Endotracheal Intubation Preparation

Aka: Endotracheal Intubation Preparation, SOAP-ME Mnemonic, CRASH Mnemonic, Physiologic Optimization Prior to Intubation, Prevention of Post-Intubation Hypotension, High Risk Conditions in Airway Management

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II. Approach: Emergency Preintubation Back-up Plan

  1. See Emergency Decision Cycle (OODA Loop, AAADA Model)
  2. Review anticipated difficulties in airway management
    1. Anticipate difficult mask ventilation (MOANS Mnemonic, ROMAN Mnemonic)
    2. Anticipate difficult Direct Laryngoscopy (LEMON Mnemonic)
    3. Anticipate difficult Extraglottic Device (RODS Mnemonic)
    4. Anticipate difficult Cricothyrotomy (SHORT Mnemonic, SMART Mnemonic)
  3. Levitan describes an emergency back-up parachute approach to intubation
    1. Every step in intubation should have a back-up plan (Boy Scout "Be Prepared" motto)
    2. Two ways to ventilate
    3. Two ways to oxygenate
    4. Two ways to intubate
  4. UMMC Shock-Trauma Advanced Airway Plan (Plan A, B, C...)
    1. Intubation attempt with any technique
    2. Intubation attempt using Video Laryngoscope and Gum Elastic Bougie
    3. Intubation attempt by back-up provider (or attending physician)
    4. Attempt Supraglottic Airway (e.g. Laryngeal Mask Airway)
    5. Surgical airway (Cricothyrotomy)
  5. Be prepared for Cricothyrotomy
    1. Have plan A and plan B (see above)
      1. Also have a "Go to Hell Plan" in case of "Can't Oxygenate, Can't Intubate"
    2. Palpate the neck for the cricothyroid membrane prior to each intubation
    3. Cricothyrotomy kit should be immediately available in case of complete airway obstruction
  6. Be prepared for failed definitive airway placement
    1. Have Extraglottic Device (e.g. Laryngeal Mask Airway or LMA) available (with practiced use)
  7. Have at least two methods of laryngeal exposure immediately available (with practiced use of each)
    1. Direct Laryngoscope
    2. Video Laryngoscope
  8. Have at least 2 Endotracheal Tubes available
    1. Estimated size for the patient's body habitus
    2. One Endotracheal Tube size smaller than expected
  9. Have two oxygen sources (not on splitter)
    1. Preoxygenation oxygen source (e.g. Non-Rebreather Mask with reservoir at 12 LPM)
    2. Apneic Oxygenation source (High Flow Nasal Cannula oxygen source at 15 LPM)
  10. Have two suction devices
    1. Open suction tubing without suction tip
    2. Yankauer suction (or preferably a better tip such as “S3,” “Big Stick,” or “Big Yank” )
      1. https://www.annemergmed.com/article/S0196-0644(16)30793-4/fulltext

III. Preparation: Mnemonic - SOAP-ME

  1. Suction
    1. Yankauer suction (or better alternative as above)
    2. Second suction tubing with no tip attached
  2. Oxygen
    1. High Flow Oxygen device (e.g. Non-Rebreather Mask with reservoir)
    2. Consider CPAP or BIPAP for preoxygenation
    3. Second oxygen source with Nasal Cannula (up to 15L/min) for Apneic Oxygenation
  3. Airway equipment
    1. Direct Laryngoscope
    2. Video Laryngoscope
    3. Elastic Bougie
    4. Endotracheal Tube
    5. Laryngeal Mask Airway (back-up plan)
  4. Patient Positioning
    1. Pull Mandible forward
    2. Sit patient up (at least 20 degrees) into ramped position (especially if obese)
      1. Reverse Trendelenburg if patient cannot be flexed at waist (e.g. Hip Fracture)
      2. Inclined torso improves oxygenation and glottis view, and decreases aspiration risk
      3. Khandelwal (2016) Anesth Analg 122(4): 1101-7 [PubMed]
    3. Ear to sternal notch
      1. http://www.emdocs.net/novel-tips-airway-management/
      2. Head parallel with ceiling
      3. Ear tragus at level of sternal notch
    4. Adjust overall bed height to align patient to clinician
      1. Patient's face should be at xiphoid of clinician for optimal intubation angle
  5. Monitoring Equipment
    1. Telemetry
    2. Oxygen Saturation
    3. Capnography (End-Tidal CO2)

