Difference between revisions of "Intubation"

(Created page with "==Indications== 1) Failure to ventilate 2) Failure to oxygenate 3) Inability to protect airway (gag unhelpful) 4) Anticipated clinical course (anticipated deterioration, tra...")
 
(Equipment Needed)
 
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==Indications==
 
==Indications==
 +
*Failure to ventilate
 +
*Failure to oxygenate
 +
*Inability to protect airway
 +
**Gag reflex is absent at baseline in ~1/3 of people<ref>Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reflex in healthy subjects. Lancet. 1995 Feb 25;345(8948):487-8.</ref>, 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<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>
 +
**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
  
1) Failure to ventilate
+
==Relative Contraindications==
 +
''See [[Predicting the difficult airway]]''
 +
{{Difficult BVM}}
  
2) Failure to oxygenate
+
===Difficult Intubation (LEMON)===
 +
*'''L'''ook externally (gestalt)
 +
*'''E'''valuate 3-3-2 rule
 +
*'''M'''allampati
 +
*'''O'''bstruction
 +
*'''N'''eck mobility
  
3) Inability to protect airway (gag unhelpful)
+
==Equipment Needed==
 +
[[File:Normal Epiglottis.jpg|thumb|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]]
  
4) Anticipated clinical course (anticipated deterioration, transport, or impending airway compromise)
+
==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
  
*5) Increased ICP (for hyperventilation)
+
==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}}
  
*6) Combative, needing imaging
+
==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 [[Rapid Sequence Intubation (RSI)|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
  
==Premedication==
+
===Active [[GI Bleed]]===
 +
#Empty the stomach
 +
#*Place an NG and suction out blood
 +
#**Varices are not a contraindication
 +
#*Metoclopramide 10mg IV
 +
#**Increases LES tone
 +
#Intubate with HOB at 45°
 +
#Preoxygenate!
 +
#*Want to avoid bagging if possible
 +
#Intubation meds
 +
#*Use sedative that is BP stable (etomidate, ketamine)
 +
#*Use paralytics (actually increases LES tone)
 +
#If need to bag:
 +
#*Bag gently and slowly (10BPM)
 +
#*Consider placing LMA
 +
#If patient vomits
 +
#*Place in Trendelenberg
 +
#*Place LMA
 +
#*Use meconium aspirator
 +
#If patient aspirates anticipate a sepsis-like syndrome
 +
#*May need [[pressors]], additional fluid (not antibiotic!)
  
 
+
==Video==
1) Lidocaine (1.5mg/kg): inc ICP, severe asthma
+
{{#widget:YouTube|id=99X2-a4mdxc}}
 
 
2) Fentanyl (3mcg/kg): ischemic CAD, inc ICP, aortic dissect
 
 
 
3) Atropine (0.02mg/kg): children <10 yrs
 
 
 
 
 
 
*consider ketamine (1.5mg/kg) in place of etomidate for induction in asthma
 
 
 
== ==
 
 
 
 
 
==Difficult BVM (MOANS)==
 
 
 
 
 
Mask seal
 
 
 
Obesity
 
 
 
Aged
 
 
 
No teeth
 
 
 
Stiffness (resistance to ventilation)
 
 
 
"Remove dentures to intubate; keep them in to bag/mask ventilate"
 
 
 
 
 
 
==Difficult Intubation==
 
 
 
 
 
Look externally (gestalt)
 
 
 
Evaluate 3-3-2 rule
 
 
 
Mallampati
 
 
 
Obstruction
 
 
 
Neck mobility
 
 
 
 
 
 
==Laryngoscopy Grades  (Cormack & Lehane)==
 
 
 
 
 
I    whole aperture    (0%)
 
 
 
II.a    ayretenoids +partial cords (4%)
 
 
 
II.b    ayretenoids only (67%)
 
 
 
III    epiglottis only (>67%)
 
 
 
IV    no epiglottis (?%)
 
 
 
 
 
 
*(failure rate)
 
 
 
 
 
 
==Nasal Intubation==
 
 
 
 
 
sniffing position (like oral ET)
 
 
 
pretreat with lido, hurricaine, or 4cc nebulized lidocaine for 5 minutes
 
 
 
Tube size = 1.0 mm smaller
 
 
 
listen with stethoscope  at end of tube (breath sounds become louder as tube approaches cords)
 
 
 
when tube hits cords patient will cough, back up 1 or 2 cm.  wait for beginning of inspiration, as patient begins inspiration advance 3-4 cm (tube should be 22-26cm in women, 23-28cm in men)
 
 
 
 
 
 
*tips: occlude other nostril to hear better, cricoid pressure when advancing, use a small suciton catheter as a seldinger guide, precurve tube before insertion.
 
 
 
 
  
 
==See Also==
 
==See Also==
 +
*[[EBQ:Effect_of_video_laryngoscopy_on_trauma_patient_survival]]
 +
{{Related Difficult Airway Pages}}
 +
{{Mechanical ventilation pages}}
  
 +
==External Links==
 +
*[http://emcrit.org/podcasts/tube-severe-acidosis/ EMCrit Podcast – Ventilatory Kills – Intubating the patient with Severe Metabolic Acidosis]
  
Air/Resus: Airway (RSI)
+
==References==
 
+
<References/>
Air/Resus: Rapid Sequence Intubation (RSI)
 
 
 
 
 
 
==Source ==
 
 
 
 
 
2/06  DONALDSON (Adapted from Rosen, Lampe)
 
 
 
 
 
 
 
  
[[Category:Airway/Resus]]
+
[[Category:Critical Care]]
 +
[[Category:Procedures]]

Latest 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

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.