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Intubation and Extubation

Daniel Motta-Calderon

Intubation

Background

  • Intubation is the definitive therapy for pts with worsening respiratory failure
  • Indications for intubation- hypoxic or hypercarbic respiratory failure, airway protection

Intubation checklist

  • Prepare the pt
    • IV access: at least two large bore IV access sites.
    • Optimize position: Supine sniffing position
    • Assess the airway: Assess for difficult intubation predictors (opening mouth <3cm, Mallampati ≥ III, neck circumference >40cm, thyromental distance <6cm, head-neck extension <30 degrees)
    • Optimal pre-oxygenation: using FiO2 100% (facemask, high flow nasal cannula)
    • Optimize medical status: resuscitation, temporize hyperkalemia, Hb >7
  • Prepare the equipment
    • Monitoring: SpO2, capnography, telemetry, BP
    • Equipment: bag valve mask, 2 endotracheal tubes (ETT) with cuffs checked, direct laryngoscope, videolaryngoscope, bougie/stylet, working suction, supraglottic airway, oropharyngeal airway
    • Medications: paralytic (ex: rocuronium, succinylcholine), induction sedative (ex: etomidate, ketamine, propofol), analgesics (ex: fentanyl), maintenance sedative, IVF hanging in room, pressors (ex: Neostick)
  • Prepare the team
    • First and second intubators, RT, RN, someone to monitor hemodynamics

Rapid-sequence intubation (RSI)

  • Preferred method of induction, associated with increased first-attempt success and fewer intubation-related complications
  • -Simultaneous IV administration of rapidly acting paralytic and induction agents to achieve sedation and paralysis

Post-intubation:

  • Ensure correct placement of ETT with capnography and confirming bilateral breath sounds
  • Secure ETT with taping, tying or tube holder
  • Obtain post-placement CXR

Immediate complications of intubation:

  • Aspiration: Suction airway, ideally prior to initiation of positive pressure ventilation to prevent distal movement of aspirated contents. Cricoid pressure maneuver historically used to reduce risk but unclear if it works so often not performed
  • Cardiovascular collapse: May be hypotension or sympathetic surge (hypertension, tachycardia, arrhythmias). Manage with fluids/pressors if need, rule out other causes (ex: hypoxia, PTX)
  • Hypoxemia: Preoxygenate with 100% FiO2 to minimize risk. Rescue maneuvers with bag mask ventilation if needed
  • Mechanical injury: Dental, soft tissue, tracheal, laryngeal. Retrieve any dislodged teeth, suction blood

Extubation

Are they a good candidate for extubation?

  • Are they oxygenating well? SpO2 ≥90% with FiO2 ≤50% and PEEP ≤8cm H20
  • Has the underlying cause of their respiratory failure improved?
  • Did pt pass their SBT?
    • See ABCDEF Bundle section for details on SBT
  • Is pt able to protect their airway?
  • Is the pt on a stable pressor requirement or no pressors?
  • Is pt coughing and clearing secretions?
  • Is pt off sedation, alert and following commands?
  • Positive cuff leak? (See below for steps)
  • Consider calculating the rapid shallow breathing index (RSBI): RR/tidal volume (L)
    • Set PS at 0cm H2O, and PEEP at 5cm H2O and, measure VT & RR for one minute.
    • RSBI ≥ 105 predicts likely failure to wean. The use of a RSBI is attending dependent.

Post-extubation complications

  • Post-extubation stridor: 2/2 laryngeal edema
    • Positive cuff leak test= high risk methylprednisolone 20mg IV Q4H for 4 doses prior to extubation to prevent
    • If after extubation: methylprednisolone 40mg IV + inhaled racemic epinephrine. If stridor >60minutes, consider reintubation
    • Cuff leak test:
      • Suction secretions and set the ventilator into the AC mode
      • Inflate the cuff and record inspiratory and expiratory VT to evaluate for differences between the two volumes
      • Deflate the cuff record the expiratory VT over the next six breathing cycles. Average the three lowest expiratory VT values
      • The cuff leak volume is the difference between the inspiratory VT (measured before the cuff was deflated) and the averaged expiratory VT. If the difference is <100cc, this is considered failure but is not an absolute contradiction to extubation
  • Post-extubation respiratory failure
    • Recurrent hypoxic or hypercarbic respiratory failure
    • Assess for aggravating factors (volume overload, shock, AMS, etc.)
    • For hypercarbic respiratory failure, may trial BiPAP. If unsuccessful -> reintubate
    • Preventative post-extubation BiPAP not routinely used in all pts but consider in select populations at high risk for failure: severe COPD with preexisting chronic hypercarbia, cardiogenic pulmonary edema