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Airway Management in the Critically Ill FREE TO VIEW

Dona J. Upson
Chest. 2003;123(4):1321. doi:10.1378/chest.123.4.1321
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By Rade B. Vukmir. New York, NY: Parthenon Publishing Group, 2001; 136 pp; $64.95

Airway Management in the Critically Ill is a comprehensive review of the acquisition and maintenance of an airway for mechanical ventilation. Vukmir directs emergency services for Northwest Health System and Medical Center in Pennsylvania, and is board certified in emergency medicine and critical care medicine. His monograph offers some interesting medical history concerning artificial airways, while providing thorough instruction in this important aspect of critical care. %The first chapter provides a wealth of information about the pharmacology of intubation, including an excellent review of muscle relaxants, and finishes with several clinical scenarios complete with helpful recommendations. Results from a multitude of studies are reported; the chapter has 179 references and could be improved by pulling them together more cohesively and with greater emphasis on interpretation.

Chapter 2 addresses difficult intubations, including a discussion of predictors, such as the Mallampati, Cormack and other scales, with complementary descriptive figures. There is a thorough review of the different laryngoscope blades and their indications, nicely summarized in tabular form. There is also a valuable table listing the proper ingredients of a difficult-intubation kit, with recommended blades for commonly encountered problems. Airway adjuncts, fiberoptic and retrograde intubation, percutaneous jet ventilation, and cricothyroidotomy are examined. The admonishment to have an established and practiced protocol for the difficult airway is rightly emphasized.

Chapter 3 provides a concise and useful discussion of confirmation of tube placement. A review of laryngotracheal injury from prolonged intubation follows. A great deal of information is presented from a vast number of articles, which might be more easily digested had the author employed more stringent selection criteria. Many of the articles discussed are outdated, and other references need more extensive clarification and discussion than was provided. For instance, the author abstracts from one reference that: “standard ICU practice has progressed from intubation (44%), using a high-pressure cuff (61%) with monitoring every week (44%), and patients remaining intubated for 7–14 days (50%).” Even if one adds the presumed missing “nasal” before “intubation,” the numbers in parentheses are a mystery. Complications of intubation, including pathology and contributing factors, are well described, and mention is made of promising new developments such as anatomically correct endotracheal tubes and foam cuffs. The author stresses the important point that while general recommendations call for 2 to 3 weeks before converting an orotracheal or nasotracheal intubation to a tracheostomy, the timing frequently requires a degree of individualization.

The book concludes with a chapter on surgical airway procedures with convenient step-by-step outlines. Indications, techniques and complications of cricothyroidotomy, percutaneous translaryngeal ventilation, and tracheostomy are covered. It is stressed that surgical recourse must be available whenever endotracheal intubation is attempted.

There are internal inconsistencies or discrepancies between sources throughout the book, which may have valid explanations that are clear to experienced practitioners but often are unacknowledged for the uninitiated. For instance, local anesthetics are described as amide based (including lidocaine) and administered IV, or ester based and applied topically. The statement, “The most commonly used amide agent is lidocaine administered by the topical route… or the IV,” follows. Conflicting results are sometimes presented without explanation or critical appraisal. The author states “diazepam has proven safe and effective” just after reporting, from a study using a lower dose, that its “adverse effects stimulated a search for alternatives,” and followed by another study, where in the setting of elevated intracranial pressure, diazepam caused significant hemodynamic instability. He goes on to say that midazolam “was associated with significant cardiovascular compromise,” followed by a statement that midazolam is the most commonly used benzodiazepine for induction, with only “occasional hypotension.” A more useful approach would have been to explore the bases for these discrepancies and strive to reconcile contradictory findings. This would have allowed the author to provide specific indications, an issue only partially addressed in the clinical scenarios.

There are a few typographic errors, most of which are obvious, such as the interposition of “indications” and “contraindications” in the first Table (“Clinical Use of Endotracheal Intubation”), or “basal” instead of “nasal.” Others are more challenging, such as the endotracheal tube that is to be “digitally included” (occluded?) for a cuff-leak test. Others are more worrisome, despite the admonition to check medication dosing. For instance, in a discussion on reversal of neuromuscular blockade:

the tertiary compounds include pyridostigmine (15 mg/kilogram) administered in a 0.5–1.0 mg IV dose, but it is not used, owing to its CNS penetration and subsequent effects. The quaternary nitrogen compounds most commonly used include neostigmine… and pyridostigmine (0.02–0.2 mg/kg) administered in a 10–20 mg dose.

Many photographs are included, for which one is grateful. Some are very useful, such as those depicting types of laryngoscope blades or cuff designs. The intent of others is not clear, such as the mannequin’s open-mouthed face entitled “laryngeal stimulus for blade insertion” while the accompanying text describes hemodynamic responses to intubation. The squeamish might find it best to cover up the figure depicting “catastrophic facial trauma” or another of an enormous fungating neck mass.

Although Airway Management in the Critically Ill could be improved with diligent editing, a lot of work clearly went into it, from which many will benefit. It is a well-referenced text providing useful information for those responsible for airway intubation.




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