The decision to intubate
- Calvin A Brown, III, MD, FAAEM
Calvin A Brown, III, MD, FAAEM
- Assistant Professor of Medicine
- Harvard Medical School
The first step in any resuscitation is the verification or establishment of a patent and protected airway. Emergent defibrillation is the sole, occasional exception to this principle. Without adequate oxygenation, all other potentially life-saving maneuvers will fail. Most often, clinicians secure the airway of an unstable patient through placement of a cuffed endotracheal tube.
The emergency clinician should be able to determine the need for a definitive airway quickly and confidently. Nevertheless, the standard resuscitation guides provide little more than brief, generalized statements about when to intubate [1-3].
This topic review discusses how to determine the need for intubation and provides a simple decision tool that is applicable to virtually all emergency patients regardless of age and presenting condition. Discussions of other aspects of airway management are found elsewhere. (See "Rapid sequence intubation for adults outside the operating room" and "Emergency endotracheal intubation in children" and "The failed airway in adults" and "Approach to the difficult airway in adults outside the operating room".)
DECIDING TO INTUBATE: THREE QUESTION ASSESSMENT
Emergency clinicians must often perform tracheal intubation under stressful conditions. Skillful execution of tracheal intubation requires a good understanding of several methods of intubation, how to identify the potentially difficult intubation, the drugs best suited for airway management in different clinical scenarios, and management of the difficult or failed airway. Deficiency in any of these areas reduces the likelihood of a good patient outcome. (See "Rapid sequence intubation for adults outside the operating room" and "Emergency endotracheal intubation in children" and "The failed airway in adults" and "Approach to the difficult airway in adults outside the operating room".)
Even knowledgeable emergency clinicians, however, can contribute to patient morbidity and mortality by waiting too long to intubate. Inappropriate delays in airway management can convert a relatively controlled opportunity to secure the airway into a hectic, unplanned airway management scenario ("crash" airway), eliminating the opportunity for a well-prepared, methodical approach. As examples, clinicians should not postpone intubation until the patient with anaphylaxis develops stridor or wait for worsening of hoarseness in the patient with smoke inhalation.
- American College of Surgeons Committee on Trauma. Advanced Trauma Life Support (ATLS) Student Course Manual, 9th ed, American College of Surgeons, Chicago 2012.
- ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2005; 112:IV1.
- Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122:S876.
- Walls RM, Murphy M. The decision to intubate. In: Manual of Emergency Airway Management, 4th ed, Lippincott Williams & Wilkins, Philadelphia 2012.
- Christ A, Arranto CA, Schindler C, et al. Incidence, risk factors, and outcome of aspiration pneumonitis in ICU overdose patients. Intensive Care Med 2006; 32:1423.
- Miller CD, Rebuck JA, Ahern JW, Rogers FB. Daily evaluation of macroaspiration in the critically ill post-trauma patient. Curr Surg 2005; 62:504.
- Hummler HD, Engelmann A, Pohlandt F, et al. Decreased accuracy of pulse oximetry measurements during low perfusion caused by sepsis: Is the perfusion index of any value? Intensive Care Med 2006; 32:1428.
- Talke P, Stapelfeldt C. Effect of peripheral vasoconstriction on pulse oximetry. J Clin Monit Comput 2006; 20:305.
- Williams TA, Finn J, Perkins GD, Jacobs IG. Prehospital continuous positive airway pressure for acute respiratory failure: a systematic review and meta-analysis. Prehosp Emerg Care 2013; 17:261.
- Vital FM, Ladeira MT, Atallah AN. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev 2013; :CD005351.