Airway management in the critically ill patient - How can we improve?

Abstract

Introduction The NAP4 demonstrated adverse airway outcomes are associated with poor airway assessment and poor planning. 25% of major airway events occur in the Intensive Care Unit (ICU) or emergency department (ED), and the outcome of these events are more likely to lead to permanent harm or death compared with the operating theatre. This study set out to review documentation of intubations in ICU patients, including the pre-procedure planning taking place to identify areas for improvement. Methods Single institution retrospective review of documentation of endotracheal intubations performed by ICU staff (on either ICU or a ward/ED) over a six week period in an English district general teaching hospital. Criteria assessed were: use of a pre-intubation checklist, documentation of name and grade of intubator, airway assessment, time of intubation, drugs and doses given, number of attempts at intubation, use of cricoid pressure, laryngoscopy grade, ETT size + length at teeth, type of laryngoscope used, monitoring used (including etCO2), ventilator settings and any complications. Results In the 6 week study period, there were 15 intubation episodes identified and reviewed (12 on ICU, 3 in ED). See attached table for full results. Discussion The lowest performing domain was airway assessment (0%). The explanation for this is likely in part due to the acutely unwell nature of ICU patients making airway assessment more challenging than in an elective setting. Another particularly low scoring domain was the use of a pre-procedure checklist (33%). Considering the NAP findings associating adverse airway events with poor airway assessment and planning, these are concerning findings, and unlikely to be isolated to this hospital. We suggested education to promote the routine use of a pre-intubation checklist that incorporates an airway assessment and procedural plan.