Intubation
Indications
- Failure to ventilate
- Failure to oxygenate
- Inability to protect airway (gag unhelpful)
- Anticipated clinical course (anticipated deterioration, transport, or impending airway compromise)
- Increased ICP (for hyperventilation)
- Combative, needing imaging
Pneumonics for Predicting Difficulties
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 (LEMON)
- Look externally (gestalt)
- Evaluate 3-3-2 rule
- Mallampati
- Obstruction
- Neck mobility
Difficult Extraglottic Device (RODS)
- Restricted motnh opening
- Obstruction
- Distorted airway
- Stiff lungs or neck (c-spine)
Difficult Critcothyrotomy (SHORT)
- Surgery
- Hematoma
- Obesity
- Radiation (Burn or other distortion)
- Tumor
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.
- Alternative technique
- Prepare Afrin in 10 cc syringe, nasal trumpet, nasal tube (or smaller ETT) without stylet, DL blade, McGills/long curved Kellys
- Afrin in both nostrils
- Nasal trumpet into R nostril to dilate nasal airway (R nostril = less bleeding, faster[1]
- Insert tube in a postero-inferior direction (may feel some crunching along ethmoid, so be careful along that surface)
- DL to visualize tube insertion past vocal cords
- McGills or Kellys to grasp tube tip and facilitate passing tube
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)
- Attach end-tidal CO2 and observe value
- Push RSI meds
- 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
GI Bleeder
- Empty the stomach
- Place an NG and suction out blood
- Varices are not a contraindication
- Metoclopramide 10mg IV
- Increases LES tone
- Place an NG and suction out blood
- Intubate with HOB at 45°
- Consider Glidescope
- 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 pt vomits place in Trendelenberg
- If pt aspirates anticipate a sepsis-like syndrome
- May need pressors, additional fluid (not abx!)
See Also
- Difficult Airway Algorithm
- Rapid Sequence Intubation (RSI)
- Ventilation (Main)
- LMA
- Needle cricothyrotomy
- Deterioration After Intubation (DOPE)
- DL vs VL
Source
Rosen
EMCrit Podcasts 3, 4, 5
- ↑ Boku et al. Which nostril should be used for nasotracheal intubation: the right or left? A randomized clinical trial. J Clin Anesth. 2014 Aug;26(5):390-4.