What is the proper procedure for preparing a patient for intubation?

Proper Procedure for Patient Intubation Preparation

Proper patient preparation for intubation requires a systematic approach including positioning, preoxygenation, monitoring, and medication administration to minimize complications and maximize success. 1

Initial Assessment and Preparation

Airway Assessment

• Use MACOCHA score to predict difficult intubation (scores ≥3 indicate higher risk) 1
  • Mallampati class III or IV (5 points)
  • Obstructive sleep apnea (2 points)
  • Reduced cervical spine mobility (1 point)
  • Limited mouth opening <3 cm (1 point)
  • Coma (1 point)
  • Severe hypoxemia (SpO2 <80%) (1 point)
  • Non-anesthetist operator (1 point)

Team Assembly and Equipment

• Assign clear roles to team members
• Conduct pre-intubation checklist
• Prepare and check all equipment:
  • Laryngoscope (with backup)
  • Appropriately sized endotracheal tubes
  • Suction device
  • Bag-valve-mask with PEEP valve
  • Capnography
  • Rescue devices (supraglottic airway, bougie)
  • Emergency front-of-neck access equipment

Patient Positioning

• Position patient with head elevated 25-30° when tolerated
• Use "sniffing position" (flex lower cervical spine, extend upper cervical spine)
• For obese patients, use "ramping" (external auditory meatus level with sternal notch)
• Ensure bed mattress is firm to optimize cricoid pressure application and access to cricothyroid membrane 1

Monitoring

• Apply standard monitoring before induction:
  • Pulse oximetry
  • Waveform capnography
  • Blood pressure
  • Heart rate
  • ECG
  • End-tidal oxygen concentration (when available) 1

Preoxygenation

For Non-Hypoxemic Patients

• Use tight-fitting facemask with 10-15 L/min of 100% oxygen for 3 minutes
• Target end-tidal oxygen concentration >85%
• Use two-handed technique to minimize mask leak
• Do not use standard Hudson-type masks for preoxygenation 1

For Hypoxemic Patients

• Consider CPAP (5-10 cmH2O) with NIV
• Use supported breaths (tidal volume 7-10 mL/kg)
• Consider high-flow nasal oxygen (HFNO) at 30-70 L/min
• For agitated patients, consider delayed sequence induction with small doses of ketamine to facilitate preoxygenation 1

Hemodynamic Optimization

• Include cardiovascular component in intubation protocol
• Consider fluid challenge before induction in hypovolemic patients
• Prepare vasopressors for early administration to prevent post-induction hypotension 1

Medication Administration

Induction Agents

• Select appropriate hypnotic agent based on patient's hemodynamic status
• Consider propofol, etomidate, or ketamine depending on clinical scenario 1

Neuromuscular Blocking Agents

• Rocuronium: 0.6 mg/kg is the recommended initial dose for routine intubation
  • Provides intubation conditions within 1-2 minutes
  • Clinical relaxation for approximately 31 minutes
• For rapid sequence intubation: 0.6-1.2 mg/kg rocuronium provides excellent intubation conditions within 2 minutes 2

Post-Intubation Care

• Apply PEEP of at least 5 cmH2O after intubation in hypoxemic patients
• Consider recruitment maneuver in hypoxemic patients
• Confirm tube placement with waveform capnography
• Secure the tube properly 1

Special Considerations

Obese Patients

• Dose rocuronium based on actual body weight, not ideal body weight 2
• Preoxygenation is enhanced in seated position (25°) 3

Critically Ill Patients

• Standard preoxygenation methods may be less effective 4
• Consider combining HFNO and NIV for preoxygenation 1
• Apply post-intubation recruitment maneuver 1

Aspiration Risk

• Consider rapid sequence induction for patients with:
  • Full stomach (no 2h liquid/6h food fasting)
  • Active vomiting
  • Ileus or sub-ileus
  • Impaired protective reflexes
  • Pregnant women in 3rd trimester 5

Common Pitfalls and Caveats

1. Inadequate preoxygenation: Ensure tight mask seal and confirm adequate preoxygenation with end-tidal oxygen measurement
2. Failure to recognize difficult airway: Complete airway assessment even in emergency situations
3. Hemodynamic collapse: Prepare vasopressors before induction
4. Delayed recognition of esophageal intubation: Always confirm tube placement with waveform capnography
5. Extending preoxygenation beyond 8 minutes: May be counterproductive in critically ill patients 6

By following this systematic approach to patient preparation for intubation, you can minimize complications and maximize success rates, ultimately improving patient outcomes in terms of morbidity and mortality.