UMEM Educational Pearls

Title: Airway Management in the Critically Ill Pregnant Patient

Keywords: Pregnant, difficult airway (PubMed Search)

Posted: 9/17/2019 by Kim Boswell, MD
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Most non-OB physicians experience some fear or anxiety over taking care of the average pregnant patient. There are two patients to consider when caring for these women. Critical illness adds another layer of complexity to an already challenging patient population. Due to the normal physiologic changes that occur during pregnancy there are specific and important factors to be aware of when considering and preparing for intubation.

Difficult intubations occur up to 5% of pregnant women.
Edema occurs in the OP regions resulting in a narrowed OP diameter, especially with advancing gestational age. A smaller than anticipated ET tube might be necessary.
Weight gain and/or obesity make visualization difficult Consider the ramp position to bring the external auditory meatus and the sternal notch into a horizontal line.
Aortocaval compression decreases blood return to the heart and can result in hypotension on induction. Consider the use of a wedge under the patient’s right hip to decrease compression during intubation, especially those in later stages of pregnancy.
Risk of aspiration is increased due to decreased lower esophageal sphincter tone. Consider administering metoclopramide prior to intubation which selectively increases esophageal sphincter.
Functional residual volume in addition to increased oxygen consumption and metabolic demand lead to quicker desaturations and a greater intolerance to hypoxia and apnea.
Be prepared with back up or adjunctive airway options including a video laryngoscope (like Glidescope), an LMA or a supraglottic airway. Although the LMA and supraglottic airways are rescue options in the setting of failed ET intubation, they can often adequately oxygenate and ventilate while urgently consulting with anesthesia colleagues in order to obtain a definitive airway.

References

Djabatey EA, Barclay PM. Difficult and failed intubationin 3430 obstetric general anesthesics. Anaesthesia 2009;64: 1168.

Izci B, Vennelle M, Liston WA, et al. Sleep-disordered breathing and upper airway size in pregnancy and post part. Our Respir J 2006; 27:321.

Lebowitz PW, Shay H, Straker T, et al. Shoulder and head elevation improves laryngoscope view for tracheal intubation in non obese as well as obese individuals. J Clin Anesth 2012; 24:104.