Intubation
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
- 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% |
Complications
Video
{{#widget:YouTube|id=99X2-a4mdxc}}
See Also
Airway Pages
- Pre-intubation
- Induction
- Intubation
- Surgical airways
- Post-intubation
Mechanical Ventilation Pages
- Noninvasive ventilation
- Intubation
- Mechanical ventilation (main)
- Miscellaneous
External Links
References
- ↑ Davies AE, Kidd D, Stone SP, MacMahon J. Pharyngeal sensation and gag reflex in healthy subjects. Lancet. 1995 Feb 25;345(8948):487-8.
- ↑ 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.
- ↑ Angus DC.Whether to intubate during cardiopulmonary resuscitation: Conventional wisdom vs big data. JAMA 2017 Feb 7; 317:477.