Combined Team Function:
Critical Care Airway
Management
Paul H. Mayo M.D.
Director MICU NSLIJ
Professor of Clinical Medicine
Hofstra NSLIJ School of Medicine
(No disclosures)
A Word About OR
Endotracheal Intubation
• Very well studied
• Very low rate of complication
• Very high rate of success
Why?
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Perfect operational environment
Optimal patient physiology
Full airway evaluation and preparation
Elective advanced airway methods
Wake-up/back out option available
Highly skilled intubators
Awake FOB option
Emergency Endotracheal
Intubation (EEI)
• Any endotracheal intubation that does
not occur in the operating room
• Venues: ICU, wards, ED
• Providers at in USA include critical care
staff, anesthesiologists (attending and
NP), and EM staff
• Often occurs in the context of training
house staff
What About EEI?
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Poor operational environment
Highly abnormal patient physiology
Difficulty in airway evaluation
No time to anticipate or prepare
No wake-up and back-out option
Personnel may be in training
How Dangerous is EEI?
• Four large studies describing EEI
performed by anesthesiologists
• Mortality 2%
• Serious complication: 25% (profound
hypotension/desaturation)
• Esophageal intubation: 10%
• EEI: the most dangerous critical care
procedure
Severe hypotension
25%
Jaber S, Crit Care Med 2006
Problems with EEI
• EEI is required in critically ill patients
who have limited physiological reserve
• They are hemodynamically unstable
or….
• They have respiratory failure or…,
• They have both
Death and Brain Injury
• Related to underlying illness and the
need to use sedating agents for EEI,
patients are at very high risk for
hypoxemia and/or hypotension
• Hypoxemia and/or hypotension result in
brain injury and if prolonged….death
A Quiet Epidemic
• Even brief periods of hypotension
and/or hypoxemia may cause brain
injury
• Many patients recover from critical
illness but have permanent brain injury
• I believe that many of these cases
derive from problems related to EEI that
are not documented
The Sad Truth
• The intubation sequence frequently
results in significant desaturation and
hypotension
• The patient survives the critical illness
but has suffered brain injury
• There is no back-up plan
• They (and we) engage in selective
memory, white washing, and “it’s the
patients fault” defense
Some Disturbing Facts
• The 80/80 rule: anesthesia residents
are successful 80% of the time on the
80th case….for routine OR intubation
• The learning curve flattens out at
between 500 to 1000 for OR EI
• EEI is much more difficult than routine
OR EI
• How many EEI have you performed?
Why Does EEI Go Wrong?
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The lone ranger syndrome
Blame the patient
The under the radar effect
Lack of hard endpoints: Saturation, BP,
attempts, failures, complications
• Lack of transparency in documentation
• Clinical chaos, CMA, lack of team effort,
emotional issues, low frequency effect
The Plight of the
Anesthesiologist
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Unfamiliar operating environment
Unfamiliar personnel
Lack of back-up personnel
Lack of back-up plan
Abrupt extreme clinical pressure
The Plight of the Intensivist
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Unstable patient with high risk airway
Low frequency/high risk event
Abrupt extreme clinical pressure
Obligation to train inexperienced
personnel in the most dangerous
procedure of critical medicine
• Often in USA….non-expert level
intubating skills
Should EEI Be Entirely Under
Anesthesiology Control?
