor comes at midnight. One might be working with a skeleton staff and with no theatre available, plus the surgeon is now on his private island and is not inclined to return to the hospital. In short, you're it.
Examination
Planning
Preparation of the staff
Preparation of the equipment
Preparation of the patient
Scanlon, Edward F., Stephen F. Sener, and E. Dennis Murphy. "Early onset of tetany following thyroidectomy: report of two cases." Journal of surgical oncology 29.4 (1985): 222-223.
Jeong, Jee Yeon, et al. "Respiratory difficulty at a postanesthesia care unit after total thyroidectomy: a case report." Korean J Anesthesiol 45.4 (2003): 540.
Ayandipo, O. O., T. A. Adigun, and O. O. Afuwape. "Airway Complications and Outcome after Thyroidectomy in Ibadan: A 15 year review." Arch Med 8 (2016): 4.
Law, J. Adam, et al. "The difficult airway with recommendations for management–part 2–the anticipated difficult airway." Canadian Journal of Anesthesia/Journal canadien d'anesthésie 60.11 (2013): 1119-1138.
A 68-year-old male remains intubated four days after an out of hospital cardiac arrest. He is agitated on low dose propofol and only intermittently follows commands. His ventilation is pressure support (PSV) with FiO2 0.45, PS 10 cmH2O and PEEP 8 cmH2O. He is generating tidal volumes of 460 mls with a respiratory rate of 22 breaths/min and oxygen saturations of 94%.
Outline how you would determine his readiness for extubation.
Not available.
This patient is at risk of extubation failure. Firstly, some might say that an FiO2 45% is still too high to consider extubation, and others might point to the relatively brisk four day course since his cardiac arrest. This question is functionally indistinguishable from Question 11 from the second paper of 2011, which asked you to extubate a "45-year-old intellectually handicapped man". The basic issue is the same: this patient's neurology is difficult, and you have to adjust your expectations. And, as in all such cases, to a considerable extent his readiness for extubation would be related to your readiness to reintubate him.
First: assure yourself that the basic preconditions are met:
Determine that the gas exchange is adequate:
Determine that the chest wall mechanics are adequate:
Assess airway protective reflexes
Assess airway patency
Reassess neurology
Consider postponing extubation.
On page 362, Bersen references this Chest article from 2001, where the evidence for extubation criteria is summarised.
MacIntyre NR (chairman), Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. CHEST December 2001 vol. 120 no. 6 suppl 375S-396S.
Recommendations regarding which conditions favour extubation has been put forward in a 2007 practice guidelines statement by the AARC:
AARC GUIDELINE: REMOVAL OF THE ENDOTRACHEAL TUBE; RESPIRATORY CARE •JANUARY 2007 VOL 52 NO 1
Karmarkar, Swati, and Seema Varshney. "Tracheal extubation." Continuing Education in Anaesthesia, Critical Care & Pain 8.6 (2008): 214-220.
Mitchell, V., et al. "Difficult Airway Society Guidelines for the management of tracheal extubation." Anaesthesia 67.3 (2012): 318-340.
Kriner, Eric J., Shirin Shafazand, and Gene L. Colice. "The endotracheal tube cuff-leak test as a predictor for postextubation stridor." Respiratory care 50.12 (2005): 1632-1638.
This is an image (Figure 12) of a 13-year-old male who rode his motorbike into a single strand of fencing wire, was thrown off and walked 500 metres for help. He now complains of difficulty in breathing. On examination he has stridor.
a) List the potential associated injuries possible in this patient. (30% marks)
b) Discuss the specific management options for securing his airway. Include in your answer the advantages and disadvantages of each and your preferred option. (70% marks)
Not available.
This question is virtually identical to Question 7.2 from the first paper of 2010. Presumably they used the same image of the boy (this dude would surely be in his thirties by now). In another act of what appears to be a slow process of improving the phrasing of old SAQs, the colloquial "How will you secure his airway? Give reasons" has given way to "Discuss the specific management options for securing his airway". Also, the list of potential injuries is new.
List of potential injuries: This is essentially blunt trauma to Zone II of the neck; or rather, one's knowledge of neck anatomy is tested here; one must think, "what could possibly have gotten in the way of that fence wire?". Thus:
Management options for securing his airway are numerous.
Strategy | Advantages | Disadvantages |
Do nothing |
|
|
Modified rapid sequence induction |
|
|
Awake fiberoptic bronchoscopy |
|
|
Elective tracheostomy or cricothyroidotomy |
|
|
"Own practice" could consist of something like...
Caron, Guy, et al. "Submental endotracheal intubation: an alternative to tracheotomy in patients with midfacial and panfacial fractures." Journal of Trauma and Acute Care Surgery 48.2 (2000): 235-240.
Barriot, P. A. T. R. I. C. K., and B. R. U. N. O. Riou. "Retrograde technique for tracheal intubation in trauma patients." Critical care medicine 16.7 (1988): 712-713.
Mohan, Raja, Rajiv Iyer, and Seth Thaller. "Airway management in patients with facial trauma." Journal of Craniofacial Surgery 20.1 (2009): 21-23.
Schaefer, Steven D. "Management of acute blunt and penetrating external laryngeal trauma." The Laryngoscope 124.1 (2014): 233-244.
