When to intubate

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mindspade

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Hi all, I understand the concept of intubation, My issue is the fine line when you jump from BVMing a pt and intubating them. I understand when the pt cant control their own airway and what not but how and a COPDer or a bad asthmatic who is still talking to you, When is the point you decided to intubate or use RSI? Thanks
 
I personally am not agressive with intubation. The only time I would be is burns to the airway. Its like anything ALS. Your going to have that small group that will have the "I did it because I can" thought process. I will always try CPAP first on a COPD or CHF pt. Once you decide to tube them its a :censored::censored::censored::censored::censored: for the hospital to get them off the vent. If a pt with asthma is still talking to you give the meds a chance to work and use a BVM for a few minutes to see if they improve.
 
It's not a decision to be taken lightly in the least, especially when you're first starting out as an advanced provider and the sole one responsible for making the decision. To put it simply, if you've tried every other non-invasive measure first, and they're not improving, or actually getting worse, and you don't believe it can wait till the hospital, that's when it's possibly time to move on.


I can tell you my first RSI was a patient with asthma/COPD/CHF where walking in and just looking at the patient I knew something had to be done. My second RSI? A little tougher to make the decision to go that route, but I could still defend it. But I also have the luxury of the excuse of being 45 minutes from a hospital, so it's a bit easier to defend the "It couldn't wait" aspect. When I was working closer to a hospital (15minutes) I deferred RSIing 3 patients until we were at the hospital, and each of the 3 were RSId on arrival.




If you can't defend your decision when asked by a peer (doctor, RT, other medics... only the ones that have to decide to RSI too), it's probably not the right decision.
 
Thanks for the advice guys. As a pretty new paramedic a question is always in the back of my mind weather or not i should tube some one or not. I am not incredibly aggressive in airway management and always attempt oxygen and medications for thinking about tubing or even putting a pt on CPAP. The only pt i have ever tubed in the field was a pt who i constantly had to remind him to breath. Im sure not all of the pts that i will have to tube will be that easy determine, but any advice helps, thanks again.
 
Generally if they require mechanical ventilation (including BVM), may require one in the future, or are so monumentally unconscious/altered that there is a risk of losing the airway then they are going to need a tube. The REAL question is should you be doing it prehospitally or not. And the answer is...it depends.

First and foremost, is the patient a good candidate for intubation? If the I have a patient that's a b!tch to ventilate and looks like they're going to be even harder to tube then you can bet I'm seriously evaluating whether we can make it to the ED where there's a ton more space, light, help and usually toys to help the process. Another thought is as above, do you need to wait to see if other options start to take effect? Do you have access to NIPPV and is that a better option for the conscious patient?

All this must be balanced with the understanding that RSI done early generally goes smoother than RSI done late in the game.

So in the end I don't have a good answer. It's one of those things you have to learn by doing. Just hope you don't futz it up too monumentally.
 
Just noticed you said your not aggressive with CPAP. Be VERY aggressive with CPAP. You'll save a lot of patients from tubes that way.
 
mindspade said:
Thanks for the advice guys. As a pretty new paramedic a question is always in the back of my mind weather or not i should tube some one or not. I am not incredibly aggressive in airway management and always attempt oxygen and medications for thinking about tubing or even putting a pt on CPAP. The only pt i have ever tubed in the field was a pt who i constantly had to remind him to breath. Im sure not all of the pts that i will have to tube will be that easy determine, but any advice helps, thanks again.
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There is nothing wrong with being agressive in airway management. But you have to understand that agressive airway management DOES NOT mean intubation
 
The few times that i have used CPAP i have loved it. A lot of times i find myself doing nebs first since my first service was not big into CPAP, and i have just stared with a service that uses CPAP regularly. Must of the times when i ask medics here about uses they just tell me that ill know when i need it. That doesn't really help since the teacher on CPAP in school in a complete joke.
 
CPAP is wonderful. Where I worked before they didn't have it prehospital but where I'm at now they do and it's just a great tool to have. Utilize it, because as others have said, that can cut down quite a bit on the act of having to tube someone, let alone other issues it alleviates while being much less invasive.

I like the other answers I've seen on here...and being a newer medic (I'm still newer myself) this is a great question to ask. I have nothing to add further because anything I would've said has been said i.e try all the meds first barring them totally crashing in front of you, CPAP, take into account distance/time from the hospital,etc.
 
As you consider a drug facilitated intubation, you should ask yourself three questions...

1) Can this patient protect and maintain their airway?

2) Is there a deficiency in oxygenation or ventilation?

3) Is intubation anticipated in the clinical course?

If you answer no to the first and yes to the second two, you're heading down the road to a DFI.
 
Once you decide to tube them its a for the hospital to get them off the vent.
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Eh....that's a very broad statement. Granted it's much better to non-invasively ventilate them (BiPAP) but it's not THAT difficult to wean most CHFers one you get past the initial crisis.

Just noticed you said your not aggressive with CPAP. Be VERY aggressive with CPAP. You'll save a lot of patients from tubes that way.
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What he said.

As you consider a drug facilitated intubation, you should ask yourself three questions...

