airway management and mechanical ventilation
TRANSCRIPT
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Airway Management andMechanical Ventilation
John Angelo PerezSt. Luke’s Medical Center
International Institute of NeurosciencesOctober 21, 2015
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Management of ICP is multi-modal
Increased ICP
Head Positioning
Osmotherapy
Sedation and Analgesia
Seizure ControlHypothermia
BP Control
Ventilation
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Questions for today
• What makes neurologic patients special?
Some considerations
• What are the steps for intubation?
Intubation as a life-saving intervention
• What is the role of ventilation in neurocritical care?
Ventilation in the NCCU
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Part 1: Some considerationsWhat makes neuro patients special?
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More patients require intubation in the NCCU
Bhardwaj and Mirski. Handbook of Neurocritical Care 2nd Ed. 2011
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The airway is divided into parts
Butterworth et al. Morgan and Mikhail's Clinical Anesthesiology 5th Edition. 2013
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Cranial nerves supply the airway
Butterworth et al. 2013
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Conditions Requiring Intubation
• Strokes• TBI• Status epilepticus• Encephalopathies• CNS Infections• Hydrocephalus• Cerebral Edema• Neuromuscular disorders
Bhardwaj and Mirski. Handbook of Neurocritical Care 2nd Ed. 2011
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Three principles guide intubation
Failure to Protect or Maintain Airway
Failure to Oxygenate or
Ventilate
Anticipate a deteriorating
course
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Conditions Requiring Intubation
• Strokes• TBI• Status epilepticus• Encephalopathies• CNS Infections• Hydrocephalus• Cerebral Edema• Neuromuscular disorders
Failure to Protect or Maintain Airway
Failure to Oxygenate or
Ventilate
Anticipate a deteriorating
course
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Part 2:A life-saving intervention
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RapidSequenceIntubation
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RapidSequenceIntubation
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PLAN: use LEMON to evaluate difficult airways
L – Look!E – Evaluate the 3-3-2 ruleM – Mallampati ScoreO - ObstructionsN – Neck mobility
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Butterworth et al. 2013
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POSITION: Extend the neck to align the oro-pharyngo-tracheal axis
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PRE-OXYGENATE: An ill patient has 6 minutes to be intubated
Torbey, Michael. Neurocritical Care. 2010
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PREPARE: Keep everything within reach
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Patients must intubated within 60 seconds
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RapidSequenceIntubation
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RapidSequenceIntubation
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PARALYZE: three classes of drugs are used in RSI
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Part 3:Ventilation in the NCCU
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Hyperventilation
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Hyperventilation induces hypocapnea
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Hypocapnea decreases CBF
30
Butterworth et al. . 2013
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Decreased CBF decreases ICP
Hyperventilation
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How long? How fast?How deep? Which diseases?
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Secondary infarction is the most important complication of hyperventilation
Normal: 50mL/100g/min
Stochetti et al. Hyperventilation in Head Injury: A Review. Chest 2012
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The meta-analysis did not find sufficient evidence of improved outcomes
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What have we learned today?Failure to Protect or
Maintain Airway
Failure to Oxygenate or
Ventilate
Anticipate a deteriorating
course
Increased ICP
Head Positioning
Osmotherapy
Sedation and Analgesia
Seizure ControlHypothermia
BP Control
Ventilation
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Questions?Failure to Protect or
Maintain Airway
Failure to Oxygenate or
Ventilate
Anticipate a deteriorating
course
Increased ICP
Head Positioning
Osmotherapy
Sedation and Analgesia
Seizure ControlHypothermia
BP Control
Ventilation