• Repeated examples of profound failure
of EEI when Anesthesiology was in
primary control
• A need to train fellows
• A perception that careful CQI analysis
might improve EEI sequence
The Challenge
• How to intubate the critically ill patient
safely in a training environment
• Simple goals: SaO2>90%, systolic BP>
100 systolic, stable cardiac rhythm, and
successful ET intubation performed by
the trainee
• Alternative: Call for anesthesiology as
primary or immediate back-up intubator
Improve the Process
• Define the process in segmental detail
• Identify points of improvement
• Improve those that are most likely to
yield greatest benefit…. “low hanging
fruit”
• Always measure effect, and proceed
with continuous segmental process
improvement
The Very Low Hanging Fruit
• The best way to avoid desaturation is to
have a well saturated patient
• We observed terrible bag mask
ventilation (BVM) technique during EEI
• Solution: train an army of BVM experts
• Who to train: an army of medical interns
• How to train: scenario based training
with a computerized patient simulator
(SBT with CPS)
Other Low Hanging Fruit
• High risk low frequency events require
team work; this requires a team leader
• We observed poor team function and
absence of team leadership
• Solution: train team leaders
• Who: PCCM fellows
• How: SBT with CPS
Other Low Hanging Fruit
• A complex process should be done in a
standardized manner
• We observed marked variation in set up
• Solution: develop a standard approach
• Who: PCCM faculty and fellows
• How: read, discuss, review clinical
events….constantly rethink and refine
Other Low Hanging Fruit
• Only qualified clinicians should perform
a difficult procedure
• Solution: only qualified clinicians should
perform the act of intubation
• Other team members perform critical
tasks for which they are trained
Other Low Hanging Fruit
• EEI set up requires a well planned
bailout plan
• Solution: develop a plan and acquire the
equipment
High Hanging Fruit
• How to find it?
• Detailed debriefing following EEI
• Solution: improve process by identifying
failure points
Examples
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Addition of PEEP valve to BVM
Careful briefing of medication nurse
Separation of pressor from sedative
External auditory meatus horizontal to
supraclavicular notch
• Careful head positioning in the obese
• RUQ ultrasound/ response to emesis
• Load pressor line/early use of pressor
Combined Team Function
• Used by military, police, fire fighters
• For high risk/low frequency events
• Characterized by CRM communication,
simulation training, analysis of process
• Can it be adapted to the ICU?
The Team
• The team is composed of crew
members
• A crew is one or more in number and is
highly skilled in their assigned task
• The team leader is in overall charge and
is trained in crew resource management
1. Team leader ( Fellow )
4. Medicator/Equipment Set-up
• directs the team
• prepares the intubation equipment
• is the primary intubator
• Runs checklist
• nurse(s)
• gives medications with call-back
• Sets up equipment/monitoring
• Maintains situational awareness
2. Bag valve mask crew
5. Supervisor
• Two 1st year house officers
• set up bag/mask equipment
• start bag/mask ventilation once
patient sedated*
• helps in general setup
• available as backup intubator
• corrects any safety violations if
needed
3. Watcher
6. Standard crew positions
• house officer
• calls out vital signs every 30
seconds
• escalates communication if team
leader violates predetermined cutoffs
• bagger on patient right
• mask holder at head of bed
• team lead on patient left
• medicator at IV site
• watcher at foot of bed
The EEI Team
• The team leader: directs the crews, and
performs the intubation
• The airway crew (2): BVM ventilation
• The medication nurse
• The watcher: responsible for monitoring
V.S./saturation and calling cutoffs
• The supervisor: for advanced back-up
SBT with CPS for EEI
• How to train the airway crew?
• How to train the leader?
