What is the process and protocol for intubation?

Intubation Protocol and Process

Endotracheal intubation should be performed by the most experienced airway practitioner available, using appropriate sedation and possibly neuromuscular blockade, with careful preparation and standardized protocols to maximize success and minimize complications. 1

Pre-Intubation Assessment and Preparation

Risk Assessment

• Assess for difficult intubation using the MACOCHA score 1:
  • Mallampati score III or IV (5 points)
  • Obstructive sleep Apnea (2 points)
  • Cervical spine limitation (1 point)
  • Opening mouth <3 cm (1 point)
  • Coma (1 point)
  • Hypoxemia (1 point)
  • Anesthesiologist untrained/non-anesthesiologist (1 point)
  • Score ≥3 indicates high risk of difficult intubation

Equipment Preparation

• Ensure mandatory equipment is available 1:
  • Capnography for confirmation
  • Difficult airway trolley with various laryngoscopes
  • Videolaryngoscope
  • Supraglottic devices
  • Cricothyroidotomy kit
  • Bronchoscope (conventional or single-use)
  • Intubation stylet or bougie
  • Appropriate endotracheal tubes

Patient Positioning

• Position patient optimally with head extension and neck flexion ("sniffing position") 1
• Consider head-up position for obese patients 1

Pre-Oxygenation

• Pre-oxygenate with FiO2 of 1.0 to maximize oxygen stores 1
• Aim for FEO2 above 0.9 to extend safe apnea time 1

Rapid Sequence Intubation (RSI) Protocol

Step 1: Pretreatment (3 minutes before induction)

• Consider pretreatment medications to attenuate physiologic response 2:
  • Fentanyl for hemodynamic stability
  • Lidocaine for increased intracranial pressure
  • Atropine for pediatric patients or vagal response

Step 2: Induction and Paralysis

• Administer sedative induction agent 2:

  • Etomidate (0.3 mg/kg) - hemodynamically stable patients
  • Ketamine (1-2 mg/kg) - patients with bronchospasm
  • Propofol (1-2 mg/kg) - patients with increased ICP
  • Consider reduced doses in shock states

• Follow immediately with neuromuscular blocking agent 2:

  • Succinylcholine (1-1.5 mg/kg) - fast onset, short duration
  • Rocuronium (1-1.2 mg/kg) - when succinylcholine contraindicated
  • Ensure full paralysis before attempting laryngoscopy

Step 3: Laryngoscopy and Intubation

• Perform laryngoscopy with appropriate technique 1:

  • Direct laryngoscopy with Macintosh blade as first-line
  • Consider videolaryngoscopy, especially for anticipated difficult airway
  • Apply optimal external laryngeal manipulation (OELM) or BURP if needed 1
  • Limit attempts to three maximum 1

• For difficult view (Grade 2b-3a) 1:

  • Use bougie or stylet
  • Consider different device or blade
  • Change operator if needed
  • Avoid blind attempts with Grade 3b-4 views

Step 4: Confirmation of Placement

• Confirm tube placement with waveform capnography (mandatory) 1
• Absence of waveform indicates failed intubation unless proven otherwise 1
• Secondary confirmation with:
  • Chest rise
  • Bronchoscopy via tube
  • Avoid relying solely on auscultation 1

Failed Intubation Management

Plan B: Secondary Intubation Plan

• Insert supraglottic airway device (SGA) for rescue oxygenation 1
• Limit to two insertion attempts 1
• Maintain oxygenation and ventilation

Plan C: Maintenance of Oxygenation

• Consider fiberoptic intubation through SGA 1
• Postpone surgery if elective
• Maintain oxygenation and consider awakening patient

Plan D: Can't Intubate, Can't Ventilate

• Proceed to front-of-neck airway access 1
• Follow established emergency cricothyroidotomy protocol

Post-Intubation Management

Immediate Post-Intubation Care

• Secure tube at appropriate depth
• Initiate mechanical ventilation with lung-protective strategy
• Provide post-intubation sedation and analgesia 2
• Monitor for complications

Extubation Planning

• Assess readiness for extubation 1:

  • Perform cuff leak test to assess subglottic caliber
  • Ensure full reversal of neuromuscular blockade (TOF ratio ≥0.9)
  • Optimize cardiovascular stability and fluid balance
  • Provide adequate analgesia

• Pre-extubation preparation 1:

  • Pre-oxygenate with FiO2 1.0
  • Position appropriately (often head-up)
  • Suction oropharynx under direct vision

Post-Extubation Management

• Monitor for post-extubation stridor 3
  • Treat with nebulized epinephrine for conscious patients
  • Consider systemic corticosteroids if symptoms persist
  • Apply CPAP with 100% oxygen if needed

Special Considerations

Infection Control During Intubation

• For infectious diseases (e.g., SARS) 1:
  • Use negative pressure isolation rooms
  • Wear appropriate PPE (gowns, gloves, eye protection, respiratory protection)
  • Practice proper hand hygiene
  • Limit aerosol-generating procedures
  • Consider intubation earlier than usual to allow for infection control precautions

Difficult Airway Considerations

• For anticipated difficult airway 1:
  • Consider awake intubation techniques
  • Have difficult airway equipment immediately available
  • Consider using airway exchange catheter for extubation 1
  • Ensure availability of rescue devices

Common Pitfalls and Caveats

1. Multiple intubation attempts increase risk of hypoxemia, trauma, and progression to can't-intubate-can't-ventilate scenario - limit attempts to three 1

2. Failure to confirm tube placement with capnography is a preventable cause of morbidity - always use waveform capnography 1

3. Inadequate pre-oxygenation reduces safe apnea time - ensure thorough pre-oxygenation 1

4. Inappropriate medication selection can cause hemodynamic instability - tailor medications to patient condition 2

5. Delayed recognition of failed intubation - have a clear plan for failed intubation and proceed through algorithm without delay 1

6. Poor team communication - ensure clear roles and communication during the procedure 1

7. Inadequate preparation for extubation - assess risk factors and have equipment ready for reintubation if needed 1