inpatient / Pulmonology and Critical care

Preparing for Intubation

Last Updated: 3/27/2023

Indications and Red Flags
-- Severe hypoxemia or hypercarbia despite treatment (PaO2 <60 or PaCO2 >45) with HFNC or NIPPV
-- Ongoing increased work of breathing - inability to compensate for acidemia
-- Unable to protect airway - AMS, trauma, N/V, UGIB/hemoptysis, pooling secretions
-- Anaphylaxis

Things to Know
-- Reason for Intubation (one-liner, acute change, clinical assessment, data)
-- Current Hemodynamics, RV function, volume status
-- Current Access; have IVF and push line ready to go
-- Code Status - not DNI and okay for ICU transfer
-- History of previous intubations - difficult airway or anesthesia issues (may include obese, OSA, poor dentition, huge beard, small mouth, unique anatomy)
-- Know the time of last meal, other aspiration risk factors
-- Last potassium (succinylcholine can cause hyperK)
-- Comorbidities that may pose risks/challenges or inform initial vent settings (pHTN, ARDS, concern for RV strain or PE)
-- Allergies
-- Decision-makers - who do we need to contact or update
-- Planned Sedation - propofol, fentanyl, midazolam
-- Planned Pressors - levo in most, phenylephrine in afib

Consequences of Intubation
-- PPV - increased intrathoracic pressure → drops preload, stroke volume, BP
-- Sedation - drops BP - give norepinephrine

Making patient comfortable will lead to less need for sedation
-- Fentanyl - bolus 50-100mcg, then 0.7-10ug/kg/hr titrated to pain relief; fast onset, hemodynamcially neutral, okay in renal dx
-- Dilaudid or Morphine - avoid in renal failure

Goal is light (RASS -2, wake to voice for <10 seconds), deeper if fights vent or increased WOB; less sedation = better outcomes
-- Propofol - bolus 0.25-1 mg/kg (60-80mg), then infuse 10-50mcg/kg/min; fast on, fast off, okay renal and liver dx, vasodilatory, cardiac depression, propofol infusion syndrome
--Midazolam (Versed) - resp depression, hypotension, preferred if patient hemodynamically unstable, avoid in renal failure
-- Dexmedetomidine (precedex) - slower onset (not great for RSI), brady, hypotension (but usually hemodynamically neutral), best when weaning vent (anxiolytic, but not as sedating)
-- Ketamine - myocardial depressant, salivation, good option for unstable patients, can actually raise BP
-- Etomidate - no effect on hemodyanmics, but suppresses adrenal production of cortisol for 24 hours, studies show increased mortality in septic patients

Paralytics - avoid unless breath stacking, fighting vent, ARDS

Addressing Insomnia and Delirium 
-- melatonin 3mg, quetiapine 25-50mg, clonidine 0.2-0.3; avoid benzos and zolpidem
-- up on precedex at night, then lower it during the day
-- Trazadone as last choice