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Shyam Murali
Fellow in Trauma and Surgical Critical Care - University of Pennsylvania,
Senior Editor - CriticalCareNow.com,
Writer - RebelEM.com,
Saxophonist, EDM remixer, husband, puppy father, and new human father
Determining whether a patient needs endotracheal intubation is a complex decision that requires experience and nuance. While potentially life-saving, the procedure’s complications include worsening of their current illness, development of new ventilator-related and endotracheal tube-related complications, and even death. Therefore, the decision must not be made lightly. Here are some broad categories that necessitate close monitoring of the airway or endotracheal intubation:
Respiratory failure (each of these will have a dedicated post in the future)
- Failure to ventilate (consider when pH < 7.3 +/- PCO2 > 45)
- Failure to oxygenate (although there is no exact definition of hypoxemia, consider intubation when SpO2 < 88-90% despite supplemental oxygen)
Airway protection
- Tissue swelling or obstruction of the airway (eg. anaphylaxis, angioedema, tumor, or infection)
- Bleeding in the airway (eg. trauma, massive GI bleed, hemoptysis)
- Decreased consciousness and/or loss of airway reflexes; patients at risk for aspiration
Impending respiratory failure or airway compromise
- Uncooperative (combative, agitated, etc.) patient with life-threatening injuries or requiring immediate procedures/imaging
- Progressive airway swelling or potential obstruction
- Urgent aggressive sedation required (eg. elevated ICPs requiring tight ICP and blood pressure control, refractory status epilepticus)
- Muscle/CNS/metabolic disorders (eg. Guillain Barré, amyotrophic lateral sclerosis, myasthenia gravis, botulism, hypocalcemia, brainstem infarction)
- Patients requiring aggressive fluid hydration (eg. severe burns, necrotizing pancreatitis)
References
- Şahiner, Y. Indications for Endotracheal Intubation. InTech Open. 2017. doi: 10.5772/intechopen.76172.
