Intubation

Indications

    • Inability to maintain airway patency or protect the airway against aspiration
    • Failure to ventilate or oxygenate
    • Anticipation of a deteriorating course that will eventually lead to respiratory failure

Airway checklist

    • Consider relative contraindications to intubation - HOp Killers (Hypotension, Oxygenation, low pH)
      • **Remember: Resuscitate before you intubate!**
    • Failed Plan Verbalized "Laryngoscopy +/- Bougie x 3 -> Intubating supraglottic airway placement -> Surgical Airway"
      • Prepare surgical airway
        • Feel thyroid cartilage
        • Mark cricothyroid membrane with marker, prepare kit
    • Look in Mouth
      • Keep dentures for bagging, remove dentures right before intubation
    • Range of Motion of Neck

"O BLAST HIM"

    • O2, nasal prongs, face mask
    • Blade (Mac 3-4 in most adults) and Bag-valve-mask with waveform capnograph/end-tidal CO2 +/- PEEP valve
    • Laryngoscope, Video laryngoscope
    • Airway (oropharyngeal, nasopharyngeal)
      • Supraglottic airway (intubating LMA if possible): Size 3 small female, 4 large female or small male, 5 large male
    • Suction, Syringe, Stylet/Bougie, Scalpel
    • Tube (ET tube size 7-8), Team (Eye/Face protection)
      • Curve tube 30-40 degrees for direct laryngoscopy
      • Curve tube 60-70 degrees for video laryngoscopy (avoid more acute bend as will be difficult to go down trachea)
    • Help (for bimanual laryngoscopy, keep head stabilized by holding ears like earmuffs) and Hinder (signs of difficult airway)
    • IV access, fluids
    • Monitors (including end tidal CO2), Medications

Medications

    • Induction (half in hypotension)
      • Ketamine 1.5mg/kg IBW
        • Consider if unstable hemodynamic, or reactive airway disease (causes bronchodilation)
        • Drawbacks: Secretions, cardiovascular disease (hypertension/tachycardia), elevated intraocular pressure (not ICP)
      • Propofol 1.5-3mg/kg induction bolus IBW (risk of hypotension)
        • Consider for hemodynamically stable, reactive airway disease, status epilepticus
        • Drawbacks: Hypotension (avoid in BB/CCB overdose), myocardial depression, reduced cerebral perfusion, short acting
      • Etomidate 0.3-0.4mg/kg TBW
        • Drawbacks: Risk of adrenal suppression in multiple doses
      • Fentanyl 1-2mcg/kg IBW bolus, then 10mcg/kg/h
      • Midazolam 0.1-0.3mg/kg TBW (max 20mg) for amnesia/induction
    • Neuromuscular blockers/Paralytic (double in hypotension)
      • Succinylcholine 1.5mg/kg TBW
        • Intubate once fasciculations stop
        • Contraindicated in high potassium (burns, renal failure, polytrauma), malignant hyperthermia, myopathy, recent spinal cord damage or CVA (1w - 3-6 mo)
        • Decrease dosing in organophosphate poisoning, hypothyroidism
        • Drawbacks: Bradycardia, hyperkalemia, fasciculations, elevated intra-ocular pressure
      • Rocuronium 1.2-1.5mg/kg IBW
        • Safer (less side effects), longer duration (30-45 minutes)
    • Expect bradycardia
      • Atropine 0.5mg q3-5min, max 3mg
    • Expect hypotension
      • Push-dose Epinephrine
        • Take a syringe with 9mL NS
        • Add 1 ml of Cardiac-Arrest Epinephrine (0.1 mg/mL or 100mcg/mL or 1:10000)
        • Shake well and label “Epinephrine 10 mcg/ml”
        • Dose 0.5-2 ml (5-20 mcg) q2-5 mins
      • Phenylephrine 50-200mcg q2-5 mins
      • Norepinephrine 3-12 mcg q1-2 mins

