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)