Chapter 29  Proper preparation is key to successful

intubation.
Tracheal Intubation  Have basic airway, intubation, rescue,
and surgical airway equipment
INTRODUCTION immediately accessible, ideally in the
same cart with other airway
 Tracheal intubation is a cornerstone of
management equipment.
emergency airway management,
 If treating a child, have enough and
creating a direct conduit to the trachea,
appropriately sized pediatric airway
allowing airway patency, aiding
devices accessible
oxygenation and ventilation, and
 Ensure ongoing cardiac rhythm
preventing aspiration.
monitoring with continuous displays of
 intubation may also be needed to safely
the heart rate, blood pressure, oxygen
allow sedation or paralysis needed in
saturation, and end-tidal capnography.
critically ill patients requiring diagnostic
 Establish IV access and appropriate
or therapeutic interventions.
fluids.
 intubation is one component of the
 Raise the patient to the level of the
spectrum of emergency airway
operator’s xiphoid.
interventions.
 Supraglottic airways and the conversion
 Although ventilation and intubation are
of a supraglottic airway to an
typically performed with the patient
endotracheal tube (ETT)
fully supine, positioning the patient so
that the external ear is aligned with the
PREPARATION sternal notch may improve glottis
visualization
 Refrain from applying padding under
the shoulders or neck as this position is
suboptimal for facilitating emergency
intubation.
 A more upright position for intubation
may be necessary if the patient cannot
lay supine—for example, the patient
with severe pulmonary edema or morbid
obesity
 Ensure that the oxygen source and
regulator are functional.
 Have a bag-valve-mask ventilator and
oral and nasal airways at the bedside,
and make sure that a large-diameter
suction catheter and functional suction
unit are ready.
 For potential uncontrolled emesis, use
an assistant to place a Yankauer catheter
AIRWAY ASSESSMENT
 Approximately up to 15% of initial
emergency airway attempts and 1% to
 3% of overall attempts at tracheal  Preoxygenation optimizes blood
intubation fail with standard techniques. oxygen content + displaces nitrogen in
 It is best to expect difficulty with all the alveoli
emergency airway cases, applying a o = potential reservoir of oxygen
uniform approach to all patients. While -> prevent hypoxia and
the terms difficult intubation and hypoxemia (first minutes of
difficult laryngoscopy are often used apnea).
interchangeably, there are important
distinctions. **hypoxia develops more quickly in children,
pregnant women, and obese patients and in
 Difficult intubation refers to a situation
hyperdynamic states.
To preoxygenate:

 administer 100% oxygen for 3

minutes, using a non-rebreather
mask supplied with 15 L/min of
oxygen.
 Nasal cannulas alone do not provide
optimal preoxygenation
 Non-rebreather masks typically
deliver 60% to 70% oxygen.
 bag-mask ventilator can deliver 90%
to 97% oxygen. (requires a tight seal,
with either active bagging or enough
inspiratory pressure from the patient
to open the one-way valve.
 Number of bag-mask devices that
vary in their oxygen delivery; use a
where multiple attempts are made at bag-valve mask device with one-way
intubation, inspiratory and expiratory valves.

Some anesthesia scales associate anatomical **In patients who have arterial oxygen
features with intubation difficulty; for saturations( below 95% ), a short period of
example, Mallampati criteria relate the noninvasive positive pressure ventilation may
degree of posterior pharyngeal obstruction by improve the oxygen reservoir.
the tongue with intubation difficulty o This strategy is particularly effective
**Although potentially applicable to some ED in obese patients.
patients, in select situations, formal airway o Elevating the head of the patient 20
assessment may be impractical or impossible. to 30 degrees improves
preoxygenation.
Preoxygenation

 Begin preoxygenation as soon as

possible, even for patients with no
apparent hypoxia/hypoxemia.
o Finally, providing high-flow nasal
cannula oxygen (≥15 L/min) or the
OptiflowTM oxygen delivery system
(which allows even higher flow)
throughout the apneic phase of
RSI prolongs the period of safe apnea
during paralysis and is wise in all
patients undergoing emergent RSI.

