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)

Absolute Contraindications

• No absolute contraindications when performed as an emergent procedure.

Relative Contraindications (Mnemonics 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 Supraglottic Device (RODS)

• Restricted motnh opening
• Obstruction
• Distorted airway
• Stiff lungs or neck (c-spine)

Predictors of Difficult Cricothyrotomy (SHORT)

• Surgery
• Hematoma
• Obesity
• Radiation (Burn or other distortion)
• Tumor

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
  • 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	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

Special Situations

Severe Metabolic Acidosis

• Further drop in pH during intubation can be catastrophic

1. NIV (SIMV Vt 550, FiO2 100%, Flow Rate 30 LPM, PSV 5-10, PEEP 5, RR 0)
2. Attach end-tidal CO2 and observe value
3. Push RSI meds
4. Turn the respiratory rate to 12
5. Perform jaw thrust
6. Wait 45sec
7. Intubate
8. Re-attach the ventilator
9. Immediately increase rate to 30
10. Change Vt to 8cc/kg
11. Change flow rate to 60 LPM (normal setting)
12. 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°
   • Consider Glidescope
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 pt vomits place in Trendelenberg
7. If pt aspirates anticipate a sepsis-like syndrome
   • May need pressors, additional fluid (not abx!)

See Also

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

Mechanical Ventilation Pages

• Noninvasive ventilation
• Intubation
  • Intubation (peds)
• Mechanical ventilation (main)
  • Ventilation modes
  • Initial mechanical ventilation settings
    • Initial mechanical ventilation settings (peds)
  • Adjusting mechanical ventilation settings
    • Deterioration after intubation
    • Lung recruitment maneuver
    • Ventilator high pressures
    • Ventilator associated lung injury
  • Weaning mechanical ventilation
    • Extubation
• Miscellaneous
  • ARDS and EBQ:ARDSnet
  • Airway pressure release ventilation
  • Ideal Body Weight Estimation