The first step in any resuscitation is the verification or establishment of a patent and protected airway.
Emergency defibrillation is the sole, occasional exception to this principle. Without adequate oxygenation, all other potentially lifesaving manoeuvres will fail.
Assessment
- Airway patency
- Breathing efficacy
- Need for supplemental oxygen
Management
In clinical practice, timely decision-making regarding non-invasive ventilation (NIV) or intubation is crucial. Opting for a well-organised and prepared approach is generally favoured over dealing with a chaotic and uncontrolled airway situation.
While there is a diverse range of presentations, deciding whether to proceed with intubation, withhold it, or opt for NIV may not always be straightforward.
Use The decision to intubate - UpToDate (NSW Health login required) for guidance.
Each facility, local health district or specialty network should have local procedures on indications and management of NIV.
NIV is an effective and safe means of treatment of ventilatory failure. It allows preservation of cough, physiological air warming and humidification, and normal swallowing, feeding and speech.
NIV may prevent the need for intubation and reduce mortality and length of hospital stay in patients experiencing a chronic obstructive pulmonary disease (COPD) exacerbation.
It is recommended for COPD exacerbations associated with hypercapnic respiratory failure and acidosis (defined as partial pressure of carbon dioxide (PaCO2) above 45mmHg and pH below 7.35) despite optimal therapy (including oxygen therapy titrated to maintain SpO2 between 88 and 92%).
These resources offer guidance on indications, contraindications, assessment set-up and care.
- Non-invasive ventilation for adult patients with acute respiratory failure
Source: Agency for Clinical Innovation - Non-invasive ventilation (NSW Health login required)
Source: Therapeutic Guidelines
Each facility, local health district or specialty network should have local procedures on indications and management of invasive ventilation.
Key questions to guide the decision to intubate:
- Is patency or protection of the airway at risk?
- Is oxygenation or ventilation failing?
- Is intubation anticipated given the expected clinical course?
The airway management clinical tool provides guidance on adult and paediatric intubation, including checklists.
Further reading: Difficult Airway Society Guidelines
Practical considerations
- Adequate sedation and analgesia
- Appropriate levels of skilled staff
- Appropriate equipment for patient monitoring and safety alarms
- Consultation with intensive care unit and/or retrieval staff, as required, until transferred to ongoing care
- Regular and ongoing communication with patient, carer and relatives
Resources
- Non-invasive ventilation for adult patients with acute respiratory failure
Develop local procedures and guidelines for NIV for critically ill patients with acute respiratory failure.
Source: Agency for Clinical Innovation - Noninvasive ventilation in adults with acute respiratory failure: Benefits and contraindications (NSW Health login required)
Point-of-care clinical guidance for the use of NIV.
Source: UpToDate - The decision to intubate (NSW Health login required)
How to determine the need for intubation.
Source: UpToDate - Noninvasive ventilation (NSW Health login required)
Clinical guidance for the use of NIV.
Source: Therapeutic Guidelines
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/networks/eci/clinical/tools/ventilation