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Thursday, June 7, 2012

Indications for intubation of the critically ill

When it comes right down to it, the decision to Intubate a patient is a difficult one, and generally involves all a combination of many of the following:
  1. An assessment of the patient
  2. Interview with friends and family
  3. Knowledge of the history of patient and recent history
  4. Analysis of data if available (EKG, lab results)
  5. How critical is the patient?
  6. Is there a sense of impending doom?
  7. Past experience of the clinicians at bedside (doctor, RN, RT)
  8. Education of clinicians at bedside
  9. Common sense
Rarely is the decision an easy one.  Often do I find that both I and the doctors involved wonder whether intubation was indicated.  "Could we have done something different?" and "Did we make the right choice?" are common questions. 

The answers are never obvious, and stem to an array of ethical discussions that have no answers either, such as:  "Are we just delaying the inevitable?"  The ultimate goal, however, is always the same:  To prevent the patient from dying due to hypoxemia or hypoventilation.

The task of listing such indications is compounded by modern wisdom and technology.  For instance, we used to list intubation as indicated anytime positive pressure ventilation was required, although today not even that is true as I note below.  

Still, most RTs should be able to know what patients are candidates for intubation.  Yet to write the indications down into a guideline and suggest to intubate a patient any time they fall into such a category would be both frivolous and dangerous.  

Likewise, I have found by my experience that modern wisdom and technology (like BiPAP) has decreased the number of patients who are intubated.  Still, there will come a time when you will have no choice but to intubate.  

That said, the following are the basic indications for intubation as best as they can be written down:
  1. Relieve airway obstruction:  Severe bronchospasm (asthma, COPD), laryngeal edema (burns, epiglotitis)
  2. Facilitate removal of secretions:  Chronic bronchitis, cystic fibrosis, asthma, pneumonia, pulmonary toilet
  3. Protect airway from aspiration:  Anything that causes lack of gag reflex, such as neuromuscular disorders, drug overdose
  4. Hypoxemia:  If the patient is not oxygenating, and other means of supplying supplemental oxygen fail (NRB, BiPAP).  May include pneumonia, CHF, CF, COPD
  5. Ancicipated loss of control of airway:  Anesthesia use (as in surgery), paralytic use, trauma, increasing laryngeal edema as in from burns, worsening stridor (suspected bronchiolitis),  cardiopulmonary arrest, respiratory failure, impending loss of consciousness
The following I have removed from the list for said reason:
  1. Facilitate application of positive pressure ventilation:  In many cases of respiratory failure, BiPAP may be trialed first, and this often eliminates the need for intubation. This is particularly true for cases of COPD and heart failure. This is true so long as these patients are consciously breathing. If a patient is unconscious, or is otherwise unable to take the mask off, intubation should always be considered. 
So how long do you wait to intubate?  Do you try BiPAP first?  Did we make the right decision?  These are questions often left to the best judgement of those caring for the patient. 

  1. Egans:  Fundamentals of Respiratory Care
  2. Critical Care Medicine Tutorials

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