INDICATIONS FOR INTUBATION
Topic: Advanced Airway Management
Level: Critical Care
Next Unit: Intubation Medications
8 minute read
Indications for Intubation
Intubation is indicated when the patient's airway is blocked or compromised or cannot oxygenate or ventilate independently.
An unresponsive patient that is snoring, choking, or gurgling will likely require intubation because they cannot protect their airway. One of the best clinical indicators of a potentially compromised airway is a Glasgow coma score at or below eight.
Oxygenation or ventilation failure
A patient exhibiting hypoxia, hypercapnia, or poor/absent chest rise (despite therapies such as noninvasive positive pressure ventilation (BiPAP), supplemental oxygenation, and repositioning) is likely to require intubation for safer delivery of positive pressure breaths.
Expected clinical course
Expected deterioration is a common reason for intubation. Patients with severe head injuries, penetrating neck injury, airway burns, severe overdoses, or multisystem trauma may be intubated to control the airway before clinical deterioration.
Algorithmic Decision Making
The decision to intubate may be overcomplicated by a provider's assumptions about the severity of an illness or the expected clinical course of a patient. These decision-support tools can be used to ensure that an evidence-based decision is being made that will best serve your patient.
Choosing an algorithm
Three main algorithms attempt to determine the best approach to intubating a patient. These are the rapid sequence induction (RSI), crash, and difficult airway algorithm. Each of these algorithms terminates in either ventilation and oxygenation or failure and alternate airway access.
Choosing an algorithm only requires two questions, is your patient conscious, and do you anticipate a difficult airway?
- For an unconscious patient, use the "crash" algorithm
- For a patient with a difficult airway, use the "difficult Airway" algorithm.
- If neither of these applies, use the default RSI algorithm.
The RSI algorithm is the "default" intubation option. It is used in conscious patients and can be optimized with positioning, oxygenation, and medication before intubation occurs. OTHER UNITS WILL REVIEW the RSI algorithm and its components in detail.
The crash algorithm is used if a patient is unconscious despite sternal rub, has severe disruptions in vital signs, or signs of poor end-organ perfusion and shock. This algorithm has you attempt oral intubation before the administration of any medications. This is done due to the highly time-sensitive nature of the patient's vital signs and airway status. Only after an initial failure do you administer medications before re-attempting intubation.
Difficult airway algorithm
The difficult airway algorithm begins like RSI: optimizing the patient via oxygenation, medication, and positioning. It differs in that you will have multiple alternate methods of airway access ready in case of failure. We use the 'difficult airway algorithm' when the LEMON assessment of the patient identifies a potentially difficult airway. The section on difficult and failed airways will include further details on the assessment of airways and the steps taken in this algorithm.
Failed airway algorithm
The failed airway algorithm is based around cricothyrotomy, a surgical procedure where airway access is obtained through the neck. This procedure is considered a last resort. This algorithm intends to ensure that all reasonable options are exhausted without excess risk to the patient beyond their already compromised airway. The 'failed airway algorithm' algorithm is reviewed in detail in the 'difficult airways' unit.