When Should You Intubate?

You’ve responded to the identical nightclub thrice this month. Each name is identical: a younger grownup discovered unresponsive, almost certainly the results of an overdose on heroin. The affected person is a male in his mid-twenties, pupils pinpoint, he’s barely respiration and exhibiting the early indicators of cyanosis. You load him onto the stretcher, place him in your unit, and race to the closest hospital.


En route, you start bagging the affected person whereas one other medic hooks him as much as the monitor and begins an IV. As you squeeze the Ambu bag, you ask your self: “Is it time to intubate?


Benefits of Endotracheal Intubation

We’ve all heard the catch phrase, “Lower than eight, intubate,” which means if the affected person has a Glasgow rating of lower than eight, they’re most likely unable to guard their airway. And whereas there are a number of airway adjuncts to select from nowadays, endotracheal intubation continues to be thought of the popular methodology of controlling the airway. Its benefits embody:


  • It isolates the airway from gastric contents, thereby lowering the danger of aspiration
  • Permits air flow with 100% oxygen
  • Eliminates the necessity to preserve mask-to-face seal
  • Facilitate tracheal suctioning
  • Prevents gastric distention
  • Offers an extra route for some medicines


Figuring out these benefits, it appears a no brainer to decide on endotracheal intubation on your affected person. However needless to say there are particular elements that may hamper the location of an endotracheal tube. Be alert in case your affected person displays any of the next:


  • Receding chin
  • Brief neck
  • Massive tongue (particularly in Down syndrome)
  • Small oral cavity
  • Cervical immobilization or restricted neck mobility
  • Facial trauma
  • Bleeding within the oral cavity
  • Energetic vomiting

These elements, in isolation or mixture, could make for a troublesome intubation. But when your affected person will profit from a complicated airway, and you’re assured you may overcome these impediments, then it’s time to assemble your gear.


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Use the Proper Instruments

When you’ve made the choice to intubate, it’s essential to then assemble your gear. This stuff needs to be saved collectively in an airway bag or compartment, so that you’ve the whole lot you want for a profitable intubation. This contains:


  • PPE – gloves, masks, and goggles
  • Appropriately sized tube (most adults settle for a measurement 7.0 to eight.0)
  • Appropriately sized laryngoscope deal with and blade (both Miller or Macintosh, relying on private desire)
  • 10-ml syringe
  • Water-soluble lubricant (particularly for nasal intubation)
  • Business tube holding machine
  • Bag masks with reservoir
  • Supplemental oxygen
  • Stethoscope
  • ETCO2 detector


On account of dangers from COVID-19, it’s necessary to put on N95 with eye safety or PAPR, gloves, and a robe.


Don’t Overlook the Suction Unit!

One of the necessary instruments you’ll want when intubating is your transportable suction unit. If the affected person is bleeding, vomiting, or has extreme mucus or trauma, you’ll must clear the oral cavity earlier than visualizing the vocal cords. Endotracheal intubation can’t be carried out by way of blind insertion. To make sure you have handed by the cords, it’s essential to SEE the tube cross by the cords. If not, you’ll almost certainly intubate the esophagus.


Have the suction unit prepared and staged subsequent to the affected person. When you’ve got the personnel, put somebody in cost of suctioning the affected person whilst you place your self to visualise the cords. This twin method will save time and assist forestall hypoxia. Additionally, take into account the SALAD Method. Because the oral cavity is cleared, you may proceed with the laryngoscope.


Issues of Endotracheal Intubation

Though endotracheal intubation is a extremely efficient technique of controlling the airway, it—like most medical interventions—carries sure dangers. They embody:


  • Hypoxemia attributable to extended intubation makes an attempt
  • Vagal stimulation leading to bradycardia
  • Trauma to the airway, which can lead to bleeding and swelling
  • Intubation of the precise fundamental stem bronchus—pull again on the tube till equal breath sounds are heard
  • Esophageal intubation—at all times visualize the cords!
  • Vomiting resulting in aspiration
  • Unfastened or damaged tooth—don’t pry when positioning the laryngoscope blade
  • Trauma to the vocal cords

Deciding when to intubate is one in all many necessary choices it’s essential to make when treating important sufferers. You should weigh the professionals and cons of your determination, protecting in thoughts the dangers and advantages to your affected person. By contemplating these elements, you may really feel safe in your selection of motion.


Editor’s Notice: This weblog was initially printed in July 2017. It has been re-published with extra updated content material.


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