What is the recommended intubation protocol for a patient requiring immediate airway management, considering potential comorbidities such as Chronic Obstructive Pulmonary Disease (COPD) or asthma?

Intubation Protocol for Immediate Airway Management

For patients requiring immediate airway management, including those with COPD or asthma, perform rapid sequence intubation (RSI) using videolaryngoscopy with rocuronium 1.2 mg/kg for neuromuscular blockade and ketamine 1-2 mg/kg for induction if cardiovascular instability is anticipated, following meticulous preoxygenation for 3-5 minutes with optimal patient positioning. 1

Pre-Intubation Preparation

Preoxygenation

• Perform meticulous preoxygenation for 3-5 minutes using a well-fitting mask with a closed circuit system (e.g., anesthetic circle breathing circuit or Mapleson's C circuit preferred over bag-mask which expels exhaled gas). 1, 2
• Place a heat and moisture exchange (HME) filter between the catheter mount and circuit. 1
• Avoid non-invasive ventilation and high-flow nasal oxygen in the immediate pre-intubation period. 1

Patient Positioning

• Adopt ramping position in obese patients and reverse Trendelenburg positioning to maximize safe apnea time. 1, 2
• This positioning is critical for patients with COPD or asthma who may have reduced respiratory reserve. 2

Medication Preparation

• Have vasopressors immediately available for bolus or infusion to manage hypotension. 1, 2
• For agitated patients, consider delayed sequence intubation (DSI) technique with ketamine 3 minutes before paralysis, which reduces peri-intubation hypoxia from 35% to 8% compared to standard RSI. 3

Induction and Paralysis

Induction Agent Selection

• If increased risk of cardiovascular instability exists (common in COPD/asthma patients), use ketamine 1-2 mg/kg for induction. 1, 2
• Ketamine is preferred over propofol in hemodynamically unstable patients as it maintains cardiovascular stability. 4

Neuromuscular Blockade

• Administer rocuronium 1.2 mg/kg as early as practical to minimize apnea time and risk of patient coughing. 1, 5
• If using succinylcholine instead, the dose should be 1.5 mg/kg (not the standard 1.0 mg/kg). 1, 6
• Ensure full neuromuscular blockade before attempting intubation—wait 1 minute or use peripheral nerve stimulator. 1, 2

Critical Pitfall: Rocuronium 1.2 mg/kg provides rapid onset comparable to succinylcholine but with longer duration (45-70 minutes), which is acceptable in emergency situations where failed intubation would require sustained paralysis for rescue techniques. 5, 4

Intubation Technique

Device Selection

• Use videolaryngoscopy as the primary device—it allows the operator to stay further from the airway and improves first-pass success rates. 1, 2
• With videolaryngoscope using Macintosh blade, have a bougie available. 1
• With videolaryngoscope using hyperangulated blade, use a stylet. 1
• If videolaryngoscope unavailable, use standard Macintosh blade with bougie pre-loaded or immediately available. 1

Tube Selection

• Use tracheal tube size 7.0-8.0 mm internal diameter in women or 8.0-9.0 mm in men. 1
• Use a tube with subglottic suction port where possible. 1

Ventilation During Intubation

• Only after reliable loss of consciousness, apply gentle continuous positive airway pressure (CPAP) if seal is good, to minimize need for mask ventilation. 1, 7
• If bag-mask ventilation becomes necessary to prevent hypoxia, use minimal oxygen flows and airway pressures. 1, 7
• Insert Guedel airway to maintain patency and use 2-handed, 2-person VE-grip technique, especially in obese patients. 1, 7

Critical Pitfall: Modern guidelines prioritize preventing hypoxia over theoretical aspiration risk—gentle ventilation after loss of consciousness is recommended if needed. 7

Special Considerations for COPD/Asthma Patients

Bronchospasm Management

• These patients are at higher risk for bronchospasm during intubation, making adequate neuromuscular blockade essential before laryngoscopy. 1
• Ketamine provides bronchodilation properties, making it particularly suitable for asthma patients. 2, 4

Cardiovascular Instability

• COPD patients often have right heart strain and may develop hypotension with positive pressure ventilation. 2
• Ensure vasopressor is drawn up and immediately available before induction. 1, 2

Post-Intubation Ventilation

• Avoid high airway pressures in COPD/asthma patients to prevent barotrauma. 2
• Allow adequate expiratory time to prevent air trapping. 2

Failed Intubation Algorithm

After First Attempt Failure

• Limit intubation attempts to avoid trauma—maximum three attempts at each technique unless a "game-changer" intervention is introduced. 1
• At least one attempt should be by the most experienced clinician available. 1
• Provide and test mask ventilation after each attempt when feasible. 1

Rescue Techniques (Plan B)

• If initial intubation fails, insert second-generation supraglottic airway (SGA) after loss of consciousness to replace bag-mask ventilation. 1
• Consider fiberoptic intubation through the SGA using Aintree Intubation Catheter technique. 1

Cannot Intubate, Cannot Ventilate (Plan D)

• If ventilation impossible and serious hypoxemia developing, proceed immediately to front-of-neck access (cricothyrotomy). 1
• Do not delay—passage of time increases morbidity and mortality. 1

Post-Intubation Management

Tube Confirmation

• Pass the cuff 1-2 cm below the cords to avoid bronchial intubation, maintaining visualization on the screen. 1
• Confirm placement with capnography and bilateral breath sounds. 2

Ventilator Settings

• Use low tidal volume ventilation based on ideal body weight to prevent ventilator-induced lung injury. 2
• In COPD/asthma patients, use lower respiratory rates with longer expiratory times. 2

Sedation Maintenance

• Continue adequate sedation to prevent patient-ventilator dyssynchrony. 2
• Consider neuromuscular blockade continuation if severe bronchospasm persists. 2