Women Leaders in Medicine

ICU Airway Management: Pearls and Pitfalls: Women Leaders in Medicine, Ep. 15

​​​​​This podcast series aims to highlight the women leaders in medicine across the United States. Moderator Jaspal Singh, MD, MHA, MHS, interviews prominent women making waves in their field and breaking the glass ceiling. Listen in to gain insight on the leadership lessons learned.

In this podcast, Dr Singh interviews Juliana Barr, MD, and Kimberly Blasius, MD, about leadership lessons learned in airway management in the intensive care unit (ICU), in training advanced and novice learners, and in team dynamics during crisis situations. They also speak about memorable anecdotes from their careers in anesthesiology.

Additional Resources:

  • Brown W, Santhosh L, Brady AK, et al. A call for collaboration and consensus on training for endotracheal intubation in the medical intensive care unit. Crit Care. 2020;24(1):621. doi:10.1186/s13054-020-03317-3
  • Mosier JM, Sakles JC, Law JA, Brown CA 3rd, Brindley PG. Tracheal intubation in the critically ill. Where we came from and where we should go. Am J Respir Crit Care Med. 2020;201(7):775-788. doi:10.1164/rccm.201908-1636CI

Juliana Barr, MD

Juliana Barr, MD, is a professor of anesthesiology in the University Medical Line at Stanford University and an anesthesiologist and intensivist at the VA Palo Alto Medical Center (Menlo Park, CA).

Kimberly Blasius, MD

Kimberly Blasius, MD, is the Chief Academic Officer at Scope Anesthesia of North Carolina and a practicing pediatric and adult anesthesiologist at Atrium Health (Charlotte, NC). 

Jaspal Singh, MD
Jaspal Singh, MD, MHA, MHS, is the Medical Director of Pulmonary Oncology and Critical Care Education and a professor of medicine at Atrium Health (Charlotte, NC).



Speaker 1: Hello, and welcome to Women Leaders in Medicine, led by Dr Jaspal Singh. Dr Singh is the Medical Director of Pulmonary Oncology and Critical Eare Education, as well as a professor of medicine at Atrium Health in Charlotte, North Carolina. The views of the speakers are their own and do not reflect the views of their respective institutions or Consultant360.

Dr Jaspal Singh: Hi, everybody. Welcome to Consultant360 podcast series of Women Leaders in Medicine. And today I have the honor and privilege of meeting and talking with Dr Julie Barr and Dr Kimberly Blasius. Welcome, Julie. Welcome, Kim.

Dr Julie Barr: It's nice to be here, Jaspal. Can you hear me okay?

Dr Jaspal Singh: We can hear you just fine. Why don't you start us out, Julie? Introduce yourself and talk to us today about ICU airway management as we talk about ICU airway management pros and pitfalls.

Dr Julie Barr: Thanks, Jaspal. So I am trained in both anesthesia and internal medicine as well as critical care, and I currently practice at the VA Palo Alto Medical Center, and I'm also on the faculty at Stanford. And half of my clinical practice is working in the OR as an anesthesiologist. And the other half of my clinical practice is working in the ICU.

Dr Jaspal Singh: Fantastic. And you're being way too humble already because I know you lead a number different initiatives around there around the country as well. So thank you for taking the time today. Kim, you want to introduce yourself?

Dr Kim Blasius: Yes. Thank you, Jaspal. Honored to be here with both you. And Julie Barr. By training, I'm a pediatric anesthesiologist who practices both clinically adult and pediatric anesthesia at Atrium Health in Charlotte. And along the way, I developed a passion for simulation-based education, which led the way to my current role in leading the academic efforts as part of Scope Anesthesia of North Carolina, where I get the pleasure of working with all kinds of residents and fellows and other learners across the system, teaching airway management, anesthesia, and many other things.

Dr Jaspal Singh: Perfect. Well, I'm going to kick it off in the beginning and just ask you all. So I'm going to paint the scenario. A lot of my pulmonary critical care colleagues, we train, we do anesthesia for either electives or we do airways in the ICU. And I feel like a lot of us at some point become almost humdrum in our skillset and our approach. We find a couple of drugs we like, we find a couple of blades we like, we find a couple of ways to approach these airways, and it become almost routine until something serious happens. It always humbles me as to how often complications might happen in advanced airway management. And so I'm going to go around the horn a little bit starting with Julie. In your experience, in your thoughts, what are some of the most important lessons for people who encounter critically ill patients and managing their airways, and what things can we learn and do better?

