Intubation difficle: Pas qu'anatomique

Managing the Physiologically Difficult Airway in Critically Ill Adults
Jabaley CS. Crit Care. 2023 Mar 21;27(1):91. doi: 10.1186/s13054-023-04371-3.

 

Un document très intéressant qui présente de manière très claire les enjeux de l'intubation difficile qui n'est pas qu'anatomique.

 

Risks and risk prediction

Cardiovascular instability, hypoxemia, and cardiac arrest are the most common adverse events associated with tracheal intubation

Risk factors for cardiovascular collapse include age, shock, hypoxemia, advanced critical illness, and propofol administration

Hemodynamic optimization

Etomidate and ketamine may impact hemodynamics less than propofol

A crystalloid bolus prior to intubation has not been associated with improved hemodynamics, even in patients receiving positive pressure ventilation

Given the frequency of cardiovascular instability, vasopressors should be readied as part of preparation for tracheal intubation

Mitigating hypoxemia

Standard pre-oxygenation strategies are inadequate to safely extend the apneic interval in patients with moderate to severe respiratory failure

Non-invasive ventilation can be used with or without high flow nasal oxygen and is more effective than high flow nasal oxygen alone

While historically avoided, bag-mask ventilation improves oxygenation during airway management and can be employed either preemptively or for rescue

First pass success

Multiple attempts at intubation increase the risk of adverse events

Depending on the preferences and expertise of the intubating clinician, video laryngoscopy or direct laryngoscopy with adjuncts may improve first pass success

Checklists improve adherence to complex, multi-step processes and may help prompt preparation for physiologic trespass