VIDEO LARYNGOSCOPY

 Video laryngoscopes (VLs) use an

integrated high-resolution camera and
video monitor to facilitate indirect
glottic visualization and ETT placement.
 VL creates a magnified view that cannot iv. Once past the teeth, the operator
be obtained through direct identifies the midline by finding
laryngoscopy. the uvula.
 VL also allows shared visualization and v. The blade is then slowly
video recording useful for quality advanced down the tongue until
review, education, and training. the epiglottis is seen
 VL may be used as the primary or vi. The ideal view is usually
rescue intubation technique obtained by insertion into the
 While first-pass and overall intubation vallecula, much like a
success rates are similar between direct Macintosh blade. The handle is
laryngoscopy and VL, VL improves then gently tilted forward until
glottic visualization and reduces visualization of the glottic
intubation complications, including rates opening is obtained.
of esophageal intubation.
 However, compared with conventional The two most studied VLs are the GlideScope
direct laryngoscopy, the glottic view Video Laryngoscopeø(Verathon, Bothell,
with VL may be inferior in a small WA) and the C-MAC Video Laryngoscopeø
subset of patients. (Karl Storz, Tuttlingen, Germany) (Figure
 VL may be most useful in patients with 29A-13).
difficult airway anatomy, including
obese patients and those with limited Both brands also have conventionally curved
mouth opening or neck mobility. blades available, allowing the device to
 Avoid VL and use direct laryngoscopy function much like a conventional
if the camera may be obscured by laryngoscope; this feature allows for
emesis. supervision of novice intubators during the
 Laryngoscopic technique is slightly traditional intubation technique.
different with VL than conventional FLEXIBLE FIBEROPTIC
laryngoscopy: LARYNGOSCOPY
i. , the operator performs the
intubation watching a video
screen rather than looking
directly into the oropharynx.
ii. VL often uses a hyperangulated
blade. The combination of these
two features allows
visualization of the glottis with
only limited extension of the
head and neck. A specially
designed stylet is required when
VL is used in this manner.
iii. In contrast to traditional
laryngoscopy, a midline
insertion approach is preferred
and a tongue sweep is not
needed with VL.
The flexible fiberoptic laryngoscope (FFL) uses requires proper equipment as well as
fiberoptic technology embedded in a flexible appropriate training.
 If equipment or expertise is not
available in the ED, consult an expert
with fiberoptic skills and tools.
 FFL requires setup time as well as a
compliant, spontaneously breathing
patient. Patients needing an immediate
airway, with near-complete obstruction,
with large bleeding or vomitus, and who
cannot be ventilated to maintain
saturation are poor FFL candidates.
 Topical anesthesia is essential for FFL
intubation success.
 Use atomized or nebulized topical
anesthetics, such as 4% lidocaine.
BLIND NASOTRACHEAL INTUBATION

 may be helpful where laryngoscopy

may be difficult, RSI is contraindicated,
and FFL is not available.
 Nasotracheal intubation is less common
given other available options.
 Severe traumatic nasal or pharyngeal
hemorrhages are relative
contraindications to nasotracheal
intubation.

