Intubation: Difference between revisions
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==Special Situations==
==Special Situations==
===Hypotension===
''Induction agents (even cardiostable ones) cause vasodilation to some degree''
''Positive pressure ventilation increases afterload and decreases preload to the right ventricle''
''Shock index (SI=HR/SBP) >0.9 is strong predictor of peri-intubation arrest''
*Run fluids wide open
*Consider starting norepinephrine drip
*[[Push-dose pressors]] at bedside
*Decrease dose of induction agent and increase dose of paralytic
===Severe [[Metabolic Acidosis]]===
===Severe [[Metabolic Acidosis]]===
''Further drop in pH during intubation can be catastrophic''
''Further drop in pH during intubation can be catastrophic''

Revision as of 23:41, 21 November 2020

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[1], 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 require intubation for airway protection
  • 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)
  • 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
  • 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

Hypotension

Induction agents (even cardiostable ones) cause vasodilation to some degree Positive pressure ventilation increases afterload and decreases preload to the right ventricle Shock index (SI=HR/SBP) >0.9 is strong predictor of peri-intubation arrest

  • Run fluids wide open
  • Consider starting norepinephrine drip
  • Push-dose pressors at bedside
  • Decrease dose of induction agent and increase dose of paralytic

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

{{#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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