Dr Julie Barr: Well, wearing my two clinical hats as an OR anesthesiologist and an intensivist, I have a tremendous amount of respect for every patient's airway, particularly critically ill patients. And I have a personal philosophy of plan for the worst, hope for the best, which in practical terms, when it comes to managing an airway, I assume that every ICU patient is potentially a difficult airway. So that, to me, means I have a plan A, and then I have a backup plan B and C and sometimes D. It also means that in my approach, I try to avoid what I call bridge-burning maneuvers, where once you take the next step, it's not easy to retreat to the last place where things were more stable. Also, I'm cognizant of the fact that when you're managing an airway outside of an OR setting, that you don't have the same resources, personnel, and expertise available to you, that you do in an OR setting. And so there are systems-based barriers to ensuring that your level of success is going to be as high in the ICU setting is it is in an operating room in managing an airway.

Dr Jaspal Singh: That's great. So I'm just going to review. So I love your idea of, for clinicians everywhere, plan for the worst, hope for the best. Have a couple of plans ready, backup plans, one or two backup plans. Avoid bridge-burning maneuvers, things that you really can't go back to, basically. That step is hard to retreat and you're committed to a certain pathway, which could be problematic. And then really understand the environment, the people, the supplies, the expertise, the equipment. Did I capture that right, Julie?

Dr Julie Barr: Yeah. That's great in a nutshell. Better than I said it.

Dr Jaspal Singh: So building on that, Kim, you are the expert of simulation. And thinking about this. And I've been thinking a lot about we all... So I do a lot of telemedicine, telecritical care particularly, and I've been watching, especially during the pandemic when we've switched to a lot of things virtual, and you got to watch some of these airways, a lot more than we expected, not go as well. It just reinforced to me the importance of education and practice, practicing to do this better rather than at the patient's bedside, other places. Talk to us a little bit about how you are approaching education for not just trainees but regular full-time clinicians or people in the community. What salient points of teaching can you give them?

Dr Kim Blasius: Yes. Absolutely. So I mean, plans A through D or A through Z is very important, but having a team that's agile and able to communicate and shift between plans. When things go as planned, it's great and you can have almost an algorithm for some parts of it. But as we know, especially in the ICU setting, there's a lot of unexpected twists and turns. And so prepping and preparing as a team can make a huge difference, and doing that within a simulation environment. And you may be in a place that doesn't have high-fidelity mannequins or fancy equipment. When we were in COVID and the pandemic, we had to train across our hospital system multiple different places and different settings to do COVID intubations. And we did walk through, talk through, pause, fast-forward, rewind practice sessions to talk through and come up with and navigate kind of like a choose your own adventure to talk through a team, especially as you're mentioning too, with new providers, new teammates and staffing changes that are quite dynamic right now in these times.

Dr Jaspal Singh: So yeah, let's build on that. I'm going to push you a little bit. So that sounds great, but how do you make the time and the effort to train teams? What cadence? Are there certain things we have to do? I mean, our audience are people that some intubate all the time. I'm less worried about those who intubate a lot versus those who intubate rarely, when it's needed or when there's not a backup person or an expert available potentially to do it. What do you tell those people? Should they be doing intubations? Should they not be? If they are the only people in the hospital? Do you train them on a regular basis? Walk me through some of these challenges because I'm sure you've thought a lot about this.

Dr Kim Blasius: Yeah. Absolutely, Jaspal. And those are definitely challenging questions as well as challenges for folks in the community, especially in settings where it's not very frequent to intubate. And you and I have been partnered with some of the folks at the outside facilities within our institution to get and keep up their skills to be able to have time to come to other facilities. It also takes time for the teams to practice together. And so setting aside or finding a way, whether it's in-person or meetings or case conferences to discuss through to keep folks up on their skill levels is really important.

Dr Jaspal Singh: But it's really challenging in a working environment where things like that just aren't a high priority. Julie, what are you all doing out at Stanford area in that area?