IV. Preparation: Preintubation General Measures

  1. Prepare for Rapid Sequence Intubation
    1. Indicated if not crash airway or awake intubation needed for difficult airway
  2. Monitoring Telemetry, Capnography and Pulse Oximetry (Hypoxemia, Bradycardia)
    1. Pretreatment with Atropine 0.02 mg/kg is no longer recommended
    2. Some pediatric providers have it ready at itubation in case of Symptomatic Bradycardia (esp. age under 1 year)
  3. Check Laryngoscope for light and blade size (See above)
    1. Video Laryngoscopy is superior to Direct Laryngoscopy for successful first-pass intubation (by Odds Ratio >2)
      1. Video Laryngoscopy is also associated with reduced risk of esophageal intubation
      2. However, no difference in poor outcomes when compared with Direct Laryngoscopy
      3. De Jong (2014) Intensive Care Med 40(5): 629-39 [PubMed]
    2. Direct Laryngoscope (with working bulb and battery)
      1. When Video Laryngoscopy fails, Direct Laryngoscopy is the most common rescue device
  4. Suction (critical for all patients, especially for children)
    1. Two suction tubes are ideal (one Yankauer and one with tubing only to suction large particulate matter)
  5. Select ET size and length (See Endotracheal Tube)
    1. Cuffed ET Tubes may be used in infants and children
    2. Endotracheal Tube (including a size smaller than anticipated)
  6. Stylet should NOT extend beyond distal ET
    1. Glidescope intubation requires glidescope stylet with deep hockey-stick bend
  7. Elastic Bougie
    1. Curl into a tight loop if using a hyperangulated Laryngoscope Blade (e.g. Glidescope)
  8. Images
    1. lungAirwayStylets.png

V. Approach: Physiologic Optimization Prior to Intubation (Mnemonic: CRASH)

  1. Consumption of Oxygen Increased (outpaces Oxygen Delivery)
    1. Causes: High demand states (e.g. ARDS, Sepsis, pregnancy, children, Thyroid Storm)
    2. Endotracheal Intubation Preoxygenation (includes Apneic Oxygenation)
  2. Right Ventricular Failure
    1. See Acute Right Ventricular Failure Management
    2. Right ventricle poorly compensates for increased right-sided Afterload (pulmonary vascular resistance)
      1. RV has only Tachycardia and a marginal increase in contractility for compensation
      2. Pulmonary pressures further increase with hypercapnia, Hypoxia, Atelectasis and PPV
      3. Catastrophic decompensation and Cardiac Arrest may follow
  3. Acidosis Metabolic
    1. Hypercapnea during intubation may worsen an already severe Metabolic Acidosis
    2. Acidosis may precipitate further decreased inotropy and ventricular Arrhythmias
  4. Saturation of oxygen may fall with prolonged intubation
    1. Preoxygenation is limited in severe airspace diseases where FRC Is low (e.g. ARDS) or low V/Q (shunt)
    2. Continue Apneic Oxygenation throughout intubation (e.g. Nasal Cannula at 15 lpm)
    3. Adequate preoxygenation (tight oxygen mask at 100% FIO2) allows for a safe apneic period during intubation
      1. Leads to denitrogenation, improved Functional Residual Capacity (FRC), decreased V/Q mismatch
  5. Hypotension
    1. See below
    2. Optimize underlying conditions before intubation and have Vasopressors readily available
  6. References
    1. Brown (2022) Walls Manual of Emergency Airway Management, LWW, p. 21-2

