Intubation

Indications

• Failure to ventilate
• Failure to oxygenate
• Inability to protect airway
  • Gag reflex is absent at baseline in ~1/3 of people, 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
• 108,000 patients examined in U.S. registry of inpatient hospital arrests, with 95% of intubations occurring within 15 min of resuscitation
  • 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

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

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
7. If patient aspirates anticipate a sepsis-like syndrome
   • May need pressors, additional fluid (not antibiotic!)

See Also

• Difficult Airway Algorithm
• Rapid Sequence Intubation (RSI)
• Supraglottic airway
• Cricothyrotomy
• DL vs VL
• Nasal intubation

Mechanical Ventilation Pages

• Noninvasive ventilation
• Intubation
  • Rapid Sequence Intubation (RSI)
  • Difficult airway algorithm
  • Supraglottic airway
  • Nasal intubation
• Deterioration after intubation
• Ventilation settings
• Ventilation modes
• Ventilator high pressures
• Ventilator associated lung injury (VALI)
• Recruitment maneuver
• Ventilation weaning
• Extubation

External Links

• EMCrit Podcast – Ventilatory Kills – Intubating the patient with Severe Metabolic Acidosis

References

Authors

Ross Donaldson