What are the indications and techniques for endotracheal intubation (ETI)?

From the Guidelines

Intubation should be performed using a rapid sequence induction (RSI) approach with meticulous pre-oxygenation and the use of a videolaryngoscope to minimize the risk of complications and ensure optimal technique. This approach is supported by the most recent and highest quality study 1, which provides consensus guidelines for managing the airway in patients with COVID-19. The study recommends using a RSI approach with cricoid force, pre-oxygenation with a well-fitting mask for 3-5 minutes, and the use of a videolaryngoscope to achieve prompt first-pass tracheal intubation.

Indications for Intubation

Intubation is needed in emergency situations such as:

• Respiratory failure
• Cardiac arrest
• Severe trauma
• General anesthesia for surgery

Tips for Intubation

To perform intubation, the following tips should be considered:

• Position the patient with the head extended and neck flexed (sniffing position)
• Pre-oxygenate the patient for 3-5 minutes with 100% oxygen
• Use medications like sedatives (e.g. ketamine 1-2 mg/kg IV) and paralytics (e.g. rocuronium 1.2 mg/kg IV) to facilitate the procedure
• Use a videolaryngoscope with a separate screen to enable the operator to stay further from the airway
• Consider using a bougie or stylet to facilitate intubation
• Use a tracheal tube size 7.0-8.0 mm internal diameter (ID) in women or 8.0-9.0 mm ID in men

Difficulties and Backup Plans

Common difficulties during intubation include:

• Poor visualization
• Anatomical variations
• Secretions To overcome these difficulties, the following tips should be considered:
• Optimizing positioning
• Using external laryngeal manipulation
• Having suction ready
• Considering video laryngoscopy for difficult airways Always have backup airway plans ready, including supraglottic devices like laryngeal mask airways or surgical airway options for failed intubations, as recommended by a recent study 1.

From the FDA Drug Label

Rocuronium bromide injection is indicated for inpatients and outpatients as an adjunct to general anesthesia to facilitate both rapid sequence and routine tracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation. Succinylcholine chloride is indicated as an adjunct to general anesthesia, to facilitate tracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation.

The process of intubation is not directly described in the provided drug labels. However, the labels indicate that rocuronium 2 and succinylcholine 3 are used to facilitate tracheal intubation. Intubation is needed to facilitate general anesthesia and provide skeletal muscle relaxation during surgery or mechanical ventilation. Key points for consideration:

• Rapid sequence intubation and routine tracheal intubation are mentioned as indications for rocuronium 2.
• Tracheal intubation is an indication for succinylcholine 3. No specific tips for intubation are provided in the drug labels.

From the Research

Intubation Procedure

• Intubation is a medical procedure in which a tube is inserted into a patient's airway to provide a secure means of ventilation 4, 5.
• Rapid sequence intubation (RSI) is a technique used to quickly and safely intubate patients, often in emergency situations 4, 5.
• RSI typically involves the use of a neuromuscular blocker, such as succinylcholine or rocuronium, to relax the patient's muscles and facilitate intubation 4, 5.

Tips for Intubation

• The choice of neuromuscular blocker can affect the success of intubation, with succinylcholine generally considered superior to rocuronium for achieving excellent intubating conditions 4, 5.
• The dose of the neuromuscular blocker can also impact intubation success, with higher doses of rocuronium (at least 0.6 mg/kg) required to achieve comparable intubating conditions to succinylcholine 5.
• The use of a sedative, such as propofol or etomidate, is often necessary to facilitate intubation and provide patient comfort 6, 7.
• The choice of intubation device, such as direct laryngoscopy or video laryngoscopy, can also impact intubation success 7.

When Intubation is Needed

• Intubation is often necessary in emergency situations, such as cardiac arrest, severe trauma, or respiratory failure 4, 5.
• Intubation may also be required for patients undergoing surgery or other medical procedures that require general anesthesia 4, 5.
• The decision to intubate a patient should be made on a case-by-case basis, taking into account the patient's medical condition, the potential risks and benefits of intubation, and the availability of alternative treatments 4, 5.

Post-Intubation Care

• Patients who have been intubated require close monitoring and care to ensure their safety and comfort 6, 8.
• This may include the use of sedatives and analgesics to manage pain and discomfort, as well as regular assessments of the patient's respiratory status and overall condition 6, 8.
• The choice of sedative and analgesic medications can impact the patient's level of comfort and risk of complications, such as awareness with paralysis 6, 8.