Intubation

Indications

• Failure to ventilate
• Failure to oxygenate
• Inability to protect airway
  • Gag reflex is absent at baseline in ~1/3 of people, so lack of gag reflex is inadequate in determination of ability to protect airway.
• Anticipated clinical course (anticipated deterioration, need for transport, or impending airway compromise)
• Combative patient who needs imaging (suspicion of intracranial process, etc)

Considerations

• 2015 AHA ACLS guidelines deemphasize placement of advanced airway placement in initial resuscitation
• Out-of-hospital arrest data suggests lower survival of those intubated in field
• 108,000 patients examined in U.S. registry of inpatient hospital arrests, with 95% of intubations occurring within 15 min of resuscitation
  • Patients intubated were significantly less likely to survive to discharge, 16% vs. 19%
  • Also less likely to be discharged with good functional status, 11% vs. 14%

Absolute Contraindications

• No absolute contraindications when performed as an emergent procedure
  • Exception: cannot ventilate and anticipate near impossible orotracheal intubation, strongly consider surgical airway

Relative Contraindications

See Predicting the difficult airway

Difficult BVM (MOANS)

• Mask seal
• Obesity
• Aged
• No teeth
• Stiffness (resistance to ventilation)

Difficult Intubation (LEMON)

• Look externally (gestalt)
• Evaluate 3-3-2 rule
• Mallampati
• Obstruction
• Neck mobility

Equipment Needed

• Medications
  • Induction agent
  • Paralytic agent
• Laryngoscope (type based on clinical indication and provider preference)
  • Direct laryngoscope with blade of provider's choice or
  • Video laryngoscope (Glidescope, C-Mac, KingVision, etc.) or
  • Optical stylet (Shikani, Levitan, etc.) or
  • Fiberoptic device
• Endotracheal tube
• End-tidal CO2 device (colorimetric or quantitative)
• Ventilator
• Suction
• Intubation adjuncts (bougie, lighted stylet, etc)
• BVM
• OPA/NPA
• Method of preoxygenation (NC, NRB, C-PAP, etc)
• Nasal cannula for apneic oxygenation

SOAP-ME Checklist Mnemonic

• Suction
• Oxygen
  • Nasal cannula
  • Non-rebreather
  • Bag-valve mask
• Airways
  • Endotracheal tube
  • Rescue devices
  • Adjuncts
• Positioning
• Medications
• Equipment
  • Laryngoscope
  • EtCO2
  • Bougie

Post-Procedure

Initial ventilation settings

Disease	Tidal Volume (mL/kg^)	Respiratory Rate	I:E	PEEP	FiO2
Traditional	8	10-12	1:2	5	100%
Lung Protective (e.g. ARDS)	6	12-20	1:2	2-15	100%
Obstructive (e.g. bronchoconstriction)	6	5-8	1:4	0-5	100%
Hypovolemic	8	10-12	1:2	0-5	100%

^Ideal body weight

Complications

• Difficult airway algorithm

Special Situations

Severe Metabolic Acidosis

Further drop in pH during intubation can be catastrophic

• NIV (SIMV Vt 550, FiO2 100%, Flow Rate 30 LPM, PSV 5-10, PEEP 5, RR 0)
  • SIMV on ventilator, not NIV machine
  • "Pseudo-SIMV" mode
• Attach end-tidal CO2 and observe value
• Push RSI medications
• Turn the respiratory rate to 12
• Perform jaw thrust
• Wait 45sec
• Intubate
• Re-attach the ventilator
• Immediately increase rate to 30
• Change Vt to 8cc/kg
• Change flow rate to 60 LPM (normal setting)
• Make sure end-tidal CO2 is at least as low as before

Active GI Bleed

1. Empty the stomach
   • Place an NG and suction out blood
     • Varices are not a contraindication
   • Metoclopramide 10mg IV
     • Increases LES tone
2. Intubate with HOB at 45°
3. Preoxygenate!
   • Want to avoid bagging if possible
4. Intubation meds
   • Use sedative that is BP stable (etomidate, ketamine)
   • Use paralytics (actually increases LES tone)
5. If need to bag:
   • Bag gently and slowly (10BPM)
   • Consider placing LMA
6. If patient vomits
   • Place in Trendelenberg
   • Place LMA
   • Use meconium aspirator
7. If patient aspirates anticipate a sepsis-like syndrome
   • May need pressors, additional fluid (not antibiotic!)

Video

{{#widget:YouTube|id=99X2-a4mdxc}}

See Also

• EBQ:Effect_of_video_laryngoscopy_on_trauma_patient_survival
• Nasal intubation

Airway Pages

• Pre-intubation
  • Predicting the difficult airway
  • Bag valve mask ventilation
    • Oropharyngeal airway
    • Supraglottic airway
  • Apneic oxygenation
    • EBQ:ED Preoxygenation
• Induction
  • Critical care quick reference
  • Rapid sequence intubation
  • Delayed sequence intubation
• Intubation
  • Intubation (peds)
  • Direct laryngoscopy
  • Video Laryngoscopy
  • Bougie
  • The difficult airway
  • Advanced airway adjuncts
    • Supraglottic airway
  • Non-traditional intubation
    • Awake intubation
    • Nasal intubation
    • Blind digital intubation
• Surgical airways
  • Surgical cricothyrotomy
  • Needle cricothyrotomy
  • Pediatric jet ventilation
• Post-intubation
  • Mechanical ventilation (main)
  • Deterioration after intubation (DOPE)

Mechanical Ventilation Pages

• Noninvasive ventilation
• Intubation
  • Intubation (peds)
• Mechanical ventilation (main)
  • Ventilation modes
  • Initial mechanical ventilation settings
    • Initial mechanical ventilation settings (peds)
  • Adjusting mechanical ventilation settings
    • Deterioration after intubation
    • Lung recruitment maneuver
    • Ventilator high pressures
    • Ventilator associated lung injury
  • Weaning mechanical ventilation
    • Extubation
• Miscellaneous
  • ARDS and EBQ:ARDSnet
  • Airway pressure release ventilation
  • Ideal Body Weight Estimation

External Links

• EMCrit Podcast – Ventilatory Kills – Intubating the patient with Severe Metabolic Acidosis