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C H A P T E R 7 MEDICATIONS FOR AIRWAY MANAGEMENT You have been managing a 38-year-old man who was admitted two days ago with mild pneumonia. His condition, however, has deteriorated substantially and he is in severe respiratory distress. His oxygen saturations are only 83% despite receiving 100% oxygen. He is combative and will not keep his oxygen mask on. His heart rate is 140 bpm and his blood pressure is 75/45 despite repeated fluid boluses. Clearly, he requires intubation but he is unlikely to allow you to intubate him.What should you do? DAVE NEILIPOVITZ The above patient obviously requires respiratory assistance. He is unlikely to be a candidate for noninvasive ventilation since he is uncooperative and hemodynamically unstable. Thus, he needs the institution of positive pressure ventilation via an endotracheal tube. The problem will be to get him to allow you to place the tube. Invariably,there is aneed for medications to facilitate this. The big challenge is to select the best drug or drugs to allow you to safely place the endotracheal tube. Unfortunately, there is no perfect drug for this purpose nor is there a perfect cocktail that is appropriate for all patients. The physiologic variability ofpatients along with the different kinds of situations that require drugs for the facilitation of airway management prohibit one from recommending specific drug recipes. Instead, the goal of this chapter is, firstly, to introduce different airway management drugs but, secondly and more importantly, to present principles that should not only guide drug selection but assist with dosing. • Introduction The difficulty in discussing medications to facilitate intubation isthatphysicians havevaryingbackgrounds and training. Twoimportant principles for this section should, however, always be adhered to (Table 7.1): The first is to "use what you know and know what 55 Table 7.1- Guiding Principles for Drug Administration A. Know what you use ... use what you know. B. Youcan always give more ... but you can't take it back. you use/7 Although there will always be the first time you use a drug, you should understand how the drug works and know the dosing and what the complications with its use are. Youshould never use a drug that is recommended for a certain situation if you do not have knowledge ofthat drug. Inexperience with a drug isconsidered an absolute contraindication to the use ofthat drug, since life-threateningproblems could result if the drug is administered incorrectly. Ideally, a drug should be used in less critical situations first to obtain experiencewith itsuse. Thesecond very important principle is that you canalways administer more drug but you cannot take back drug that has already been given. A relative overdose is often inadvertently administered to a critically ill patient, which can cause life-threatening cardiovascular collapse. Drug reversal with naloxone or flumazenil isnot areliableoption and these drugs have their own unique problems associated with their use.1 '2 Thus, the best therapy for drug overdose is prevention. • Rationale forAirway Drugs The indications for using drugs to facilitate airway intubation usually fall into one of three categories: physiologic, technical or psychological (Table 7.2). The physiologic indications are primarilya reflection of the adverse responses a patient can experience during and immediately following intubation. Although direct laryngoscopy with the insertion of an endotracheal tube can sometimes initially cause a vagal response, it is virtually always followed by a marked sympathetic response if no drugs are administered to blunt the response. This adrenergic response may cause tachycardia and hypertension, which has life-threatening consequences in a patient with coronary artery disease or increased intracranial pressure.3 '5 Manipulation of the airway in a patient not pre-treated with medications can Table 7.2 - Rationale forDrug Administration during Intubation I. Physiologic indications 1. Coronary Artery Disease 2. Increased Intracranial Pressure 3. Reactive Airway Disease 4. Risks for Aspiration II. Technical Indications 1. Patient Compliance 2. Improve Visualization Ml. Psychological Indication be a potent stimulus for bronchospasm, which can have adverse consequences in the asthmatic patient.6 Laryngoscopy stimulates the gag reflex, which can cause regurgitation of gastric contents and possible aspiration ifthis reflex is not blunted by drugs. Thus, avoidance of medications to facilitate intubation can have adverse consequences. The use of drugs during intubation can make the act of intubation technically easier.7 -8 Although spontaneous airway patency and protection can be lost secondary to the effects of various drugs, the patient can become an easy intubation. A patient who is biting down or has...

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