VI. Approach: High Risk Conditions in Airway Management

  1. Trauma and Hemorrhagic Shock
    1. See Primary Survey Airway Evaluation
    2. See Hemorrhagic Shock
    3. Optimization prior to Endotracheal Intubation
      1. See physiologic optimization above
      2. See Endotracheal Intubation Preoxygenation
      3. Adequate Hemorrhagic Shock Management to prevent Peri-Intubation Hypotension and Cardiac Arrest
        1. Aggressive Resuscitation before intubation for Hypotension or Shock Index >=0.8
      4. Use a hemodynamically neutral induction agent (e.g. Etomidate, Ketamine)
    4. Maintain Cervical Spine Immobilization
      1. Video Laryngoscopy with hyperangulated blade or bougie assisted intubation may be needed
    5. Anticipate Trauma distorted Head and Neck Anatomy
      1. High risk for can oxygenate, can't ventilate scenarios
  2. Increased Intracranial Pressure
    1. Poor neurologic outcomes are associated with Hypoxia, hypercapnia or Hypotension
    2. Maintain parameters throughout the peri-intubation period
      1. Maintain Oxygen Saturation >94%
      2. Maintain PaCO2 35 to 45 mmHg
      3. Maintain Mean Arterial Pressure (MAP) >80 mmHg
    3. Other measures
      1. Use a hemodynamically neutral induction agent (e.g. Etomidate, Ketamine)
      2. Consider Fentanyl 2 to 3 mcg/kg (esp. in hypertensive patients)
  3. Upper Gastrointestinal Bleeding
    1. Peri-Intubation Hypotension risk (and Cardiac Arrest risk)
      1. Adequate Hemorrhagic Shock Management to prevent Peri-Intubation Hypotension and Cardiac Arrest
      2. Aggressive Resuscitation before intubation for Hypotension or Shock Index >=0.8
    2. Aspiration risk during intubation
      1. Raise the head of the bed during intubation
    3. Blood obscured glottic view
      1. Have 2 suctions available (e.g. Open suction tubing and Yankauer suction)
      2. Elevate head of bed
      3. Consider Nasogastric Tube placement prior to intubation
      4. Be ready with double set-up for failed airway (e.g. Cricothyrotomy with neck marked)
      5. Consider using suction tip to lead in front of the Laryngoscope (SALAD technique)
        1. Examiner holds Laryngoscope in left hand and suction in right
        2. Suction can also be used to retract the right side of the mouth to improve visibility
        3. May push suction catheter to the left side and leave in place while passing bougie
          1. Held together with Laryngoscope in left hand
        4. If catheter tip large enough, may pass suction tip through cords and bougie through catheter
          1. Bougie will fit through a large bore suction catheter tip (but not a yanker)
      6. Consider intubation of the Esophagus and inflating the balloon
        1. Push esophageal ET Tube to the left side (out of the way, but blocking GI secretions)
        2. Then intubate the trachea
      7. References
        1. Strayer in Herbert (2018) EM:Rap 18(11):1-3
  4. Cardiac Tamponade
    1. Endotracheal Intubation risks Hypotension and Cardiac Arrest in Cardiac Tamponade patients
      1. Positive Pressure Ventilation increases intrathoracic pressure, decreasing Preload
      2. Induction agents decrease Cardiac Output and Peripheral Vascular Resistance
    2. Best to avoid Endotracheal Intubation before Pericardiocentesis (if possible)
    3. Technique if Endotracheal Intubation is unavoidable
      1. Optimize Preload with IV fluid boluses of 250 to 500 ml crystalloid
      2. Consider awake intubation with Ketamine
      3. Ventilator settings: Low Tidal Volume and low PEEP
  5. Aortic Stenosis
    1. Prevent Peri-Intubation Hypotension (Cardiac Arrest risk)
      1. Optimize Preload with IV fluid boluses of 250 to 500 ml crystalloid before induction
      2. Use hemodynamically neutral induction agents (e.g. Etomidate, Ketamine)
    2. Manage significant Arrhythmias (tachy or brady) prior to intubation
    3. Have Push Dose Pressors (esp. Phenylephrine for Aortic Stenosis) available at bedside during intubation
  6. Morbid Obesity
    1. Head of the Bed at 25 to 30 degrees
    2. Preoxygenation with noninvasive Positive Pressure Ventilation
    3. Use two person technique for bag-valve-mask ventilation
    4. Place blankets or pillows behind the head and neck to align external auditory canal with the sternal notch
    5. Have a Supraglottic Device (e.g. LMA) available in case of failed airway
  7. Pregnancy
    1. See Cardiopulmonary Resuscitation in Pregnancy
    2. See Trauma in Pregnancy
    3. High rates of failed Endotracheal Intubation
      1. Difficult glottic views
      2. Decreased oxygen reserve
      3. Increased aspiration risk
      4. Difficult passage of Endotracheal Tube
    4. Approach
      1. Prepare for difficult airway (see above)
      2. Employ adequate preoxygenation and Apneic Oxygenation
      3. Head of bed at 20 to 30 degrees decreases aspiration and Hypoxia risk
      4. Use smaller diameter Endotracheal Tube (7.0 mm)
  8. References
    1. Gill and Maldonado (2024) Crit Dec Emerg Med 38(11): 18-9
    2. Lentz (2020) J Emerg Med 59(4):573-85 +PMID: 32591298 [PubMed]