Dr Julie Barr: Well, at both Stanford and the VA hospital, we have 24-7, in-house coverage with anesthesiologists available. We also have a very robust simulation program at both institutions and both anesthesiologists and non-anesthesiologists who are working in critical care environments have the opportunity to train in acute airway management on both simulated settings and real-life settings. For instance, all of our pulmonary critical care fellows are required to do a general OR rotation during their fellowship so that they can learn and master the basics of airway management in a controlled operating room setting, being mentored by a staff anesthesiologist. But we also have full human patient simulator mannequins that we train people on that we can present them with a variety of airway challenges, as Kim said, in a team-based setting. So we try to make sure that anybody working in an ICU as a provider, we should also mention that at our VA and at Stanford, they have nurse practitioners in their ICU. And so we take the nurse practitioners through simulated training as well.

Dr Jaspal Singh: That's great. So basically offer a lot of training. Now do you mandate it? I guess that's the question I'm wrestling with right now is at what point do we say we think this is important, we've seen problems happen when it's not done well. Are we at the point now where we should... airway training after your credential almost becomes a skill you have to demonstrate competency or even expertise? I mean, I'm just curious. I'm trying to understand this myself.

Dr Kim Blasius: I think that's a great question, Jaspal, and certainly something that there's not a set amount of precedent for, but there are some, for example, within our organization, our air care, air flight providers do actually have certain numbers of requirements. And so we have a program set in place for them to work within the operating room with us. However, I don't know of anything in the intensivists or others. I mean, you've developed a program that we work with bringing the new intensivists to the operating room, which I think is phenomenal, to at least give them that OR experience. But as we know, the OR experience isn't quite exactly the same and doesn't prepare you for all the situations that you would encounter in the ICU.

The other resource, as we're talking, that can be very helpful is attending some national airway crisis simulation courses. I know you teach through the Society for Critical Care Medicine. We teach them both at the American Society of Anesthesia annual meeting as well as the Post Graduate Assembly in New York. And there's multiple courses like that that are available and without equipment at your institution, or there's places that you can participate in courses like that that are tremendously helpful to practice through these scenarios.

Dr Jaspal Singh: No. That's great. Julie, any thoughts on that?

Dr Julie Barr: No. I think Kim summarized that nicely. I think that there's a lot of opportunity for anesthesiologists as airway management experts to use their expertise to train non-anesthesiologists to be better managers of the airway. As people on this call are aware, I think, 90% of critical care in the United States is delivered in community hospitals, many of which don't have 24-7 anesthesia coverage. And so the reality of it is that the people in those ICUs need to have airway management skills that go beyond just basic, direct laryngoscopy and endotracheal intubation. And so I think there's a huge, unmet need for anesthesiologists to share their expertise with non-anesthesiologists who work in those environments.

Dr Jaspal Singh: Yeah. I would agree with you. So I'm going to shift gears a little bit to tell a couple of stories. I mean, I've seen some horrible airways go horribly wrong over my career, and they're memorable, obviously, when they go horribly wrong, and in a very unfortunate way. And obviously, we can't discuss patient details on here, but some of the really challenges is we have an idea of people that their cervical spines immobilized, people who have facial trauma or facial malformations, potentially making it hard, and then people who just at some point or who develop... I've seen negative pressure pulmonary edema develop in the neurosurgical ICU where all you see is fluid and you just can't see anything. We've seen vomiting, all kinds of stuff.

And at some point, if it hasn't happened to someone who's doing a lot of clinical medicine in the ICU, it's going to happen. And so I'm asking these questions as someone who's watched things and been involved in cases where things are just so challenging, no matter how much training you have, you need a team, and you also may need... I think Julie, what you're getting at is almost surgical airway expertise and experience. Talk to us about how necessary is that training, how to go about doing it. Do we necessarily go that route or what are your thoughts on that? Because it's such a complex topic.

