Intubation

This page is for adult patients. For pediatric patients, see: intubation (peds)

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.
  • If a patient is able to tolerate placement of an oropharyngeal airway, they likely require intubation for airway protection
  • GCS <8 generally an indication for intubation in trauma patients
• 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 awake fiberoptic intubation (if possible) and also performing a surgical airway as a back up plan

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)
  • Ensure you have correct stylet for type of laryngoscope you are using
    • Direct or Mactintosh-blade videolaryngoscopes require malleable stylets
    • Hyperangulated videolaryngoscopes require rigid stylets
• 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

Procedure

Macintosh Blades 1-5, from bottom to top

The Macintosh blade is inserted into the vallecula (left) while the Miller blade is inserted under and lifts the epiglottis (right)

Direct laryngoscopy (with Macintosh blade)

1. Place patient into sniffing position
2. Use "scissor" technique with right hand to open mouth
3. Insert laryngoscope blade into right side of mouth
4. Slowly advance blade into mouth while performing "tongue sweep"
5. Identify epiglottis
6. Advance tip of blade into vallecula
7. Lift upward and away from operator to expose glottis
8. Deliver tube through vocal cords

Video laryngoscopy

• Hyperangulated video laryngoscope
  • Patient ideally in neutral spine position (as opposed to "sniffing" position for direct laryngoscopy)
  • After induction, use right hand to "scissor" mouth open
  • Place hyperangulated blade midline and slowly advance with progressive identification of airway landmarks
  • Advance blade into vallecula
  • When cords fill entire screen (Cormack-Lehane Grade I), slightly retract laryngoscopy so that cords only occupy upper 1/3 of screen (CL Grade II, allows for passage of ETT with rigid stylet)
    • If intubation is attempted with the best view possible, operators often have difficulty advancing the tube around the tongue and hypopharyngeal soft tissues

• Standard geometry video laryngoscope
  • Same technique utilized with direct laryngoscopy
  • Can either visualize directly or utilize video screen for tube delivery

Post-Procedure

• Confirm tube placement with auscultation and end tidal CO2
• Secure tube
• Place OG to decompress stomach
• Provide sedation and analgesia
• Head of bed to at least 30°
• Obtain CXR
  • Tube should be 3-5 cm from the carina
• Check ABG ~30 minutes after intubation
• Check cuff pressures - should be between 20-30 cm H2O
• Check plateau pressure using "inspiratory hold" - should be less than 30 cm H2O

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

• The difficult airway

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 with lower dose (etomidate, ketamine)
   • Use paralytics with higher dose (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

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See Also

• EBQ:Effect_of_video_laryngoscopy_on_trauma_patient_survival

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
• First 10 EM: Intubation

Videos

• Hippo ED (12:50) https://www.youtube.com/watch?v=-M3OlfmKjO8