From the Guidelines
Endotracheal intubation is indicated when a patient requires airway protection, mechanical ventilation, or airway maintenance that cannot be achieved through less invasive means, as supported by the most recent evidence from 2021 1. The primary indications for endotracheal intubation include:
- Respiratory failure with inadequate oxygenation or ventilation
- Airway protection in unconscious patients with a Glasgow Coma Scale score below 8
- Impending airway obstruction from trauma or anaphylaxis
- Need for controlled ventilation during general anesthesia or certain medical procedures Clinical signs that suggest the need for intubation include:
- Respiratory distress with increased work of breathing
- Oxygen saturation below 90% despite supplemental oxygen
- Respiratory acidosis with rising PaCO2
- Altered mental status affecting airway protective reflexes
- Hemodynamic instability Additional signs include:
- Stridor or other evidence of upper airway obstruction
- Inability to clear secretions
- Progressive fatigue of respiratory muscles The decision to intubate should be made promptly when these signs are present, as delayed intubation in a deteriorating patient can lead to cardiac arrest or hypoxic brain injury, as noted in earlier studies 1. Rapid sequence intubation typically involves pre-oxygenation, administration of a sedative and a neuromuscular blocking agent to facilitate the procedure while minimizing complications. It is essential to prioritize the patient's airway, breathing, and circulation (ABCs) and to consider the potential risks and benefits of intubation in each individual case, taking into account the latest guidelines and evidence-based practices.
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. The indications for endotracheal intubation include:
- Facilitation of tracheal intubation as an adjunct to general anesthesia
- Skeletal muscle relaxation during surgery or mechanical ventilation However, the provided text does not explicitly mention clinical signs for endotracheal intubation. 2
From the Research
Indications for Endotracheal Intubation
- Hypoxemia unresponsive to oxygen administration 3
- Hypercapnia resulting in acidemia 3
- Unstable chest wall 3
- Respiratory distress 4
- Hypoxemic respiratory failure as the indication for intubation 5
- Medication noncompliance and upper respiratory tract infections as precipitating events for exacerbation of asthma 4
Clinical Signs for Endotracheal Intubation
- Low oxygen saturation 6, 7, 5
- Severe hypoxemia, defined as any arterial oxygen saturation of less than 80% between induction and 2 min after endotracheal intubation 7, 5
- Younger age 5
- Higher body mass index (BMI) 5
- Race (white or other vs. black) 5
- Operator with fewer than 100 prior intubations 5
Prediction of Hypoxemia during Endotracheal Intubation
- A six-point score using the identified risk factors can predict severe hypoxemia with an area under the receiver operating curve of 0.714 (95% CI, 0.653 to 0.778) 5
- Lowest oxygen saturation and severe hypoxemia during tracheal intubation in the intensive care unit can be accurately predicted using routinely available preprocedure clinical data 5