Dr Julie Barr: Well, I think there's various ways to manage a difficult airway, and surgical acquisition of the airway should be a last resort. But having said that, I remember one of our former fellows who after graduation, she was a pulmonary critical care fellow, took a job at a large community hospital in Arizona. And I ran into her at the SCCM Congress a year or two after she had graduated and started working there. And I asked her how things were going and she says, "Well, the most terrifying thing is that we don't have an anesthesiologist in house and we have these patients who come to the ICU with acute cardiopulmonary failure and need to be emergently intubated." And she said, "And they often present with various airway challenges. And because of that," she said, "I've gotten really good at doing percutaneous tracheostomies," which is not something we really emphasized in her training program.

So I think that is but one tool in one's toolbox that intensivists should be exposed to and trained how to do if they have no other way to secure the airway and the patient's going to die if you don't do something. But there are other approaches to acute airway management that I think are equally important.

Dr Jaspal Singh: Yeah. That's well said. So, I guess, what I'm sort getting at is really spend some time working with your anesthesiologists, airway experts, identify them locally, take advantage of opportunities for training, be diligent about this and be proactive in this space, what I'm hearing you say. Getting really good at the non-surgical stuff is extremely important, but then you may want to spend some time developing some surgical expertise as well. Am I saying this right, Julie?

Dr Julie Barr: Yes.

Dr Jaspal Singh: Kim, any thoughts on your end on that? Sort of similar thoughts or different thoughts?

Dr Kim Blasius: Yeah. Similar to that with along the lines of, for the surgical airway, the other thing that comes to mind is just preparation and having access to where that equipment would be because you may have learned surgical airway at a conference or a workshop in a certain way, but the equipment that you have in your airway cart or whatever equipment you have may be different. And so knowing what it is that you have, what kit you may have at your local institution is really important. And then the other thing, talk about the technical skills that you need, thinking about the physiological considerations, and especially if you're in a setting that doesn't have lots of staff and support and people who are used to doing these types of airway management cases regularly, thinking ahead and having all of that stuff ready. Thinking about what you would need in advance is just going to be so important for these difficult cases that we find ourselves in.

Dr Jaspal Singh: Yeah. That's great. So staff and support, equipment, practice, take advantage of things. This is helpful. Obviously recognizing that there's staffing challenges everywhere, the teams may look different, that we have to work through some of those issues. I'm going to shift gears a little bit to say, I sent an article, I think, that came out recently that highlighted just a review to me that just hit home the number of non-airway issues related to airway management, such as the high incidence of instability, the high incidence of potentially other adverse effects with electrolyte abnormalities, cardiac effects, some of the aspects happening. This is not just the airway. It's the peri-airway issues have a really high prevalence of issues to address. The same thing goes for training those or are those a little bit different? Would you look expand the drug usage, limit drug usage, look at the population a little bit differently or train different populations? What are your thoughts on that perspective? And I'll start with you, Kim.

Dr Kim Blasius: Absolutely. When folks come to us for anesthesia rotations, sometimes folks will come and say, "Well, I'm coming for an airway rotation." And we say, "Well, we could talk about airway management and anesthesia," because of course, the physiological components of the drugs, the physiological changes and the dynamic changes that happen during an induction are very important to think about. Certainly can prevent a lot of hypoxemia, hypercarbia, acidosis, other things by being really thoughtful about the agents that you're going to use. And there's a balance. You need to have a lot of tools in your toolbox, but also keeping to what you know is also important. But sometimes, certain cases and situations will take you down certain paths. You have to be flexible and trained in using these different modalities and different agents.

Dr Jaspal Singh: Good. So basically, know your stuff well, but keep your eyes peeled for things that you could potentially do better, and have this iterative approach. Is that about right? Am I saying that right, Kim?

Dr Kim Blasius: Yes. Absolutely. I think one of the things that we've all been there at some point during our first intensive care unit intubation is doing a great job, being very excited that we get the breathing tube in, but realizing, "Oh. Wow, we forgot to start pressures before we went into this process," and we see it time and time again. And so just something so simple after the fact, or having your ventilator set up or having your sedation agents ready in the room, all these things are important and sometimes missed in the stress of the situation.

Dr Jaspal Singh: Yeah. Julie, anything to add?

