To Intubate or Not, that Is the Question
1Emergency Medicine, University of Massachusetts, Norway
This lecture will call into question some time-honored truths regarding intubation, and will also include bad humor, Shakespearian literature and 1980s classic rock.
For clarification, intubation refers to endotracheal intubation, and not other advanced airway techniques, such as supraglottic airways (LMAs), nor surgical airways (cricothyroidotomy and tracheostomy). The latter are beyond the scope of this lecture, as is the specific procedure on how to perform endotracheal intubation.
Obviously, if a patient has advanced directives stating their wishes for “do not intubate, do not resuscitate,” this should be respected. It is also possible that it may not be in a patient’s best interest to intubate, if so doing would be medically futile, although this may differ from country to country.
There are four well-recognized indications for intubation, specifically: 1) inability of the patient to maintain and protect the airway, 2) failure to ventilate, 3) failure to oxygenate, and 4) if there is anticipated decline in the patient’s condition. While some instances are clear-cut (such as a comatose head injured patient), there are many instances where intubation may be debatable, especially with regards to a patient’s potential decline.
Many EDs now have the to ability to provide non-invasive positive airway pressure ventilation (BiPAP or CPAP) which can buy a CHF or COPD patient some time for diuretics, nitrates, steroids, or beta agonist therapy to take effect, and possibly avoid intubation altogether. High flow oxygen also can be used to address hypoxia.
Did you know that the lack of a gag reflex is no longer considered an indication to intubate? There is great variation in how this test is performed (reproducibility). Additionally, the lack of a gag reflex does not predict aspiration and a large proportion of the population lacks this reflex. Phonation and swallowing are more reliable tests for a patient’s ability to protect his/her airway. By trying to elicit a gag reflex on an obtunded patient, you may cause harm by inducing vomiting with resultant aspiration. A nasopharyngeal or oropharyngeal airway may be placed while you determine whether or not the patient can maintain his/her airway. If an oral pharyngeal airway is tolerated, the patient will likely require intubation.
A well-known mantra in trauma is to intubate patients with a GCS of eight or lower. This simplified approach does not necessarily correlate to non-trauma patients. It has been shown that intoxicated patients with a GCS below eight may be safely observed without intubation.
Recent research has also called into question both pre-hospital and in-hospital intubation during cardiac arrest. A multicenter study that included over 108,000 patients over a 14-year period was published in JAMA in 2017. It showed that patients who were intubated during the first 15 minutes of cardiac arrest had a worse neurologic outcome compared to those who were not intubated.
But, alas, do not succumb to Hamlet’s fatal flaw, that of indecision. “If you choose not to decide, you still have made a choice. “ (Rush, 1980)