What is the recommended approach for emergent or urgent endotracheal intubation and subsequent management in patients aged 65 years or older?

Intubation Response in the Elderly: Recommended Approach and Management

For patients aged 65 years or older requiring emergent or urgent endotracheal intubation, use modified rapid sequence intubation (RSI) with head-up positioning, aggressive preoxygenation with noninvasive positive pressure ventilation (NIPPV) or high-flow nasal oxygen, ketamine as the preferred induction agent, rocuronium as the neuromuscular blocker, and immediate post-extubation preventative NIV for high-risk patients. 1, 2

Pre-Intubation Assessment and Preparation

Anatomical Considerations Specific to Elderly Patients

Elderly patients present unique anatomical challenges that increase intubation difficulty:

• Assess for tooth decay, edentulous mouth, oropharyngeal tumors, and significantly decreased neck range of motion, all of which complicate visualization of vocal cords and endotracheal tube placement 3
• Recognize that atrophy of perioral muscles and edentulous mouth compromise bag-mask ventilation due to difficulty achieving adequate face-mask seal 3
• Identify patients with obstructive sleep apnea and COPD, as these conditions dramatically increase risk of rapid oxygen desaturation during intubation attempts 3
• Screen for gastroesophageal reflux disease and achalasia, which elevate aspiration risk in this population 3
• Evaluate cognitive status, as dementia may impair patient cooperation during preoxygenation and preclude awake intubation techniques 3

Risk Stratification

Elderly patients (≥65 years) with underlying cardiac or respiratory disease have a reintubation rate exceeding 30% when both comorbidities are present and >20% when one is present, making them high-risk for extubation failure 2

Optimal Positioning Strategy

Position the patient in semi-Fowler (head and torso inclined 25-30 degrees) during RSI to reduce aspiration risk and potentially improve first-pass intubation success 1, 2

• This positioning is particularly important in elderly patients with reduced respiratory reserve and increased aspiration risk 1
• One RCT showed lower first-pass success in semi-Fowler position (76.2% vs 85.4% supine), but the aspiration-reduction benefit outweighs this in high-risk elderly patients 1

Preoxygenation Protocol

For Cooperative Elderly Patients

Use NIPPV for preoxygenation in elderly patients with severe hypoxemia (PaO₂/FiO₂ < 150) to reduce catastrophic desaturation risk 1, 2

• Apply 3-5 minutes of preoxygenation using a well-fitted mask with CPAP (5-10 cm H₂O) in a closed-circuit system 1
• Initiate high-flow nasal oxygen when difficult laryngoscopy is anticipated due to anatomical changes common in elderly patients 1

For Agitated or Delirious Elderly Patients

Administer medication-assisted preoxygenation (delayed sequence intubation) using ketamine 1-1.5 mg/kg IV for elderly patients who cannot tolerate preoxygenation devices due to agitation, delirium, or dementia 1

• This approach increases oxygen saturation by approximately 8.9% before neuromuscular blocker administration 1
• Ketamine is particularly appropriate in elderly patients as it maintains hemodynamic stability 1, 4

Pharmacologic Management

Induction Agent Selection

Ketamine (1-2 mg/kg IV) is the preferred induction agent for elderly patients due to minimal cardiovascular depression, no renal dose adjustment requirement, and hemodynamic stability in this vulnerable population 1, 4

• Etomidate (0.2-0.3 mg/kg IV) is an acceptable alternative in hemodynamically unstable elderly patients, as it shows no significant mortality difference compared to other agents but produces less hypotension 1
• Avoid propofol in hemodynamically unstable elderly patients due to significant vasodilation and hypotension risk 1

Neuromuscular Blockade

Administer rocuronium 0.9-1.2 mg/kg IV as the neuromuscular blocker of choice in elderly patients rather than succinylcholine 1, 4

• High-dose rocuronium provides onset comparable to succinylcholine (median ≈1 minute) with clinical duration of 58-67 minutes 1
• Ensure sugammadex is immediately available to permit rapid reversal (within 3 minutes) in "cannot intubate/cannot oxygenate" scenarios 1
• The use of neuromuscular blocking agents is strongly recommended, as avoiding them increases intubation difficulty and complications 1, 4

Intubation Technique

Use videolaryngoscopy if available and the operator is skilled, as it improves laryngeal view, reduces failures, and decreases airway trauma—particularly important given anatomical changes in elderly patients 2, 4

• Limit intubation attempts to a maximum of three; failure should prompt immediate declaration of "failed intubation" and progression to rescue plan 2, 4
• The most experienced available operator should perform the intubation in elderly patients with potential difficult airways 2
• Use waveform capnography to confirm successful tracheal intubation immediately after placement and continuously throughout mechanical ventilation 2

Post-Intubation Management

Immediate Ventilator Settings

Apply a minimum of 5 cm H₂O positive end-expiratory pressure (PEEP) immediately after intubation in hypoxemic elderly patients 1

• Perform a recruitment maneuver after intubation as part of the respiratory protocol for hypoxemic patients 1

Hemodynamic Management

Include a cardiovascular component in the intubation protocol that defines specific parameters for fluid challenge and early vasopressor administration 1

• Recognize that all induction agents can cause vasodilation and hypotension by abolishing sympathetic tone, particularly problematic in elderly patients with reduced cardiovascular reserve 1
• Consider rapid infusion of 500 mL crystalloid before or during intubation in absence of cardiac failure to mitigate hypotension risk 2

Extubation Strategy for High-Risk Elderly Patients

For elderly patients (≥65 years) at high risk for extubation failure who have been mechanically ventilated for more than 24 hours and have passed a spontaneous breathing trial, extubate to preventative NIV immediately 2

Evidence Supporting Preventative NIV

• Preventative NIV in high-risk elderly patients reduces ICU length of stay by 2.48 days (95% CI: -4.03 to -0.93) 2
• Short-term mortality is reduced with preventative NIV (RR 0.37; 95% CI: 0.19-0.70) 2
• Long-term (90-day) mortality is reduced (RR 0.58; 95% CI: 0.27-1.22) 2
• Extubation success rate improves (RR 1.14; 95% CI: 1.05-1.23) 2

High-Risk Criteria

Elderly patients are considered high-risk when they have:

• Age >65 years with underlying cardiac or respiratory disease 2
• Hypercapnia (PaCO₂ >45 mm Hg) during successful spontaneous breathing trial 2
• COPD or congestive heart failure 2
• Higher severity of illness scores 2

Alternative: High-Flow Nasal Cannula

High-flow nasal cannula may be used as an alternative to NIV in elderly patients at low-to-moderate risk for reintubation, as it reduces respiratory failure (RR improvement) and reintubation rates at 72 hours 2

Critical Pitfalls to Avoid

Do not use NIV to treat established post-extubation respiratory failure in elderly patients, as this approach increases ICU mortality (RR 1.33; 95% CI: 0.83-2.13) by delaying necessary reintubation 2

Do not delay intubation for prolonged optimization in elderly patients with severe respiratory distress, as their reduced physiological reserve leads to rapid deterioration and increased risk of cardiac arrest with multiple intubation attempts 2

Avoid succinylcholine in elderly patients with renal failure after 24 hours, as upregulated acetylcholine receptors and baseline hyperkalemia create life-threatening risk of severe hyperkalemia and cardiac arrest 1

Do not perform more than three intubation attempts, as delays and multiple attempts are associated with increased complications including cardiac arrest and death, occurring in approximately 2% of ICU intubations and up to 12.5% when four or more attempts are required 2