Dr Julie Barr: Yeah. I totally agree with Kim. And I think the most important drug in our arsenal doesn't come in a syringe. It's oxygen. And these patients in the ICU often have limited oxygen reserves, but that doesn't mean we shouldn't make every attempt to pre-oxygenate them to the best of our ability. And in critically ill patients, that means really delivering 100% FiO2 for at least five minutes unless it's a code situation, which is different, but that's time well spent. And also maximizing the size of their oxygen reservoir, i.e. their FRC by sitting them up at 25 to 30 degrees when you're pre-auctioning them, if they're hemodynamically able to tolerate that, so their diaphragms descend and you have a bigger auction reservoir in their lungs. And then also the use of CPAP, BiPAP, and high-flow nasal cannula as oxygenation adjuncts can be very helpful.

Dr Julie Barr: A non-rebreather mask does not truly deliver as high an FiO2 as those other tools I just mentioned in patients that are breathing rapidly. And putting an Ambu bag on their face, you have to synchronize with their ventilation and make sure you get a tight seal. And that can be challenging. So in my practice, I try to make use of these other pre-oxygenation tools like IPAP/CPAP and high-flow nasal cannula. But then, if you're going to intubate a patient and you think that they really are going to be a difficult intubation, in order to facilitate direct laryngoscopy or video laryngoscopy, you need to be able to open their mouth and insert the blade, position their head and neck appropriately in order to be successful in placing the endotracheal tube. And it's very hard, in most cases, I would say impossible to do that in a truly awake patient unless you've anesthetized their airway adequately.

And so I think there's also more opportunity for training of intensivists in awake fiber optic intubation techniques and learning how to achieve adequate airway anesthesia in an awake patient so that they'll cooperate with your efforts. Otherwise, if you're going to induce what is essentially general anesthesia, there's a variety of sedative-hypnotics. And don't be fooled by what you've heard about the two most common sedative-hypnotics, propofol and etomidate. It's true propofol will cause more hypotension than etomidate. But basically, once you anesthetize somebody, even with etomidate, and take away their catecholamines, they can still become acutely hypotensive. And so you have to be prepared to manage cardiopulmonary instability following intubation. To Kim's point, it's not just about getting the plastic tube in the right hole and congratulating yourself. You have to be prepared for what comes after that. And so having resuscitation drugs available, as we like to say, the uppers and the downers to support drops in blood pressure, or conversely, to manage acute hypertension is also important.

And then, of course, there's the whole to use or not to use muscle relaxants in an out of OR setting. So there is no short-acting, non-depolarizing agent. There's one rapidly-acting non-depolarizing agent, rocuronium. If you give the RSI dose for rocuronium, it's going to last more than an hour. And if you can't secure the airway subsequent to giving that drug, you're out of luck at that point and you should be prepared to probably move to a surgical airway. And the rocuronium, reversing it with sugammadex is not a practical, easy solution because it takes 16 milligrams per kilogram of sugammadex to emergently and immediately reverse that dose of rocuronium. Usually, that amount of sugammadex is not immediately available to you. And even if it was, it takes time and another person to draw it up and give it. Comes in a little baby vial. So for all those reasons, again, you have to have a clear understanding of what your pharmacologic agents are, don't leave oxygen out of your recipe, and prepared to manage cardiac instability following intubation.

Dr Jaspal Singh: That's great. That's a great summary, and I think the other part is understanding positioning that you mentioned earlier, and the recap, really being good at positioning and all that stuff. And I think managing the entire environment, including the team, including the dynamics. And then I assume both of you also... We didn't mention it, but really practicing amongst a patient population you're serving, whether it be specific to certain ICU patients or certain aspects. So I assume that's part of it. But switching gears, once in a while, bad things happen or near-miss events. Do you all do reviews of airways that have gone badly? Over the years, I've not seen a systematic review process, and I've worked at a few different places. And is that something that's important or is that done? I'm just kind curious because I know that happens in the surgical world, but I haven't seen it in intensivist world. Julie, any thoughts on that?

Dr Julie Barr: Well, again, I think I work in a unique environment because as I mentioned earlier, at our two hospitals, the VA and Stanford, we have 24-7, in-house anesthesia coverage. And so anesthesia is always there to manage these airways. And if one goes horribly bad, that's definitely reviewed in a structured M&M format. I can't speak to how those things are reviewed outside of a traditional anesthesia airway management model at other facilities.

Dr Jaspal Singh: Yeah. I don't know either. Kim, have you seen anything similar to that?

