Response

Abstract

We thank Russotto et al for their interest in our review1Scott J.A. Heard S.O. Zayaruzny M. Walz J.M. Airway management in critical illness: an update.Chest. 2020; 157: 877-887Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar and for providing further insight into preoxygenation methods prior to laryngoscopy and intubation. Although we mentioned the combination of noninvasive ventilation (NIV) with high flow nasal cannula (HFNC) to be superior to bag-valve mask (BVM) in preventing hypoxemia during intubation, we did not explicitly reference the investigation by Baillard et al,2Baillard C. Fosse J.P. Sebbane M. et al.Noninvasive ventilation improves preoxygenation before intubation of hypoxic patients.Am J Respir Crit Care Med. 2006; 174: 171-177Crossref PubMed Scopus (324) Google Scholar which showed that NIV alone is superior to BVM. We appreciate their reference to the investigation by Frat et al3Frat J.P. Ricard J.D. Quenot J.P. et al.Non-invasive ventilation versus high-flow nasal cannula oxygen therapy with apnoeic oxygenation for preoxygenation before intubation of patients with acute hypoxaemic respiratory failure: a randomised, multicentre, open-label trial.Lancet Respir Med. 2019; 7: 303-312Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar comparing preoxygenation by HFNC with NIV. As Russotto et al mentioned, there was no difference between the two methods in reducing the risk of hypoxemia for all patients, but NIV did reduce the risk in patients with moderate to severe preexisting hypoxemic respiratory failure. The study highlights the challenges of preoxygenating patients with severe hypoxemia. We also appreciate the comments of Agrawal et al on the importance of fiberoptic intubation in the patient with a difficult airway. We agree completely with their comments and suggestions. Other than a brief mention of fiberoptic technology in the summary, space constraints prevented us from going into detail regarding fiberoptic intubation. At our institution, we have adopted a multidisciplinary team approach, similar to that described by Mark et al4Mark L.J. Herzer K.R. Cover R. et al.Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies.Anesth Analg. 2015; 121: 127-139Crossref PubMed Scopus (68) Google Scholar at Johns Hopkins Hospital. This team can be activated both during anticipated and unanticipated difficult airway situations with critical care, anesthesia, and surgical personnel at the ready to perform awake fiberoptic intubation and surgical airway management. The positive effects of this team-based approach have been supported by a subsequent publication by Mark et al.5Mark L. Lester L. Cover R. Herzer K. A decade of difficult airway response team: lessons learned from a hospital-wide difficult airway response team program.Crit Care Clin. 2018; 34: 239-251Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Preoxygenation of Critically Ill Patients With Acute Hypoxemic Respiratory FailureCHESTVol. 157Issue 6PreviewWe congratulate Scott et al1 for their comprehensive update on airway management in the critical ill in a recent issue of CHEST (April 2020). Recent literature provides relevant insights on the ability of different preoxygenation methods to reduce the risk of severe hypoxemia during tracheal intubation in the critically ill.2 Hence, we think that in the section on Preoxygenation and Ventilation Strategies, it might have been worth providing more details on the current evidence, comparing preoxygenation methods. Full-Text PDF Response to Airway Management in Critically Ill Patients: Don’t Forget the Bronchoscope!CHESTVol. 157Issue 6PreviewWe read with interest the article by Scott et al1 regarding airway management in critically ill patients in a recent issue of CHEST (April 2020) and agree with many of the author’s recommendations. Interestingly though, there was no mention of the use and technique of fiber-optic bronchoscopic intubation (FOI) when a clinical situation warrants direct visualization of not only the vocal cords but also the trachea, and for those patients where an upright, semi-awake endotracheal intubation seems prudent. Full-Text PDF Airway Management in Critical Illness: An UpdateCHESTVol. 157Issue 4PreviewExpertise in airway management is a vital skill for any provider caring for critically ill patients. A growing body of literature has identified the stark difference in periprocedural outcomes of elective intubation in the operating room when compared with emergency intubation in the ICU. A number of strategies to reduce the morbidity and mortality associated with airway management in the critically ill have been described. In this review, we provide an updated framework for airway assessment before direct laryngoscopy and video laryngoscopy, and use of newer pharmacologic agents; comment on current concepts in tracheal intubation in the ICU; and address human factors around critical decision-making during ICU airway management. Full-Text PDF