Intubation: Difference between revisions

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*Combative patient who needs imaging (suspicion of intracranial process, etc)
*Combative patient who needs imaging (suspicion of intracranial process, etc)
==Considerations==
==Considerations==
*2015 AHA ACLS guidelines deemphasize placement of '''advanced airway''' placement in ''initial resuscitation''
*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<ref>Hasegawa K et al. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA 2013 Jan 16; 309:257.</ref>
*Out-of-hospital arrest data suggests lower survival of those intubated in field<ref>Hasegawa K et al. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA 2013 Jan 16; 309:257.</ref>
*108,000 patients examined in U.S. registry of inpatient hospital arrests, with 95% of intubations occurring within 15 min of resuscitation<ref>Angus DC.Whether to intubate during cardiopulmonary resuscitation: Conventional wisdom vs big data. JAMA 2017 Feb 7; 317:477.</ref>
*108,000 patients examined in U.S. registry of inpatient hospital arrests, with 95% of intubations occurring within 15 min of resuscitation<ref>Angus DC.Whether to intubate during cardiopulmonary resuscitation: Conventional wisdom vs big data. JAMA 2017 Feb 7; 317:477.</ref>
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==Absolute Contraindications==
==Absolute Contraindications==
*No absolute contraindications when performed as an emergent procedure
*No absolute contraindications when performed as an emergent procedure
**Exception: cannot ventilate and anticipate near impossible orotracheal intubation, strongly consider surgical airway


==Relative Contraindications (Mnemonics)==
==Relative Contraindications==
''See [[Predicting the difficult airway]]''
{{Difficult BVM}}
{{Difficult BVM}}


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==Equipment Needed==
==Equipment Needed==
[[File:Normal Epiglottis.jpg|thumb|Normal intubation view.]]
*Medications
*Medications
**Induction agent
**Induction agent
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**Direct laryngoscope with blade of provider's choice '''or'''
**Direct laryngoscope with blade of provider's choice '''or'''
**Video laryngoscope (Glidescope, C-Mac, KingVision, etc.) '''or'''
**Video laryngoscope (Glidescope, C-Mac, KingVision, etc.) '''or'''
**Fiberoptic device
**Optical stylet (Shikani, Levitan, etc.) '''or'''
**Fiberoptic device  
*Endotracheal tube
*Endotracheal tube
*End-tidal CO2 device (colorimetric or quantitative)
*End-tidal CO2 device (colorimetric or quantitative)
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*[[OPA]]/NPA
*[[OPA]]/NPA
*Method of preoxygenation (NC, NRB, C-PAP, etc)
*Method of preoxygenation (NC, NRB, C-PAP, etc)
*Nasal cannula for apneic oxygenation
*Nasal cannula for [[apneic oxygenation]]


==Procedure==
==SOAP-ME Checklist Mnemonic==
*'''S'''uction
*'''O'''xygen
**Nasal cannula
**Non-rebreather
**Bag-valve mask
*'''A'''irways
**Endotracheal tube
**Rescue devices
**Adjuncts
*'''P'''ositioning
*'''M'''edications
*'''E'''quipment
**Laryngoscope
**EtCO2
**Bougie


==Post-Procedure==
[[File:ETtubeGoodPosition.png|thumb|An endotracheal tube in good position on CXR. Arrow marks the tip.]]
[[File:ETtubeToHigh.png|thumb|An endotracheal tube not deep enough. Arrow marks the tip.]]
{{Initial ventilation settings table}}
{{Initial ventilation settings table}}


==Complications==
==Complications==
[[Difficult airway algorithm]]
*[[The difficult airway]]


==Special Situations==
==Special Situations==
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#**Increases LES tone
#**Increases LES tone
#Intubate with HOB at 45°
#Intubate with HOB at 45°
#*Consider Glidescope
#Preoxygenate!
#Preoxygenate!
#*Want to avoid bagging if possible
#*Want to avoid bagging if possible
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#*Bag gently and slowly (10BPM)
#*Bag gently and slowly (10BPM)
#*Consider placing LMA
#*Consider placing LMA
#If patient vomits place in Trendelenberg
#If patient vomits
#*Place in Trendelenberg
#*Place LMA
#*Use meconium aspirator
#If patient aspirates anticipate a sepsis-like syndrome
#If patient aspirates anticipate a sepsis-like syndrome
#*May need pressors, additional fluid (not antibiotic!)
#*May need [[pressors]], additional fluid (not antibiotic!)
 
==Video==
{{#widget:YouTube|id=99X2-a4mdxc}}


==See Also==
==See Also==
*[[Difficult Airway Algorithm]]
*[[EBQ:Effect_of_video_laryngoscopy_on_trauma_patient_survival]]
*[[Rapid Sequence Intubation (RSI)]]
{{Related Difficult Airway Pages}}
*[[Supraglottic airway]]
*[[Cricothyrotomy]]
*[[EBQ:Effect_of_video_laryngoscopy_on_trauma_patient_survival|DL vs VL]]
*[[Nasal intubation]]
{{Mechanical ventilation pages}}
{{Mechanical ventilation pages}}


Revision as of 05:59, 8 May 2019

Indications

  • Failure to ventilate
  • Failure to oxygenate
  • Inability to protect airway
    • Gag reflex is absent at baseline in ~1/3 of people[1], 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[2]
  • 108,000 patients examined in U.S. registry of inpatient hospital arrests, with 95% of intubations occurring within 15 min of resuscitation[3]
    • 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

Normal intubation view.
  • 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

An endotracheal tube in good position on CXR. Arrow marks the tip.
An endotracheal tube not deep enough. Arrow marks the tip.

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

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

Airway Pages

Mechanical Ventilation Pages

External Links

References

  1. ↑ Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reflex in healthy subjects. Lancet. 1995 Feb 25;345(8948):487-8.
  2. ↑ Hasegawa K et al. Association of prehospital advanced airway management with neurologic outcome and survival in patients with out-of-hospital cardiac arrest. JAMA 2013 Jan 16; 309:257.
  3. ↑ Angus DC.Whether to intubate during cardiopulmonary resuscitation: Conventional wisdom vs big data. JAMA 2017 Feb 7; 317:477.
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