Training The Airway Crew
• All medical interns receive
individualized one on one SBT training
• Perfect performance in BVM ventilation
required at end of training
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Mayo PH et al. Achieving house staff competence in emergency airway
management: results of a teaching program using a computerized patient
simulator. Crit Care Med 2004 ;32:2422-7
• Results in an army of interns highly
skilled in BVM ventilation
The Airway Crew
• Critical element in EEI
• Goal is to maximally saturate the patient
to a stable plateau value before any
attempt
• Intubation function separate from BVM
ventilation
• Their function is to defend saturation
The Airway Crew
• Absolutely critical to safe operation
• Standard ACLS training completely
ineffective
• Intensive SBT training is key element to
success
The Watcher
• Calls out BP and saturation every 30
seconds
• Red flags cut-off violation
• Avoids inattention and distraction error
• No other responsibility
Nurse Crew
• Sets up medication, pumps,
monitoring
• Listens only to the leader
• Calls back all orders
• Medication nurse and the
watcher need bedside briefing
• Maintains situational awareness
Training the Leader
• Repeated small group training in July
• Each fellow rotates through each crew
responsibility multiple times
• Initial repeated task training, then
interrupted SBT, finally full out SBT
• No OR rotation for intubation training
Training the Leader
• CPS used both as a simple task trainer
and as full SBT device
• Physical practice of setting up the
environment, equipment, and personnel
• Use of basic CRM
• Video debriefing
• Mastery of a comprehensive checklist
CRM
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Call back all orders
Identification/briefing of crew members
Use of command voice/presence
No non-pertinent communication
Communication through team leader
Red flag all critical events
Post-event debriefing
Mandatory checklist
Situational awareness
The Checklist
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Airway evaluation
Patient set-up
Equipment set-up
Personnel set-up
Pharmacology-up
Cut off/bail-out
Verification
Table 3. Checklist for emergency endotracheal intubation
1. Airway Evaluation
Mouth Opening (cm)
Mallampati score
Dentures/dentition
Difficult anatomy
TM distance (cm)
Neck extension
Prior difficult intubation
Gastric contents with US
5. Cutoff/Bailout Plan
Stop intubation attempt if saturation drops more than 5% below
maximum achievable by bag mask ventilation; re-bag patient to maximal
saturation
Bailout options: supervisor attempt, intubating stylet, trans-tracheal jet
ventilation, mini-cricothyroidotomy, fiber-optic bronchoscope, laryngeal
mask airway
2. Patient Setup
Bed away from wall
Headboard off
Side rails down
Patient well-positioned (centered in bed, vertex at head of bed)
Head fully supported in sniffing position
LUQ ultrasonography
Stomach suctioned (if gastric tube in place)
Unnecessary equipment/furniture cleared from around bed
6. Pharmacology
Sedation dose
Pressor on standby loaded in IV line; immediate use to maintain
systolic blood pressure > 90mmHg
3. Equipment setup
Suction catheter placed to right of
patient head
BVM connected to O2 (10L/min)
Oral airway at head of bed
ETCO2 at head of bed
Laryngoscopes ready and placed
to left of patient head
ETT checked and placed to right
of patient head
7. Verification sequence
End tidal carbon dioxide detector color change
Tube frost
Bilateral breath sounds
Resaturation
Back-up: direct visualization of tube through vocal cords
Fiber-optic scope
4. Crew Setup
Airway crew assigned
and instructed
Supervisor identified
Watcher assigned & instructed
Blood pressure by A-line or non
invasive cuff (every 2 min)
Continuous EKG monitoring and
pulse oximetry
Reliable IV access
Pulse oximeter and BP cuff on
contralateral arms
PEEP valve (10cm H2O) on BVM
Advanced airway equipment at
bedside
Cutoffs identified
Nurse assigned and instructed
Crew members in standard
position
8. Debriefing
Formal post-procedure debriefing with fellow and attending
Quality Assessment
• Continuous saturation and blood
pressure measurement
• Audio recording of EEI
• Formal scoring of audio
• “You can run but you can’t hide”
Outcomes
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Number of intubation attempts
Duration of intubation attempts
Verification of tube placement
Compliance with checklist
Hypotension
Hypoxemia
Complications
So What Happens if….
• The MICU team assumes responsibility for
all EEI and does not “cherry pick”?
• By policy, anesthesiology is not
called….ever?
• The team leader is a fellow trained with 20
hours of intensive simulation training?
• The bagging team are two interns who are
heavily pre-trained and have no other
function?
What Happens if….
• There is mandatory 42 point check list?
• CRM communication is standard?
• There is a watcher, medicator and
attending supervisor for true combined
team tactics?
• There is debriefing following each EEI?
• An ongoing iterative process of quality
improvement?
What Happens if….
• If there is truly accurate determination of
the important endpoints of EEI
• So that the team can work to improve
safety
• And not just blame the patient or notch up
another “successful” intubation while there
has been neuro injury that is covered up
by a long MICU stay?
What Happens if….
