Airway Management in Critical Settings

Airway management continues to be a challenging task for healthcare practitioners and when it comes to critical settings; it carries more challenges even for the skilled persons. Critical settings could be in fact of suits; where intervention takes place, equipment or practitioners taking care of airway management. Critically ill patients with multiple comorbidities, increasing oxygen demand and high respiratory work; that may require elective airway securing. Various protocols, guidelines and recommendations advocated for this task with the prospects of less hemodynamic alteration and prevention of pulmonary aspiration. In the former, starting oxygen therapy for all critical patients on admission was a routine following the concept; if some is good, more must be better. Nowadays excess oxygen may be unfavorable in some acute critical conditions e.g. ischemic strokes, post-acute myocardial infraction and those with hypercapnic respiratory failure. However, still high flow inspired oxygen concentration is the protocol until they are stable then its reduction to reach the targeted arterial oxygen saturation. Oxygen devices used for oxygen delivery are plenty and its selection depends on the many factors; airway patency, patient’s conscious level and compliance, and assessment of gas exchange based on arterial blood sample which is recommended for all critically ill patients. Early prompt evaluation of the airway and assessment of gas exchange using arterial blood sample analysis is curial in all critically ill patients to guide for subsequent oxygen supply and whether the patient needs ventilatory support or not. This chapter will focus on airway management, oxygen therapy and types of ventilatory support required for adult critically ill patients, while other situations’ airway management’s tools and skills will be discussed in another ones.

Use and Abuse of the Apgar Score

This is a revised statement published jointly with the American College of Obstetricians and Gynecologists that emphasizes the appropriate use of the Apgar Score. The highlights of the statement include: (1) the Apgar Score is useful in assessing the condition of the infant at birth; (2) the Apgar score alone should not be used as evidence that neurologic damage was caused by hypoxia that results in neurologic injury or from inappropriate intrapartum treatment; and (3) an infant who has had "asphyxia" proximate to delivery that is severe enough to result in acute neurologic injury should demonstrate all of the following: (a) profound metabolic or mixed acidemia (pH <7.00) on an umbilical arterial blood sample, if obtained, (b) an Apgar score of 0 to 3 for longer than 5 minutes, (c) neurologic manifestation, eg, seizure, coma, or hypotonia, and (d) evidence of multiorgan dysfunction.