Immediately place LMA/SGA, call for advanced airway provider
Contraindications to NG/OG tube placement?
#2 intubation attempt
- Must modify at least one core approach to intubation technique
- Surgical airway supplies should be open and at the bedside
Place surgical airway, off pathway
Confirmation of placement checklist (minimum)
- Visualization of tube through cords
- Chest rise
- Auscultate
- End tidal CO2 (Inline or Cap) present
- Oxygen saturation rises appropriately
- Chest x-ray
Concern for COPD or asthma?
IV access established x2?
C-Collar present?
- Clinically requires urgent intubation
- Delayed sequence or awake intubation candidates
- Severe facial trauma or anatomical abnormalities (including morbid obesity)
- Do not resuscitate / Do not intubate directive
- Place patient on cardiorespiratory monitor with pulse oximeter
- BP cycling Q1 min
- Place nasal cannula AND non-rebreather on patient at 15 L/min (goal: minimum of 3 min)
- Move the head of bed to 30 degrees or other techniques to optimize airway
< 2 months old?
Patient requires positive pressure ventilation?
2 attempts by trained provider at peripheral IV access (max time 60 seconds)
Select sedation/induction agent
Status epilepticus or < 1 years old?
Concern for COPD or asthma?
Catecholamine depleted shock?
Select paralytic medication
< 1 years old?
NG/OG tube placement
Obstructive strategy
- I:E ratio: goal of 1:4, titrate as needed
- Assure that expiratory phase is complete prior to initiation of inspiration. Adjust rate or inspiratory time accordingly.
- Permissive hypercapnia (Goal to keep pH above 7.25; may rarely need a bicarb drip)
< 10 years?
Optimize oxygenation (PEEP + FiO2)
Goal PaO2 55-80 mmHg or SpO2 88-95% Use a minimum PEEP of 5 cm H2O
FiO2 | PEEP |
0.3 | 5 |
0.4 | 5 |
0.4 | 8 |
0.5 | 8 |
0.5 | 10 |
0.6 | 10 |
0.7 | 10 |
0.7 | 12 |
0.7 | 14 |
0.8 | 14 |
0.9 | 14 |
0.9 | 16 |
0.9 | 18 |
1.0 | 18-24 |
Post-intubation care
- Secure tube, return head of bed to 30 degrees if not present
- Maintenance fluids
- Vitals Q15 min and continuous EtC02 monitoring
- VBG 10 min after intubation, then as needed
- Vecuronium 0.1 mg/kg IV available in case of movement (consider giving preemptively to prevent self-extubation if patient to be relatively unsupervised - e.g. imaging)
Contraindications to Succinylcholine?
Successful bag-mask ventilation?
Bag-mask ventilation with PEEP valve
Intraossous line placement
Consider intubation without paralytics. May consider adding analgesia such as morphine. Also may consider placing OG tube prior to intubation to evacuate stomach.
In-line stabilization
Optimize panoxygenation (preoxygenation + apnic oxygenation)
Complete timeout and checklist
< 1 yrs or < 5 yrs with SCh?
2 mg/kg (< 2 years), 1.5 mg/kg (> 2 years) - max 200 mg
#1 intubation attempt
Consider video larnygoscopy (especially VL/DL combination devices)
Checklist verbalized, give sedation and paralytic medications
Signs of potential difficult airway
- Short neck (Turners syndrome, etc.)
- Thick neck
- Protruding upper incisors
- Receding or small mandible
- Facial trauma
- Blood in airway
- Expanding hematoma
- Swelling of intra-oral structures
- Laryngeal edema
- Obesity
- Facial hair
- C-spine collar or other devices
Indications for RSI
- Failure to oxygenate
- Failure to ventilate
- Loss of airway tone
- Decreased consciousness/loss of airway reflexes
- Increased work of breathing likely leading to clinical deterioration
- Airway protection
- Combative patients at risk of harm to self or others
Fentanyl 2 mcg/kg bolus then 1 mcg/kg/hr
Any one of the following
- Status epilepticus
- Requires frequent neuro checks
- Bradycardia
Head positioning to optimize airway (sniffing position with ear canals level with sternal notch)
- Infant: Due to large occiput, add a shoulder roll
- Child: Often optimized with no additional support
- Adult: Support with towels or pillow under patient's head
- Obesity: May require more support under patient's head and neck
If patient has g-tube, consider venting prior to intubation attempts.
Modifiable intubation techniques for each attempt
Attempt defined as any time the laryngoscope enters the mouth
- Change of airway provider
- Manipulation of head, neck, larynx or device
- Adjunct devices (LMA, SGA, bougie, etc.)