• The EEI team recognizes that the
patient is extremely vulnerable to brain
injury and organ damage from….
HYPOXEMIA and HYPOTENSION
• The EEI team focuses on defense of
physiological function rather than the
endotracheal intubation itself
Complications of EEI
Comment
• Lowest complication rates compared to
EEI reports in anesthesiology literature
• Iterative process analysis combined with
sequential quality improvement
• Focus on defense of physiology
• Combined team approach
• Sustainable and transferable
Query #1: Ultrasonography?
• Koenig SJ, Lakticova V, Mayo PH. Utility of
ultrasonography for detection of gastric fluid during
urgent endotracheal intubation. Intensive Care Med.
2011 ;37:627-31
• The last two deaths that I saw were related to death
by drowning from unrecognized gastric content
• Also useful for post intubation trouble shooting
Save a Life
Query #2: 10% Esophageal
Intubation!!!!????
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Similar to anesthesiology reports on EEI
Inexperienced fellows at work?
High rate of difficult airway
Not a problem if recognized promptly
Still….is there a solution?
Standard Larnygoscopy
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Works well in the OR
Patients are pre-screened
Recognized DA?: awake FOB
Patients start with favorable physiology
Very high skill level with SL
“Wake up and back out” option available
SL in “The Jungle”
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Usually works well in the in ICU
Patients are not pre-screened
Recognized DA?: FOB not an option
Patients have unfavorable physiology
Limited skill level with SL
No “Wake up and back out” option
Enter the Video Laryngoscope
Complications of SL vs. DL
90%
80%
70%
60%
50%
40%
SL
140
30%
VL
252
20%
10%
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6%
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VL 252
6%
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22%
54%
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79%
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VL: A Game Changer
• For the intensivist: VL is mandatory as
primary device
• Any other approach violates mandate of
patient safety
• High probability that VL will be industry
standard within several years
Other Questions
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RSI versus graded sedation?
Cannot bag/cannot intubate?
Standard vs. disposable VL
Super high risk patients
Awake Fiberoptic Intubation
• Widely used for recognized difficult
airway in the OR
• Can be adapted to ICU/EM use
• Not for unstable or agitated patients
• Not for non-patent upper airway
• Requires careful execution to avoid
dangerous pitfalls
Prepare for Failure!
• Set up full equipment and team as for
standard EEI
• Prepare for urgent bailout solution
• Train on simulator with bronchoscope
Upper Airway Anesthesia is
Essential
• Heavy application of lidocaine gel to
posterior 1/3 of tongue
• Consider nebulized lidocaine
• Forget about local nerve blocks
Specialty Airway is Mandatory
• Mallampati or variant
Bronchoscope
• Large diameter
• Must have suction channel
• Operator must practice on task trainer
before patient use
Crew Member #1
• The oxygenator
• Only assignment is to blow high flow 02
into the airway throughout procedure
• This may be supplemented with mask
• Additional method: put 02 through
suction channel
Crew Member #2
• Inserts specialized airway
• Inserts ET tube into airway until tip is at
end of airway (pre-measured)
• Holds airway in place throughout
• Holds ET tube in vertical position
• Slides ET tube forward when indicated
Crew Member #3
• Inserts bronchscope into ET tube
• Passes vocal cords
• Inserts to carinal level
Crew Member #4 with #2
• Rotates ET tube clockwise 900
• This allows easier passage of ET tube
• If ET tube does not advance, uses
laryngoscope to straighten out airway
• May also perform jaw thrust
Problems
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ET tube bronchoscope size mismatch
Solution: smaller ET tube or larger FOB
Lack of visualization
Solution: reposition ET tube, perform
jaw thrust, practice on task trainer
• Desaturation when hung up on cords
• Solution: put 02 on suction port of FOB
Consider This Option
• For the patient with RDA and very
unstable oxygenation function
• Nasal bilevel NIV throughout the
procedure
Reminder
• Practice fiberoptic intubation in
simulation training environment
• With your whole team….repeatedly
• Practice bronchoscopy with task
trainer….repeatedly