What are the 7 Ps of intubation?

The 7 Ps of Intubation

The 7 Ps represent a systematic checklist for preparing and performing intubation, ensuring all critical elements are addressed before attempting the procedure to maximize first-pass success and minimize complications. 1

The 7 Ps Checklist

1. Preparation

• Ensure all equipment is immediately available and functional, including laryngoscope (with tested light), endotracheal tubes of multiple sizes, stylet/bougie, suction, and backup airway devices 2, 1
• Have a difficult airway trolley and bronchoscope immediately accessible for anticipated difficult airways 3
• Verify waveform capnography is ready for mandatory confirmation of tube placement 2
• Position the "front of neck access" (FONA) equipment within immediate reach before starting 2

2. Preoxygenation

• Administer high-flow oxygen to achieve maximal oxygen saturation before induction, particularly critical in ICU patients with reduced functional residual capacity 2, 1
• This is especially important in patients with acute respiratory failure, obesity, or pregnancy where desaturation occurs rapidly 2
• Continue oxygen delivery during the procedure (peroxygenation) when possible 2

3. Pretreatment

• Administer medications to mitigate the physiologic response to intubation, including agents to blunt sympathetic response and prevent increases in intracranial pressure when indicated 1
• Consider cardiovascular optimization in hemodynamically unstable patients, as 20-50% of ICU intubations are complicated by severe hypotension or collapse 2

4. Paralysis with Induction

• Use neuromuscular blocking agents (NMBAs) as they significantly reduce intubation complications in critically ill patients 2
• Rocuronium is preferred over succinylcholine in critically ill patients due to succinylcholine's numerous side effects including life-threatening hyperkalemia 2
• Avoiding NMBAs is associated with increased difficulty and complications 2
• Ensure full neuromuscular blockade before laryngoscopy to optimize conditions 2

5. Positioning

• Place patient in optimal position with head elevated and neck extended (unless contraindicated) 2, 1
• Use 35-degree head-up positioning when possible to reduce airway swelling and improve laryngoscopic view 4, 5
• Proper positioning is mandatory before attempting laryngoscopy 2

6. Placement with Proof

• Limit attempts to a maximum of three laryngoscopy insertions, with each blade entry constituting one attempt 2
• Use videolaryngoscopy as it is superior to direct laryngoscopy, providing better glottic view, higher success rates, and fewer complications 2
• Use a bougie or stylet when the laryngeal opening is poorly visualized (Cormack-Lehane Grade 2b or 3a views) 2
• Mandatory waveform capnography must confirm tracheal placement - absence of a recognizable waveform indicates failed intubation unless proven otherwise 2
• After one failed attempt, immediately get the FONA set to hand and summon senior help 2

7. Post-Intubation Management

• Secure the tube and document the depth at the teeth/lips 1
• Initiate mechanical ventilation with appropriate settings 1
• Monitor for complications including hypotension, desaturation, and tube displacement 2
• Watch for "airway red flags" including absence or change of capnograph waveform, increasing airway pressure, reducing tidal volume, or inability to pass a suction catheter 2

Critical Risk Assessment Before Starting

Use the MACOCHA score to predict difficult intubation risk - a score ≥3 has 97-98% negative predictive value for ruling out difficult intubation 3:

• Mallampati III or IV (5 points) 3
• Apnea syndrome/obstructive sleep apnea (2 points) 3
• Cervical spine limitation (1 point) 3
• Opening of mouth <3 cm (1 point) 3
• Coma (1 point) 3
• Hypoxemia (1 point) 3
• Anaesthesiologist untrained or non-anaesthesiologist (1 point) 3

Common Pitfalls to Avoid

• Never attempt more than three laryngoscopy attempts - declare "failed intubation" and move to rescue strategies 2
• Do not perform blind tube passage attempts with Grade 3b or 4 views as this causes trauma and worsens the situation 2
• Avoid single-operator attempts without a trained, briefed team present 2
• Do not proceed without confirming all equipment is functional - equipment failure during attempts increases complications dramatically 2
• Never assume tracheal placement without capnography confirmation, even if chest rise appears adequate 2