VII. Prevention: Post-Intubation Hypotension

  1. Anticipate post-intubation Hypotension (related to sedation, Positive Pressure Ventilation, PEEP)
    1. Monitor Blood Pressure frequently in the period around intubation
    2. Post-intubation Hypotension is associated with worse outcomes
    3. Hypotension occurs in up to 25% of emergency intubations (Cardiac Arrest in 3% of intubations)
  2. Avoid intubating a severely hypotensive patient (outside of crash airway without RSI)
    1. RSI, NIPPV and Endotracheal Intubation may all significantly lower Blood Pressure further
    2. Transition from negative pressure ventilation (diaphragm) to intubation decreases Preload
    3. Peri-Intubation Hypotension is ominous, and may herald imminent Cardiac Arrest
    4. Temporize airway and breathing management (Nasal Airway, bipap) during stabilization
    5. Consider awake intubation
  3. Predict Hypotension following RSI and intubation (consider fluid bolus prior to intubation)
    1. Extremes of age (children or age >65 years)
    2. Extremes of body habitus (morbid Obesity or cacchexia)
    3. Hypoxemia or COPD
    4. Shock states
      1. Hypovolemia
      2. Vasodilatory shock (e.g. Sepsis)
      3. Cardiogenic Shock
      4. Shock Index (HR/SBP) > 0.8
      5. Borderline MAP (65-70 mmHg) pre-intubation
        1. Even a preintubation SBP <140 mmHg may fall significantly with intubation
  4. Evaluation
    1. Consider Arterial Line for Blood Pressure Monitoring
      1. Place before radial pulses are lost
      2. Arterial Lines remain reliable even in Hypotension and Tachycardia (contrast with Blood Pressure cuffs)
    2. Consider Inferior Vena Cava Ultrasound for Volume Status
      1. Fluid responsiveness may be assessed with Passive Leg Raise Maneuver combined with IVC Ultrasound
      2. IVC <1.5 cm on Ultrasound immediately after intubation, is associated with Hypovolemia
  5. Management: Optimize systolic Blood Pressure prior to RSI
    1. Use agents less likely to lower Blood Pressure
      1. No RSI agents are needed in Cardiac Arrest (crash airway)
      2. Avoid Propofol as Sedative (induction agent) for emergency intubation
      3. Choose induction agents with less risk of Hypotension (Etomidate, Ketamine)
        1. Ketamine in 0.25 to 0.5 mg/kg boluses until dissociation
        2. Etomidate 0.3 mg/kg IV
      4. References
        1. Jabre (2009) Lancet 374:293-300 +PMID:19573904 [PubMed]
    2. Fluid Resuscitation
      1. Consider Normal Saline 10-20 ml/kg (to 500 to 1000 ml) bolus prior to RSI (especially in children)
      2. Standard bolus of crystalloid in a peri-intubation hemodynamically Unstable Patient is 20 cc/kg IV
        1. Even in CHF, 250 to 500 ml crystalloid bolus is tolerated to stabilize BP for intubation
    3. Vasopressors
      1. Optimize mean arterial pressure >80-85 mmHg prior to intubation (fluids, Vasopressors)
      2. Phenylephrine
      3. Norepinephrine
        1. Peri-intubation Norepinephrine is associated with increased mortality in-hospital and 90 day
        2. Smischney (2015) BMC Res Notes 8:445 [PubMed]
    4. Other measures
      1. Consider Delayed Sequence Intubation
        1. Gradual titration of Ketamine while optimizing oxygenation and mean arterial pressure
  6. References
    1. Mallemat in Herbert (2017) EM:Rap 17(2): 4-5
    2. Weingart and Swaminathan in Herbert (2021) EM:Rap 21(10): 3-5

VIII. Prevention: Aspiration

  1. Decompress Bowel Obstruction with Orogastric Tube prior to intubation
    1. Vomiting otherwise may be profuse and result in significant aspiration and very difficult intubation

IX. Resources

  1. Airway Cam (Levitan)
    1. http://www.airwaycam.com/

X. References

  1. Levitan (2013) Practical Airway Management Course, Baltimore
  2. Weingart et al in Herbert (2016) EM:Rap 16(11): 4-5

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