1) Can this patient protect and maintain their airway?

2) Is there a deficiency in oxygenation or ventilation?

3) Is intubation anticipated in the clinical course?

If you answer no to the first and yes to the second two, you're heading down the road to a DFI.
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4. Am I certain that I can secure his airway?
5. What am I going to do if I give the drugs and then can't intubate?

If you don't ask those two questions along with the first three, you're heading towards a lawsuit.
 
If a pt with asthma is still talking to you give the meds a chance to work and use a BVM for a few minutes to see if they improve.
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If they are talking to you, you're probably not going to be bagging them. ;)
 
usafmedic45 said:
4. Am I certain that I can secure his airway?
5. What am I going to do if I give the drugs and then can't intubate?

If you don't ask those two questions along with the first three, you're heading towards a lawsuit.
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Agreed, but this is not the answer to "when to intubate", the question the OP asked. These are the questions you ask yourself once you've decided that you've going to head down the DFI road. And let's be totally honest, it's a foolish provider that doesn't set himself up for success.

The answer to the questions that USA asked should be, "Yes, I'm sure I can secure the airway, if not with an ETT, then with a supraglottic rescue airway such as a Combi-Tube or a Cricothyrotomy. If I push the drugs and can't secure the airway with an ETT, I'll move right to the failed airway plan."

Every practitioner that even thinks about DFI should have a failed airway plan, with the rescue airway out and available.

When I do a DFI, and I'll admit, I've only done 7, I always have all of the tools I may require to secure the airway out and ready for use. That includes a bougie, a combi-tube, the Quick-Trach kit, a different blade, a size smaller tube, the suction on and the catheter at the ready...

A DFI isn't anything to be taken lightly... luckily I haven't had an airway prove to be so difficult that I can't manage it... yet. I'm sure that day will come, and every time I start to consider a DFI, I wonder if this will be the one that I can't get and will have to cut.

I am a firm believer that if I can manage the airway without a DFI, I will. Close proximity to the ED or an airway that looks very difficult after a LEMONS/BONES eval will give me pause. However, if the PT needs that tube, I'll do what needs to be done, knowing that I've got a couple of backup plans if things start to go sideways.
 
Thanks for all the advice guys. I actually had a CHFer last night at work who i put put on CPAP even thought the thought of intubation quickly went through my mind. His stats went from the eighty's to ninty-five percent and his work of breathing became a lot easier. I definitely going to consider CPAP on lots more pts i wish all of the cases where so cut and dry for the need of CPAP or intubation.
 
The answer isn't as complicated as one might think. There are two diagnoses: Respiratory Distress and Respiratory Failure

Respiratory Distress does not require intubation. Respiratory Failure does. They both have different clinical manifestations and should be listed in your protocols. Go by those guidelines.
 
That might be somewhere i am tripping up. I obviously know a pt who needs to be intubated because they don't have an airway or i don't think that they can maintain it them selves. The same thing goes with cpap. I obviously know the CHFer who is talking to me but having a hard time breathing could benefit from it. Being a brand new paramedic, i appreciate all of the help and hints.
 
When the answer is not clear of when to intubate, this is where experience and good assessment skills will be your guide. It is the nature of the beast, and unfortunately... the training offered and opportunities to get that experience can be tough to get. The lack of said training will ultimately be the demise of in field intubation. Those passionate about it, need to be proactive and get together with experienced folks and train. Get the training dept involved and get yourself in a hospital that offers you the hands on. A training hospital should be used to the requests, and anesthesiologists tube people every day... get on the inside track and hang out with them, see what they see, smell what they smell, feel what they feel, learn.. ask questions.
Yeah, it takes time and some sacrifice.... but the benefits will be great!!
 
usalsfyre said:
Just noticed you said your not aggressive with CPAP. Be VERY aggressive with CPAP. You'll save a lot of patients from tubes that way.
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About 10 years ago (or so) when I was first learning about CPAP, the RT's that were doing that portion of the airway lecture made that point very clearly and strongly. CPAP wasn't yet an option out here back then... but they were very passionate about it. Those guys were also very into mixed-gas use with certain patients as well.

I like to be very aggressive with non-tube options, but sometimes your best option is to simply intubate. We just don't have many good options for a failed airway... and Facilitated Intubation of any variety is not an option.
 
MasterIntubator said:
the training offered and opportunities to get that experience can be tough to get. The lack of said training will ultimately be the demise of in field intubation. Those passionate about it, need to be proactive and get together with experienced folks and train. Get the training dept involved and get yourself in a hospital that offers you the hands on. A training hospital should be used to the requests, and anesthesiologists tube people every day... get on the inside track and hang out with them, see what they see, smell what they smell, feel what they feel, learn.. ask questions.
Click to expand...

I don't think paramedics should rely on hospitals for ETI experience. Medic training programs have a hard enough time as it is. Trying to get practicing medics in to the OR on top of medic students, med students, EM residents, anesthesia residents, and CRNA students is going to be near impossible for most EMS systems. Ultimately, a sea-change in who intubates is required (i.e. it should be a limited skill). The "field" should provide the experience, which it can, if allowed.
 
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