Intubation basics

"By failing to prepare, you are preparing to fail"

One cannot emphasised the importance of the preparation phase when intubating a patient. The insertion of the tube is only 1/7th of the process... of the 7 big steps for intubation. It was only in the ER, when faced with all sorts of difficult airways, from the anatomically difficult ones to the physiologically difficult ones, did I learn to appreciate the value of the preparation phase before intubation.

Terminology

• Rapid sequence intubation
• requires emergency intubation, but not a crash intubation
• on a patient who is not fasted and hence at risk of aspiration
• hence involves a fast acting muscle relaxant and avoid using the BVM to prevent the risk of aspiration
• Crash intubation
• patient is near-death or near collapse

Why intubate?

• Failure to oxygenate
• Failure to ventilate
• Anticipated clinical deterioration
• Unable to protect their own airway

Planning phase

• Intubation is only 1/7th of all the steps involved in safely intubating a patient.
• It may not always be successful; hence we needs back up plans.



A sample from Kangaroo Island SA

• Melbourne launched the concept of VORTEX, to reinforce the 3 pillars of BVM-LMA-ETT before deciding to plunging into surgical airway. It also represents the steps taken and the difficulty level of each step when faced with a difficult airway
• 

How to intubate?

1) Preparation	→ Assess patient’s airway 4D Dentition Dysmotility Distortion Disproportion Difficult BVM & LMA NOMADS N: no teeth O: obese M: mask fit A: age D: distortion S: stiff lungs Difficult DL & intubation LEMON L: look externally (jaw, teeth, neck, obesity, face) E: evaluate 3:3:2 M: Mallampati score (erect) O: obstruction N: neck immobility Difficult cricothyroidotomy AIR A: access I: injury R: radiation Physiological difficult airway HOPA H: hypotension O: hypoxia P: pH (metabolic acidosis) A: agitation → Prepare staff & checklist Example of a checklist from HCMC → Difficult airway team → Prepare equipment Suction NP/OP airway ET tube Laryngoscope Direct Video Glidescope: hyperacute angulated laryngoscope blade allows visualisation of the vocal codes with less head & neck movement The C-MAC® video laryngoscope is available in the original MACINTOSH blade shapes (sizes 2, 3 and 4), the MILLER shape (sizes 0 and 1), and in the blade shape for difficult airways – the D-BLADE™ Airway adjuncts Bougie Failure plan equipment LMA Silicon LMA with port for gastric suction Intubating LMA Cricothyroidotomy set
2) Pre-oxygenation	Mechanism: Nitrogen washout- replace alveolar nitrogen with oxygen Purpose: to maximise the time available to perform intubation before desaturation occurs Time to desaturation to less than 90% is: Healthy adults: 8mins Moderately ill adults: 5mins Obese adults: 2.7mins Methods: 3-5 mins with NRM 8 vital breaths Apneic oxygenation Nasal cannula with high flow oxygen NIV DSI
3) Pre-treatment	Children: Atropine to reduce secretions Atropine to prevent bradycardia Head injury Fentanyl 2-3mcg/kg Lidocaine
4) Paralysis with induction	Use of either depolarising or  non depolarising paralytic Suxamethonium or Rocuronium found in ED
5) Position	Prepare the patient’s position Align tragus with the sternal notch horizontally This aligns the oral axis, pharyngeal & laryngeal axis Ramp position if very obese to achieve the above
6) Placement of tube	Confirm placement by: End tidal capnography Watching the black line past the vocal cord Misting of the tube Chest rise bilateral 5 pt auscultation Colour change on colorimetric capnograph (purple→ yellow)
7) Postintubation management	ECG, BP Ionotropes, targetted temperature management CXR Urinary catheterisation

• Links

• https://emergencymedicinecases.com/episode-8-emergency-airway-controversies/
• https://canadiem.org/crackcast-airway/
• http://www.foamem.com/2015/04/03/red-hot-emergency-intubation/
• http://www.foamem.com/2015/05/08/a-video-tutorial-for-endotracheal-intubation/
• https://ruraldoctors.net/anaesthesia/airway/
• https://emin5.com/category/airway/

• Interesting videos

• Video of intubation gone wrong: Elaine Bromley's case
• Even the most experience people may not be able to perform certain tasks; rather than be obsessed about performing the task, we should step back and relook at the situation. Its not about the task but about patient safety and well-being.
• http://www.foamem.com/2013/03/02/how-to-laryngoscopy-and-intubation-by-scott-weingart/