What warrants intubation?

Indications for Intubation

Intubate immediately when Glasgow Coma Scale (GCS) ≤8, as this represents severe impairment of consciousness with inability to protect the airway and is the standard of care across all major trauma and critical care guidelines. 1

Absolute Indications Requiring Immediate Intubation

Neurologic Criteria

• GCS ≤8 in any patient population (trauma, medical, overdose) 1
• Deteriorating consciousness: Fall in GCS ≥2 points or motor score ≥1 point, regardless of absolute GCS value 1
• Respiratory arrest or peri-arrest unless rapid recovery occurs with manual ventilation/NIV 2
• Apnea or imminent respiratory arrest 3

Airway Protection Failures

• Inability to protect the airway from aspiration risk 2
• Difficult ventilation (face mask/supraglottic airway failure) combined with difficult intubation 2
• Fixed upper airway obstruction, severe facial deformity, or facial burns preventing non-invasive interface use 2

Physiologic Derangements

• Severe hypoxemia refractory to noninvasive support: Failure to improve gas exchange and respiratory rate within a few hours of NIV/HFNC initiation 2
• Tidal volumes persistently >9.5 mL/kg predicted body weight on NIV, suggesting patient self-inflicted lung injury 2
• Rapid shallow breathing index (RSBI) >105 breaths/min/L on NIV 2
• Cardiovascular collapse or hemodynamic instability requiring vasopressor support 2

Specific Clinical Scenarios

• Acute liver failure with GCS <8 1
• Severe malaria with coma (GCS ≤8) in children 1
• Suspected meningitis with GCS ≤12 warrants consideration for intubation, especially before lumbar puncture 1
• Obesity with BMI >30 kg/m² presenting with acute respiratory failure (twice the complication risk; four times if BMI >40) 2

Relative Indications (Awake Intubation May Be Preferred)

Any single factor alone may warrant awake intubation when the patient is cooperative: 2

• Anticipated difficult intubation with increased aspiration risk 2
• Patient incapable of tolerating brief apneic episode 2
• Expected difficulty with emergency invasive airway rescue 2
• Significant glottic narrowing where awake technique success must be balanced against post-induction technique 2

Awake Intubation Requirements

• Only attempt with suitably skilled/experienced clinician 2
• Careful head-up positioning 2
• Minimal sedation if needed 2
• Adequate topical anesthesia 2
• Active preoxygenation (e.g., high-flow nasal oxygen) 2
• Clear plan for failure 2

Critical Pitfalls to Avoid

Timing Errors

• Never delay intubation for CT imaging in patients with GCS ≤8—secure airway first, then image 1
• Never delay intubation waiting for "better conditions" when deterioration is evident 2
• Delayed intubation is associated with increased mortality in acute respiratory failure 2

Technical Errors

• Limit laryngoscopy attempts to maximum of three—repeated attempts cause trauma and progression to cannot-intubate-cannot-oxygenate (CICO) 2
• Avoid hyperventilation except as brief life-saving measure for cerebral herniation; maintain normocapnia (PaCO₂ 4.5-5.0 kPa) 1
• Prevent hypoxemia aggressively (PaO₂ ≥13 kPa) but avoid prolonged hyperoxia 1
• Maintain hemodynamic stability: Target systolic BP >100-110 mmHg and MAP >80-90 mmHg during intubation in brain-injured patients 1

Medication Errors

• Confirm proper drug selection—accidental administration of neuromuscular blockers may be fatal 4
• Never administer succinylcholine before unconsciousness induced except in true emergencies 4
• Use succinylcholine with GREAT CAUTION in patients with electrolyte abnormalities, burns >7-10 days old, extensive denervation, or upper motor neuron injury due to hyperkalemia risk 4

Procedural Approach

Preparation (Before Induction)

• Position optimally: Head-up/ramped position, especially in obesity 2
• Preoxygenate thoroughly: Use CPAP/NIV or HFNC in obese patients 2
• Identify cricothyroid membrane and mark before induction if difficult airway anticipated 2
• Have FONA (front-of-neck-access) set immediately available after first failed attempt 2
• Summon senior help after first failed attempt 2

Induction

• Use rapid sequence induction as preferred method 5
• Achieve full neuromuscular blockade for optimal conditions 2
• Succinylcholine is recommended neuromuscular blocker for rapid sequence intubation 5
• Adult dose: 0.6 mg/kg IV (range 0.3-1.1 mg/kg) 4
• Pediatric emergency dose: 2 mg/kg for infants/small children; 1 mg/kg for older children/adolescents 4

Confirmation

• Mandatory waveform capnography to confirm tube placement 2
• Absence of capnograph waveform indicates failed intubation unless proven otherwise 2
• Auscultation and chest wall movement are unreliable in critically ill patients 2

Rescue Strategy

• Second-generation supraglottic airway (SGA) insertion preferable to face mask ventilation for rescue 2
• Continue peroxygenation with nasal oxygen between attempts 2
• Proceed to surgical cricothyrotomy if cannot intubate/cannot oxygenate 2