- Size/type of device
- Suction/O2 flow
- Pharyngeal muscle tone
Drug (IV) | Onset | Duration |
Ketamine | 30 sec | 5-10 min |
Etomidate | 30-60 sec (peak 1 min) | 3-5 min |
Succinylcholine | < 60 sec | 4-6 min |
Rocuronium | 1-2 min (peak 4 min) | 30 min |
Vecuronium | 2-3min (peak 3-5 min) | 25-40 min |
Fentanyl | 30 sec | 30 min - 1 hour |
Midazolam | 3-5 min | < 2 hours |
If at any point ventilation becomes severely compromised, immediately progress to surgical airway
Propofol 0.5 mg/kg bolus then 20 mcg/kg/min, titrate to adequate sedation
Consult advanced airway provider
Obtain primary equipment
- Oxygen (2 sources)
- Suction (2 sources tested and active)
- Bag-valve mask with PEEP valve (tested)
- Proper sized oral and nasopharyngeal airway (and lubricant)
- Laryngoscope (video or direct) - check light source
- Endotracheal tube (plus a size larger and smaller than expected) - test cuff
- Stylet
- Devices to secure endotracheal tube
- Bougie
- Monitors/Capnometer/Esophageal detection device
- Broselow tape (for pediatric patients)
Obtain backup equipment
- Secondary airway visualization device (video, direct, etc.)
- Backup airway devices (supraglottic airway, laryngeal mask airway, etc.)
- Code medications / Push dose pressors
Contraindications to Succinylcholine
- History of malignant hyperthemria
- Renal failure or other known/risk for hyperkalemia
- Myopathy/Muscular dystrophy
- Neuromuscular junction diseases
- Guillain-barré syndrome
- Severe burns
- Crush injuries
- Stroke with hemiparisis > 72 hours old
- Bedbound or prolonged immobility (including developmentally delayed individuals)
Off pathway, consider repositioning and surgical airway
Comparing Paralytics
| Rocuronium | Succinylcholine | |
| Depolarizing | No | Yes |
| Onset | 30 sec | 5-10 sec |
| Time to intubation | 90 sec (at 1-1.2 mg/kg) | 30-60 sec (at 1.5-2 mg/kg) |
| Fasciculations | No | Yes |
| Duration | 45-60 min | 8-15 min |
Pretreatment medications
Atropine
- May be useful in patients < 1 year, or < 5 years if receiving Succinylcholine (SCh)
Lidocaine
- No evidence to support routine use
Opiates
- No evidence to support routine use
Defasciculating dose of paralytics
- No evidence to support routine use
#3 intubation attempt
- Must modify at least one core approach to intubation technique
- Must be performed by most advanced airway provider immediately available
Suggested age specific ventilation rates (titrate as needed)
0 - 2 mo | 30 bpm |
2 mo - 1 yr | 25 bpm |
1 yr - 2 yrs | 22 bpm |
2 yrs - 10 yrs | 20 bpm |
> 10 yrs | 18 bpm |
Protective strategy
- Mode: SIMV with pressure support
- Tidal Volume: 7 ml/kg, assess for air entry and chest excursion
- PEEP: Start at 5, titrate as needed
- Rate (RR): Start at age appropriate rate (18 bpm for adults), titrate as needed
- FiO2: start at 100% (unless contraindications), titrate down as possible
- I:E ratio at 1:2 seconds
Richmond agitation-sedation scale (RASS) scoring system
Points | Criteria |
1 |
|
2 |
|
3 |
|
4 |
|
Label | Description | |
+4 | Combative | Combative, violent, immediate danger to staff |
+3 | Very Agitated | Pulls to remove tubes or catheters; aggressive |
+2 | Agitated | Frequent non-purposeful movements, fights ventilator |
+1 | Restless | Anxious, apprehensive, movements not aggressive |
0 | Alert & calm | Spontaneously pays attention to caregiver |
-1 | Drowsy | Not fully alert, but has sustaind awakening to voice (more than 10 sec) |
-2 | Light sedation | Briefly awakens to voice (less than 10 sec) |
-3 | Moderate sedation | Movement or eye opening to voice |
-4 | Deep sedation | No response to voice, but movement or eye opening to physical stimulation |
-5 | Unarousable | No response to voice or physical stimulation |
Calculate sedation score (RASS, N-PASS, COMFORT, etc.) and select post-intubation sedation
NOTE: All intubations should be approached as 'difficult' no matter what the underlying assumptions may be.
Intubation by advanced airway provider?
