Financial Disclosures None Optimizing Intubation Rahul Bhat, M.D. FACEP Associate Program Director Associate Professor of Emergency Medicine MedStar Georgetown University Hospital MedStar Washington Hospital Center Goal Get that ET tube in on your first attempt without your patient desatting or dying Overview Maximizing Preparation Positioning Post Intubation Care Goal: O 2 crashing patient = more time for laryngoscopy Exchange alveolar nitrogen for oxygen Start high- non-rebreather mask Increase alveoli available for oxygenation N 2 O 2 Length of pre-oxygenation 3 minutes (if possible) Position Head elevated Reverse Trendelenberg Buys you 50-100 sec 1
Flush Rate Standard 15 L/min Rotate dial to max Increased FeO 2 RCT of NIV vs NRB pre-intubation Driver, B. E., Prekker, M. E., Kornas, R. L., Cales, E. K., & Reardon, R. F. Ann Emerg Med 2017;69(1):1-6. Baillard C, et al. AJRCCM. 2006. Peri-intubation mean SpO 2 100% 90% Non-Invasive Ventilation: Upside pre-oxygenation, no gastric distension Downside lose access to airway 85% 80% NIV NRB 75% 70% Baseline Before ETI During ETI ETI + 5 ETI + 30 Baillard C, et al. AJRCCM. 2006. BVM Avoid If possible gastric distension No extra O 2 Use only when BiPAP/CPAP failed use PEEP valve Apneic Oxygenation Nasal cannula (requires second O 2 tree) High and tight valve= CPAP Levitan RM. No DESAT! Emergency Physicians Monthly December 9, 2010. 2
Risk Category Oxygenation strategy Preoxygenation 91- < 91% Onset of paralytic >96% Nonrebreather Nonrebreather and NC high As above or Weingart SD, Levitan RM. Ann EmergMed 2012;59(3):165-175. Apneic Period Risk Category Oxygenation strategy Preoxygenation 91- < 91% Onset of paralytic >96% Nonrebreather Nonrebreather and NC high As above or Weingart SD, Levitan RM. Ann EmergMed 2012;59(3):165-175. Apneic Period Risk Category Oxygenation strategy Preoxygenation 91- < 91% Onset of paralytic >96% Nonrebreather Nonrebreather and NC high As above or Weingart SD, Levitan RM. Ann EmergMed 2012;59(3):165-175. Apneic Period O 2 sat > Take Home Points In the non-agonal respirations patient Optimize O 2 prior to pushing drugs O 2 sat < Apneic O 2 for All Apneic/ Obtunded Suction Backup device IV with saline ing CO 2 detector Tube Preparation Tube Prep - Straight to Cuff Cadaver study bend of tube < 35 o provides optimal tube passage Levitan RM. Pisaturo JT, Kinkle WC, Butler K, Everett WW. Acad Emerg Med. 2006 Dec;13(12):1255-8. 3
Patient Positioning Ear to sternal notch Obese patients All patients best view Airway positioning Cricoid pressure Aka Sellick s maneuver Greenland KB, Edwards MJ, Hutton NJ, Challis VJ, Irwin MG, Sleigh JW. Br J Anaesth. 2010 Nov;105(5):683-90. Cricoid Pressure End of an Era MRI studies Inferior laryngeal view Airway collapses Esophagus incompletely/not occluded > 80% attempts Boet S, Duttchen K, Chan J, Chan AW, Morrish W, Ferland A, Hare GM, Hong AP. J Emerg Med. 2012 May;42(5):606-11. BURP Is there a better way? Is there a better way? RCT: Bimanual laryngoscopy/elm vs BURP vs CP Better view Easier to pass tube Levitan RM, Kinkle WC, Levin JL, et al. Ann Emerg Med. 2006;47:548-555. 4
Goal Get that ET tube in on your first attempt without your patient desatting or dying Intubation Checklist Preoxygenate (15L/min NC + NRB, BiPAP) Prepare (Suction, Backup, Code Crit Airway?) Peripheral IV (with IVF ing) Plan vent settings (estimate MV; IBW) Position (Ear to sternal notch) Premedicate (Etomidate 0.3 mg/kg) Paralyze (Sux 1.5 mg/kg; Roc 1 mg/kg IBW if K) Placement check (Graphic EtCO 2 ) Tube s In! Patient s alive! Post Intubation Care ABG OGT placement CXR Sedation Vent settings Continuous ETCO 2 (non c-spine precautions) Head of bed > 30 o Post Intubation Care Post-Intubation Checklist Ventilator: TV 6cc/kg IBW Match pre-intubation min. vent. Titrate FiO 2 < 60% (Goal SpO 2 96-98%) Sedative (consider adding opiate) OGT pre-cxr Bhat, R., Goyal, M., Graf, S., et al Western JEM, 2014; 15(6): 708. Head of Bed 30 (except ischemic CVA) ABG within 30 minutes Consider restraints 5
Take Home Points In the non-agonal respirations patient Cricoid Pressure Airway positioning Optimize O 2 prior to pushing drugs O 2 sat > O 2 sat < Apneic/ Obtunded Apneic O 2 for All Take Home Points Bimanual laryngoscopy/elm Better view Easier to pass tube Post Intubation Care ABG OGT placement CXR Sedation Vent settings Continuous ETCO 2 (non c-spine precautions) Head of bed > 30 o Levitan RM. No DESAT! Emergency Physicians Monthly December 9, 2010. Thank You! rgbhat77@gmail.com @GTownEM 6