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 (Mnemonics)

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

Procedure

Initial ventilation settings

Disease TV (cc/kg) Respiratory Rate I:E PEEP FiO2
Normal lung 8 10-12 1:2 5 100%
Bronchoconstriction 6 5-8 1:4 5 100%
ARDS 6 12-20 1:2 2-15 100%
Hypovolemic 8 10-12 1:2 0-5 100%

Complications

Difficult airway algorithm

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

[[Category:WikEM]]

See Also

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.