Intubation

    • Denitrogenate/preoxygenate x 3mins
      • Nasal prongs titate to max tolerated (above 15L/min) +/- non-rebreather or CPAP or BVM + PEEP valve
        • Keep nasal prongs to max during intubation
        • If nasal cannulae compromise seal of facemask during preoxygenation, keep them above mask until prior to attempting laryngoscopy
        • Ensure SpO2 >95%
        • Pulse oxygen visible or audible (turn bed if needed)
      • Sit-up
      • Pull on mandible (jaw thrust)
    • Position for intubation
      • Face plane parallel to ceiling, ear (holes) horizontally aligned to sternal line
      • Consider focused neuro exam (GCS, pupils, limb movements)
    • Deliver induction medications (consider paralyzer first) with flush
      • Wait 60 seconds (risk of vomiting if too early)
      • May consider slow bag-mask ventilation during drug onset (PreVent)
    • Observe teeth
      • Open mouth wide with scissor-3rd finger technique
    • Roll blade down tongue
    • Visualize uvula (suction as needed)
    • Visualize epiglottis (suction as needed)
      • Light grip on laryngoscope
      • Push down on thyroid with right hand (bimanual laryngoscopy) to create a large valecula space
      • Make sure deep in vallecula to get to "sweet spot"
      • Tongue control to open right side for tube delivery
      • Push blade forward and up (avoid rotate/leverage on upper teeth)
    • Visualize vocal cords (suction as needed)
      • Consider
        • Suction (uvula points to epiglottis, define epiglottis edge)
        • Bimanual laryngoscopy then have assistant maintain pressure at right location
        • Head lift
        • Two-handed lift
        • Use Mac as Miller (lift epiglottis)
        • Use Miller "Straight blade" (especially if pathology prevents from getting to vallecula - eg. anaphylaxis, epiglottitis, radiation)
          • Work blade to right and down to corner of mouth because front teeth in way
    • For VL (eg. GlideScope)
      • Back up blade/camera to have room to maneuver (aim for a view of <50% of glottis)
      • Introduce ETT midline holding top as a "slot machine handle"
      • "Pull down slot machine handle" motion to get ETT to enter glottis
    • For DL
      • Introduce ETT (+stylet) or bougie using right corner of mouth, insert tube below line of sight and horizontally so rotating can direct to anterior or posterior glottis
    • Stylet gets caught on tracheal rings, rotate tube RIGHT
      • Thumb flick to remove stylet ~3cm
    • Bougie get stuck on gap, rotate tube LEFT
      • Feel tracheal rings and go all the way down to confirm "hold-up" at carina or bronchial tree (eg. at 40cm), then pull back to 25cm, place ETT over and use lube
    • ETT depth usually 19-24cm depending on height of patient (eg. 5' = 19cm, 5'6" 21cm, 5'10" 22cm, 6' 23cm)
    • Inflate cuff (10mL air)
    • Confirm placement
      • Bilateral air entry (unreliable), end CO2 on capnography
      • CXR
        • ETT tip 5cm +/-2cm above carina (at level of medial clavicles)
      • Ultrasound
        • If you see two air-mucosal surfaces = esophageal intubation
        • Proper depth can be confirmed at sternal notch seeing air bubbles when using saline to fill ETT balloon

Ventilator settings

    • Mode: Assist Control (AC) Volume
      • Tidal Volume (Vt) = Protection
        • 6-8mL/kg (if ALI/ARDS goal 6mL/kg)
      • Flow Rate (IFR) = Comfort
        • 60-80 L/min
      • Rate (RR) = Ventilation
        • Initially 18 bpm, adjust based on CO2
      • FiO2/PEEP = Oxygenation
        • Start at 100% and PEEP of 0 or 5
          • Titrate to O2 sat 88-95%, usually can turn FIO2 down to 40%
        • ABG at 5 mins
          • Goal of PaO2 55-80mmHg or SpO2 88-95%
            • Combination of FiO2/PEEP increments every 5 mins (or quicker if low saturations)
              • See table below
      • Plateau Pressure
        • Check regularly
          • Hold inspiratory hold button x 0.5 seconds, look at plateau measure, goal <30cm H2O
            • Lower Vt until Plat <30 (you may need to go as low as 4mL/kg)
      • Disadvantages
        • Not comfortable for awake, spontaneously breathing patients
        • Use sedation/pain medications
    • Obstruction (Asthma/COPD)
      • Mode AC volume
      • Vt 8mL/kg
      • IFR 80-100lpm
      • PEEP 0
      • FiO2 target as above
      • RR start at 10bpm, allow full expiration, goal I:E of 1:4 or 1:5
        • Allow for hypercapnea
      • Peak plateau pressure goal <30cm H2O, if higher pressures - decrease RR to allow time for exhalation

Post-Intubation

  • Goal:
    • Light sedation, as early deep sedation may lead to delirium, longer ICU stay, mortality
      • Titrate up to RASS 0 or -1
    • Start with Analgesia, and if not enough can add sedation (usually Fentanyl, then Propofol)
  • Analgesia
    • Fentanyl bolus 25-50mcg bolus q3-5mins, then drip 1mcg/kg/hour (100-500mcg/hour)
    • Morphine/hydromorphone
  • Sedation
    • Propofol 0.25-0.5 mg/kg q1min, then drip 0.5-5 mg/kg/hour
    • Ketamine 0.25-1mg/kg bolus q3-5mins, then drip at 0.5-4mg/kg/hour
    • Midazolam 1-5mg bolus q3-5mins, then drip at 5-10mg/hour
  • Raise head of bed (reduces aspiration and improves ventilation/oxygenation)
Intubation Dump Kit.pdf