Dr Kim Blasius: Well, certainly within the anesthesia departments I've been in, we have done these conferences and discussions particularly on difficult airway situations. One of the challenges with the ICU intubations, and definitely ICU airway management has been the topic of many of those conversations that the institutions I've been at, has been there's just so much more uncertainty sometimes with what the patients have. And so the circumstances and the environment make it challenging, particularly one patient I can recall having unknown esophageal fistula, a patient that had just gotten up there that didn't realize in advance that there had been neck radiation. It leads to, getting back to what Julie said, again, A to D or A to Z plans because there's a lot more unexpected than a scheduled case for the operating room. And these complex situations are worth having a debrief and discussion afterwards because you can set up a systematic approach and at least optimize the environment and prepare your teams to face these uncertain situations that will most certainly, that's the one thing that is certain, right? They will come up.

Dr Jaspal Singh: Yeah. No, that's actually very helpful. I'm trying to think through that as we're talking. I'm thinking to myself, all right, so what I need to tell people out there in the community, to basically how to make sure that such a high-risk procedure that is often seen as mundane, that can lead to a lot of different things. I just want to review a little bit, we talked about, I think going back, we talked about planning for the worst, but hope for the best. Really understanding your plan A, plan B and plan C, and particularly from I heard you say over the podcast, is practice at them. Know the stuff around them. Know the semantics, know the logistics, know the supplies, know your teammates if you can as well, and train in that space.

Two, avoid bridge-burning maneuvers, which I like that idea, making sure if you're going to go down a pathway that's going to be no way back, if you can't march back, make sure you have a good, appropriate understanding and backup systems in place, or at least alerted in that situation. You'll not do that alone. Be cognizant of the environment, the people, the supplies, the stressors, the various aspects of the patient themselves, like what unique aspect, like Kim, you mentioned the TE fistula cases and other specifics of all kinds of cases that might go along. But really understanding the environment is extraordinarily important.

Team dynamics. Ideally, it's nice to have a team, especially a team of experts that do this all the time around. But if you don't have that environment, at least get to know who potentially might do certain things well and then basically make sure that you practice together. If there are things that are challenging, like near-miss events or events that are scary, for example, a debriefing piece or things that especially things don't go well, would be very helpful.

If it's high enough importance, definitely systematic review in some places could be very helpful, that ideally you'd have a place to practice, a simulation. I'm a big believer in simulation-based education. I think I share that with you, Kim, that I think simulation is extraordinarily important and sometimes underutilized. Doesn't have to be necessarily high-fidelity, but it can be. But there are places that offer that. But seek those courses out because I'll tell you, even when I go, I learn a lot.

And then the other thing is understanding not just an airway aspect, it's all the aspects of the pre-airway, the post-airway, understanding the oxygenation strategies, the positioning, the local anesthetic effects that you can do to minimize drug usage, for example, the cardiopulmonary effects of intubation and invasive mechanical ventilation. The drugs, what drugs you're comfortable with, knowing some ideas of the dosing regimens and then the side effect profiles of some of these. And if you can't manage all of that in the environment that you're in, maybe calling out for help early to help manage some of those things. Am I missing things, Kim?

Dr Kim Blasius: That's a great recap, Jaspal. The other thing that came up as you're talking is thinking about the plans and communicating that with your team. If you know that this will be plan A, but then you really think this patient's going to be difficult in one way or another or whatever, out loud saying and verbalizing to your team to get everyone thinking ahead with you and having that shared mental model is so important. And getting back to just the basics, positioning. Do you have the pulse ox volume turned on? Because that'll help you, one more piece of information when you're practicing or doing this, practicing through these scenarios as a team.

Dr Jaspal Singh: Great. Julie?

Dr Julie Barr: Yeah. One of the things that you mentioned early on in this conversation, Jaspal, is about your experience intubating patients in the ICU and doing a series of straightforward, happy outcome intubations, and then suddenly, seemingly out of nowhere, you encounter a difficult intubation, and how frustrating, terrifying, and humbling that can be, in my opinion. And I want your audience to understand that there are actually predictive characteristics of patients that can help them anticipate and plan for a possible difficult intubation to achieve the best possible outcome for patients. So there was a scoring system that was developed and validated by Dejung and colleagues initially published in the American Journal of Respiratory Critical Care Medicine in 2013 and referenced in an article that they wrote in Critical Care in 2014. And basically, it's a 12-point scoring system that looks at patient characteristics, their underlying pathology and the operator as predictors of a difficult intubation.