Peady, "Initial Airway Management of Blunt Upper Airway Injuries: A Case Report and Literature Review" Australasian Anaesthesia 2005
Kelly, James P., et al. "Management of airway trauma I: Tracheobronchial injuries." The Annals of thoracic surgery 40.6 (1985): 551-555.
Kelly, James P., et al. "Management of airway trauma II: combined injuries of the trachea and esophagus." The Annals of thoracic surgery 43.2 (1987): 160-163.
Shearer, Vance E., and A. H. Giesecke. "Airway management for patients with penetrating neck trauma: a retrospective study." Anesthesia & Analgesia 77.6 (1993): 1135-1138.
Devitt, J. Hugh, and Bernard R. Boulanger. "Lower airway injuries and anaesthesia." Canadian journal of anaesthesia 43.2 (1996): 148-158.
Jain, Uday, et al. "Management of the Traumatized Airway." The Journal of the American Society of Anesthesiologists 124.1 (2016): 199-206.
Bhojani, Rehal A., et al. "Contemporary assessment of laryngotracheal trauma." The Journal of thoracic and cardiovascular surgery 130.2 (2005): 426-432.
Kummer, Carmen, et al. "A review of traumatic airway injuries: potential implications for airway assessment and management." Injury 38.1 (2007): 27-33.
Outline the advantages and disadvantages of the methods that enable speech in a patient with a tracheostomy tube in situ.
Not available.
This has appeared before, as Question 17 from the first paper of 2017.
Method | Advantages | Disadvantages |
Cuff up, fenestrated tube: |
|
|
Cuff down, speaking valve: Gas only exits through the upper airway during exhalation (one way valve) |
|
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Cuff down, no speaking valve i.e. gas freely exists via both the tracheostomy and the upper airway |
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Cuff down, finger occlusion - i.e. the patient blocks the tracheostomy and exhales using the upper airway instead |
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The author has also been present at attempts to facilitate speech by attaching low flow wall oxygen to the above-cuff suction port of the tracheostomy, thereby directing a flow of gas up into the mouth through the vocal cords. The first time you do this, you should expect to have a Yankeur sucker ready, as god-awful filth will rise bubbling from the nethermost hell of that long term patient's airway, forced out by the gas pressure. The author was subsequently surprised to discover that this was not a Mad Hatter sign of senior intensivist cognitive deterioration, but in fact a described technique (McGrath et al, 2016). It was left out of the table above mainly because most people would agree that it does not form a part of the normal spectrum of practice.
Hess, Dean R. "Facilitating speech in the patient with a tracheostomy."Respiratory care 50.4 (2005): 519-525.
Morris, Linda L., et al. "Restoring speech to tracheostomy patients." Critical care nurse 35.6 (2015): 13-28.
McGrath, Brendan, et al. "Above cuff vocalisation: a novel technique for communication in the ventilator-dependent tracheostomy patient." Journal of the Intensive Care Society 17.1 (2016): 19-26.
A 73-year-old patient with a history of ankylosing spondylitis and type 2 diabetes presents with severe respiratory failure.
You are asked to review the patient in the Emergency Department as there has been progressive deterioration since presentation. The patient is clearly dyspnoeic with a respiratory rate of 35 breaths/min and oxygen saturation of 86% on supplemental oxygen of 15 L/min through a non-rebreather mask. A decision has been made to progress to urgent intubation.
Discuss potential difficulties or challenges you foresee and your strategies for dealing with them under the following headings.
a) Infection control measures during the airway procedure. (20% marks)
b) Securing the airway. (80% marks)
Not available.
The first two marks of this question are dedicated to a topic which, during the COVID pandemic, had a remarkable amount of ink spilled over it. Trainees may recall how countless airway management policies were hastily drafted and revised to minimise staff exposure to aerosols, draping the patient in various plastic sheets, clamping tubes and performing checklist rituals. This "infection control measures during the airway procedure" section expects those same trainees to purify the last two years of confusing and rapidly mutating guidelines into some kind of point-form condensate, for under fifty words.
The best resource for this that probably crosses the most international boundaries is the NEJM video from 2021 by Shrestha et al. To narrow things even more, for COVID patients with difficult airways, this 2021 set of guidelines from the Society of Airway Management spells out all the issues that need to be considered. The reader is warned that these are not standard guidelines by any means, i.e the recommendations they make may not be endorsed by every jurisdiction around the world, and every airway expert is likely to have their own opinion on this situation. As the result, the possible range of answers to this question is quite broad, and what follows should be viewed as a guide or suggestion for how to approach this SAQ rather than any sort of model answer
Infection control measures
Preparation for intubation
Shrestha, Gentle Sunder, et al. "Emergency Intubation in Covid-19." The New England Journal of Medicine 384.7 (2021): e20-e20.
Apfelbaum, Jeffrey L., et al. "Practice Guidelines for Management of the Difficult Airway An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway." The Journal of the American Society of Anesthesiologists 118.2 (2013): 251-270.
Foley, Lorraine J., et al. "Difficult airway management in adult coronavirus disease 2019 patients: statement by the Society of Airway Management." Anesthesia & Analgesia 133.4 (2021): 876-890.