Airway - Intubation (RSI)

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Indications

Airway

Loss of airway patency (burns, angioedema, facial trauma, upper airway obstruction)

Loss of airway protection (reduced level of consciousness, copious secretions)

Breathing

Type 1 or 2 respiratory failure

Respiratory distress with exhaustion

Apnoea or arrest

Circulation

Reduce oxygen consumption and lactate production (sepsis)

Disability

Status epilepticus

Facilitate neuroprotective ventilation after serious head injury

Anticipated deterioration

Severe agitation with risk to harm refractory to less restrictive alternatives

Environmental

Facilitate safe transfer or procedure

Cooling requiring paralysis

Refractory pain or distress

Contraindications (absolute in bold)

Advanced directive precludes intubation

Anatomy precludes attempt (laryngectomy, tracheal transection)

Sufficiently experienced operator unavailable

Alternatives

Laryngeal mask airway

Non-invasive ventilation

Antidotes to precipitant

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

Potential complications

Airway

Failure to intubate

Failure to ventilate or oxygenate (after failed intubation)

Oesophageal intubation

Dental trauma

Damage to airway (cord injury, false passage creation)

Breathing

Endobronchial intubation

Aspiration

Barotrauma

Bronchospasm

Cardiovascular

Hypotension (drug-induced, loss of sympathetic tone, adverse drug reaction)

Hypertension and myocardial ischaemia

Disability

Increased intracranial pressure

Procedural hygiene

Standard precautions

PPE: non-sterile gloves, consider gown, mask and surgical or P2 respiratory mask (depending on infectious state)

Procedure

Intubation is a complex high-risk procedure best conducted in a resuscitation bay using a checklist and prepared airway plans in case of fail attempts

Preparation (area, staff, equipment)

Patient optimisation (positioning, oxygenation, haemodynamics)

Planning (verbalisation of airway plan to team)

Drug, doses and induction

Airway checklist

Intubation checklist

Airway plans

Airway plans

Post-procedure care

We recommend a post-intubation checklist incorporating:

Airway and endotracheal tube care

Breathing and ventilator setup

Circulation and fluids

Disability and sedation

Post-intubation checklist

post tube

Tips

Rapid-sequence induction checklists should not be bypassed outside of cardiac arrest

Expect to fail, mentally prepare yourself for the later steps in the airway plan prior to induction

Discussion

The ECI airway plan was designed by Chris Partyka and Daniel Gaetani (FACEMs Liverpool, Sydney, NSW). It contains the common elements of most airway checklists augmented by audit of over 500 consecutive intubations in the Liverpool Hospital emergency department and the data from the NSW airway registry. Every intubation requiring more than one attempt or resulting in hypoxia or hypotension was reviewed and repetitive oversights addressed.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Greater Sydney Area Helicopter Emergency Service

CareFlight

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Winters BD, Gurses AP, Lehmann H, et al. Clinical review: checklists - translating evidence into practice. Crit Care. 2009;13(6):210. doi:10.1186/cc7792

Hales B, Terblanche M, Fowler R, Sibbald W. Development of medical checklists for improved quality of patient care. Int J Qual Health Care. 2008;20(1):22‐30. doi:10.1093/intqhc/mzm062

Alkhouri H, Vassiliadis J, Murray M, et al. Emergency airway management in Australian and New Zealand emergency departments: A multicentre descriptive study of 3710 emergency intubations. Emergency Medicine Australasia.2017 Oct;29(5):499-508.

Existing Australasian checklists: Emergency Care Institute checklist 2014, Royal North Shore Hospital, Westmead Hospital, Dubbo Base Hospital, Nepean Hospital, Wollongong Hospital, Queanbeyan Hospital, Royal Prince Alfred Hospital, Sunshine and Western Health, Royal Children's Hospital Melbourne, Sir Charles Gairdner Hospital (WA), Christchurch Hospital

Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018;120(2):323‐352. doi:10.1016/j.bja.2017.10.021

Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827‐848. doi:10.1093/bja/aev371

Greater Sydney Area Helicopter Emergency Medical Service. Prehospital emergency anaesthesia manual. (Ver.3.) Sydney: NSW Ambulance; 2017. Available from: https://nswhems.files.wordpress.com/2018/06/prehospital-emergency-anaesthesia-manual-3-01.pdf

Chrimes N. The vortex approach to the difficult airway. 2016. [Cited Feb 2017.] Available from: http://vortexapproach.org

Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301‐1308. doi:10.1056/NEJM200005043421801

Wilcox SR, Richards JB, Fisher DF, et al. Initial mechanical ventilator settings and lung protective ventilation in the ED. Am J Emerg Med. 2016;34(8):1446‐1451. doi:10.1016/j.ajem.2016.04.027

Hayes-Bradley C, Lewis A, et al. Efficacy of nasal cannula oxygen as a preoxygenation adjunct in emergency airway management. Ann Emerg Med. 2016;68(2):174‐180. doi:10.1016/j.annemergmed.2015.11.012

Binks MJ, Holyoak RS, Melhuish TM, et al. Apnoeic oxygenation during intubation in the intensive care unit: A systematic review and meta-analysis. Heart Lung. 2017;46(6):452‐457. doi:10.1016/j.hrtlng.2017.08.001

Oliveira JE Silva L, Cabrera D, Barrionuevo P, et al. Effectiveness of apneic oxygenation during intubation: a systematic review and meta-analysis. Ann Emerg Med. 2017;70(4):483‐494.e11. doi:10.1016/j.annemergmed.2017.05.001

White L. Apnoeic oxygenation during intubation: a systematic review and meta-analysis. Anaesthesia Intensive Care. 2017 Jan;45(1):21-27.

Stewart J, Bhananker S, Ramaiah R. Rapid-sequence intubation and cricoid pressure. Int J Crit Illn Inj Sci. 2014;4(1);42-49. doi:10.4103/2229-5151.128012

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges' clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

Walls RM, Murphy, MF. Manual of emergency airway management. (4th ed). Philadelphia PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2012.

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