It's a 12-point scale and the first item is a Mallampati airway classification of three or four. Your audience should all be familiar with how to assess that. That gets five points. If the patient has obstructive sleep apnea, that gets two points. A c-spine mobility, both flexion and/or extension gets a point. A mouth opening smaller than three centimeters gets a point. Coma, one point. Baseline hypoxemia with SATs below 80% gets a point. And then whether or not the operator is an anesthesiologist or not gets a point. So it's a 12-point scale. And basically, if you have a score of three or less, in all likelihood, that will be a straightforward intubation that will not prove to be difficult. But if you add up those points and it's above 3, it gets increasingly difficult, up to 12, which is considered very difficult.

So in terms of planning for the worst, hoping for the best, and not burning any bridges, it's important to pre-assess the patient's risk factors so that you can invest more time and energy in developing those backup plans in case you need to move to them quickly. And I like what Kim said earlier. You may have been trained at your initial institution on a Blue Rhino perc tracheostomy kit, but then you go to Hospital X and that's not the kit that they have or the kit that they have is locked up in somebody's Omnicell in another part of the hospital. So really knowing your environment, knowing where you are, knowing where the necessary equipment is, is key. And the last thing I would say is to ensure first pass success, there are many studies now that show that video laryngoscopy should be the first step, not direct laryngoscopy, which requires better airway anatomy and better positioning than you can necessarily achieve in an ICU setting. So those are my pearls. Know your risk factors and use a GlideScope whenever possible.

Dr Jaspal Singh: That sounds great. So video laryngoscopy, obviously, I use that for all my trainees, especially. And then I agree, looking at those 12 things and being systematic about it and doing it even on what might be routine cases just through the scoring system, just so that you learn it and understand it pretty well. Thank you for that, Julie. Kim, do you have something to add?

Dr Kim Blasius: Yes. Absolutely. One other thing that is great that we're seeing now in training is conversations about self-awareness and self-regulation of your stress levels during these critical situations and something that would've been wonderful to have. And to some extent, simulation has that as well. But having those conversations in these crises or on your own, mental pause to be, "Well, the patient's heart rate's this, but I'm going to keep mine down and cool and calm, or at least on the outside," so you can think as critically as possible during these challenging situations, and then also help keep your team calm around you. It's a different perspective to think about.

Dr Jaspal Singh: No. That's well said. All right. Well, I mean, I will conclude this, but we learned a lot of stuff about airway management in the critically ill patient, and I think learners have a lot to think through and ponder. I will close it a little bit by saying I've been practicing long enough and seeing some airways go very poorly that I think sometimes, you get jolted back to recognizing that a lot of us have, I think sometimes a false sense of security about the management of these. Things that become routine can suddenly deteriorate very quickly. And so I think practicing the skills, spending the time and effort to getting trained and coached is not a bad thing.

I think back to when Atul Gawande wrote this really nice section where he opens his textbook where he says he got coached by his mentor, what he thought was a routine surgery, and his coach and his mentor actually came back with a whole list of things he could do better. And I almost at times wonder, maybe next time I'll do this live, Julie, Kim, where you'll watch me do an airway intubation and I'll bite my ego and my ego will take a dive down, and you'll tell me all the little things I could have done a little bit better. I wonder if that'd be possible at some point. Maybe we should all do more of that. What are your thoughts?

Dr Julie Barr: That could be fun.

Dr Kim Blasius: Something simple. Sounds like a great plan.

Dr Jaspal Singh: All right. Well, on behalf of Consultant360, we'll conclude today's podcast. I just want to thank Kimberly Blasius and Julie Barr for taking the time and effort. That was about airway management.

Dr Julie Barr: Thanks, Jaspal.

Dr Kim Blasius: Thank you for having us.

Dr Jaspal Singh: Yeah. And then we'll have on the website, we'll have some links for our audience members about some key articles, including the ones that were referenced. Take care, everybody. Have a great day.

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