1. Position the patient upright with the

head in a neutral or slightly extended
position (“sniffing position”).
2. Stand to the side of the patient with one
tube to facilitate visualization of and access to
hand on the tube and with the thumb
the airway
and index finger of the other hand
 Newer flexible scopes use video straddling the larynx.
technology, not fiberoptics, and 3. Insert and advance the lubricated tube
interface directly with VL monitors. along the nasal floor; the right naris is
FFL aids when anatomic limitations, often larger.
such as angioedema, epiglottitis, 4. Pass the ETT straight back toward the
Ludwig’s angina, congenital anatomic occiput (not upward), and then advance
abnormalities, and cervical spine it while rotating it medially 15 to 30
immobility, prevent traditional degrees until maximal airflow is heard
laryngoscopy. through the tube
 Growing numbers of ED practitioners 5. Steady, gentle pressure or slow rotation
are becoming skilled with FFL.30 FFL of the tube usually bypasses small
obstructions.
 6. Gently but swiftly advance the tube at  The more challenging clinical scenario
the initiation (upswing) of inspiration is the case of unanticipated intubation
7. The typical optimal depth of difficulty occurring after the
nasotracheal tube placement is 28 cm at administration of sedative and paralytic
the nares in men and 26 cm at the nares medications.
in women.  A single failed laryngoscopy attempt
8. Confirm tracheal placement using should signal potential airway difficulty
multiple methods. and prompt corrective action.
 Although there is no single pathway or
MANAGING INTUBATION
approach to unanticipated intubation
DIFFICULTY difficulty, operators should consider
1) ANTICIPATED several guiding principles.
INTUBATION  Stay calm. Think clearly. Communicate
DIFFICULTY directly and clearly.
 Use available team members (nurses,
Several factors can help identify a potentially respiratory therapists, technicians, and
difficult intubation other physicians) to assist with care and
 Assess the patient’s clinical condition mobilize needed equipment,
and identify factors that will impede medications, and personnel
successful intubation.  Use of cognitive aids (e.g., checklists
 Weigh these observations against the and difficult airway algorithms) can help
urgency of the patient’s condition. If to minimize the stress while providing
patient consciousness or agitation is the cognitive offloading.
sole anticipated obstruction, proceed  Call for help. Where readily available,
with sedation and paralysis. In the assistance from anesthesiologists,
presence of major anatomic barriers surgeons, otolaryngologists, intuitivists,
(tumor, trauma, obesity, difficult or fellow emergency physicians may be
anatomy), consider deferring RSI, helpful but often requires time to
preserving the patient’s natural mobilize.
respiratory drive and protective airway  If you anticipate the need for assistance,
reflexes. call for help early.
 In these situations, strategies of awake  Plan and communicate the next two
intubation using FFL or (for those steps. Plan not only the next therapeutic
skilled with the technique) blind intervention but also the subsequent
nasotracheal intubation are options. intervention in the event of failure. For
 In the case of severe facial trauma, example, “I will switch to a Miller blade
immediate or urgent surgical airway with bougie insertion.
placement (cricothyroidotomy or  if unsuccessful, I will insert a laryngeal
tracheostomy) is always an option. mask airway.” Engage team members so
 awake orotracheal intubation with that they are aware of your planned
topical anesthetic is theoretically actions. Alter airway techniques with
possible but rarely achievable in the each attempt. Modify intubation blade
emergency setting. type, blade size, approach, or operator
2) UNANTICIPATED with each attempt.
INTUBATION  Do not repeat the same unsuccessful
DIFFICULTY methods with successive attempts.
 Let RSI medications wear off.
Recovery of even a minimal degree of
protective airway reflexes and
spontaneous respirations may facilitate
critically needed airway patency.
 Use noninvasive airway measures
 . Bag-valve mask with an oral or nasal
airway or insertion of a supraglottic
airway may be helpful, mitigating
clinical deterioration
 . Bag-valve mask or supraglottic airway
insertion may allow additional time for
surgical airway execution.
3) HYPOTENSION
ASSICIATED WITH
INTUBATION
 Physiologic changes
triggered by
laryngscopy or the
medications used
during RSI can induce
hypotension. While
some advocate for
empiric isotonic
crystalloid infusion just
prior to RSI, others
believe dilute low dose
boluses or ‘push-dose’
pressors prior to ETI
help mitigate
hypotension
 . The ideal fluid
volume and timing, and
the optimal vasopressor
choice and dose, are
unknown.
 common vasopressor
preparations used in
this manner, commonly
epinephrine or
phenylephrine ready
ahead of time in
syringes (rather than
quickly drawn at the
time of perceived need.