DECIDING TO INTUBATE

ARTERIAL BLOOD GAS OR CLINICAL JUDGEMENT

Introduction
Emergency endotracheal intubation most often
perform under stressful conditions.
Execution of endotracheal intubation requires a
good understanding :
How to identify the potentially difficult
intubation,
the drugs best suited for airway management
in different clinical scenarios, and
Management of the difficult or failed airway.
Deficiency in any of these areas reduces the
likelihood of a good patient outcome

 By waiting too long to intubate. can contribute to

patient morbidity and mortality
Inappropriate delays in airway management can
convert into a "crash" airway scenario, eliminating
the opportunity for a well-planned approach.
Clinicians should not postpone intubation until the
patient with anaphylaxis develops stridor or wait for
worsening of hoarseness in the patient with smoke
inhalation.

 The decision to intubate can be obvious as with

the comatose head-injured patient, who
requires immediate intubation, or
conversely the patient in moderate respiratory
distress from heart failure who is rapidly
improving with treatment and is unlikely to
need invasive airway management.

 A simple assessment consisting of four basic

questions can distinguish patients requiring
intubation :
1. Is there failure of airway maintenance or
protection?
2. Is there failure of ventilation?
3. Is there failure of oxygenation?
4. Is there an anticipated need for intubation
(ie, what is the expected clinical course)?

IS THERE FAILURE OF AIRWAY

MAINTENANCE OR PROTECTION?
A patient who can phonate clearly and answer
questions appropriately demonstrates airway
patency, adequate ventilation, vocal cord function,
and cerebral perfusion with oxygenated blood.
The level of alertness needed to maintain airway
and protective reflexes to prevent aspiration of oral
and gastric fluids.
Aspiration of gastric contents can cause
pneumonitis and result in prolonged mechanical
ventilation

 The absence of a gag reflex to be only 70 percent

sensitive in detecting the need for a definitive
airway, while
the presence of a GCS of 8 or less was a better
overall indicator of the need for intubation
The ability to swallow secretions is a more reliable
sign of the patient's capacity for airway protection
than the gag reflex.
A patient with pooling secretions, unable to
swallow, requires intubation.

IS THERE FAILURE OF OXYGENATION?

Clinicians assess the patient's oxygenation using
clinical
criteria
and
oxygen
saturation
measurements.
Clinically, hypoxic patients act restless and agitated,
and with severe hypoxemia can appear cyanotic.
As hypoxia worsens, confusion, somnolence, and
obtundation occur.
Pulse oximetry provides an accurate estimate of
arterial oxygen tension, but can be unreliable when
peripheral perfusion is compromised

IS THERE FAILURE OF VENTILATION?

Removal of carbon dioxide (CO2) depends on
proper lung function and ventilation.
Impaired ventilation results in impaired CO2
elimination.
Gauge a patient's ventilations by observing
respirations and mental status.
Capnography provides a simple means of
continuously measuring end-tidal CO2 to assess
the adequacy of ventilation.

 Patients with inadequate ventilation require

intubation, unless the cause is rapidly reversible
(eg, opioid overdose).
In select patients with acute exacerbations of
COPD, the use of continuous positive airway
pressure (CPAP) or bilevel positive airway pressure
(BLPAP) obviates endotracheal intubation
Continual reevaluation of patients treated with
CPAP or BLPAP is required to detect clinical
deterioration and provide definitive airway
management if needed.

IS THERE AN ANTICIPATED NEED FOR

INTUBATION?
Failure to maintain airway protection, oxygenation,
and ventilation comprise straightforward criteria for
intubation.
Some emergency patients may meet none of these
criteria yet still require intubation.
The progression of their disease would result in airway
compromise or an inability to maintain oxygenation.
By pursuing early, aggressive airway management,
emergency clinicians avoid "crash" airway situations,
when equipment, medications, and personnel may not
be ready.

 It is preferable to err on the side of caution and place a

definitive airway if the potential for airway
compromise exists.
Patients
with
potential
for
respiratory
decompensation who must be transported out of the
emergency department often require intubation.
It is better to secure the airway preemptively than to
face a crash airway in an unfavorable setting.
For trauma patients, intubation may be indicated
before transport if the likelihood of deterioration is
high, based on mechanism, injuries discovered on
primary and secondary surveys, and initial
hemodynamics.

 No guidelines or algorithms exist to anticipate

every possible scenario in which preemptive
intubation is needed.
A careful clinical assessment (pulse oximetry,
capnography, vital signs, the patient's mental and
respiratory status, the patient's comorbidities and
response to the acute threat, and a knowledge of
the natural history of the condition) will guide the
clinician regarding the need for preemptive
intubation.
If there is any significant concern that a patient's
deterioration will ultimately threaten the airway or
make intubation more difficult, early intubation

Utilization of Arterial
Blood Gas Measurements

 The most common reasons for requesting an ABG

test were a change in ventilator settings (27.6%), a
respiratory event (26.4%), and routine (25.7%)
Table 1.
Of the 107 respiratory events, 56 (52.3%) were
identified as hypoxia and 18 (16.8%) as tachypnea.
Of the 36 metabolic events, 13 (36%) were
described as respiratory acidosis and 10 (28%) as
metabolic acidosis.
Cardiovascular events were noted only twice as a
reason for an ABG test.

 By using data from Table 1, as outlined in the

Results section, and the preceding arguments,
we estimate that at least 30% of ABG tests may
be unnecessary.
The laboratory would save the cost of reagents,
the lease payment on 1 blood gas analyzer, and
0.75 full-time equivalents if the ABG test volume
was reduced by 30%.
This translates into a savings of approximately
$100,000 per year.

 The clinicians considered PO2, pH, and PCO2 the

most important parameters in the ABG test results
Table 2.
A minority (20.2%) selected oxygen saturation,
base deficit, hematocrit, or total carbon dioxide as
the most important parameter.
Clinicians were instructed to rank the parameters
in order of importance; however, many simply
checked all parameters that applied.
In 67 patients (16.5%), PO2 and/or oxygen
saturation were marked as the only important
parameters.

 Of the results, approximately 79% were expected.

A change in patient management occurred in 172
cases (42.5%).
There was a change in ventilator settings in 64.5%
(111/172) of patients.
Among the most frequent changes in ventilator
settings were a change in FIO2 (27%) and a
change in pressure support (13%).
Less common reasons for a change in
management in response to an ABG test result
included a blood transfusion or extubation.
Some of the changes classified as other in Table 3
included fluid status changes, delaying surgery,
changing or increasing medications, and
administering electrolytes.

 Arterial blood gas (ABG) tests are widely utilized,

particularly in intensive care units (ICUs). A total
of 99,456 ABG tests were ordered in our 722-bed
hospital in 2004.
Some authors have developed guidelines for the
appropriate utilization of ABG tests in ICUs,
including significant changes in minute
ventilation, significant decline in oxygen
saturation, and a significant change in the clinical
condition. In ventilated patients in stable
condition,

 Wang et al and Roberts et al suggest ordering an

ABG test every 12 hours, and Pilon et al
recommend routine ABG tests once daily.
However, not all changes in the fraction of
inspired oxygen (FIO2) or in ventilator settings
should require an ABG tes
The clinician ordering each ABG test was asked to
fill out a utilization survey.
The most common reasons for requesting an ABG
test were changes in ventilator settings (27.6%),
respiratory events (26.4%), and routine (25.7%).

 Of the results, approximately 79% were expected,

and a change in patient management (eg, a change
in ventilator settings) occurred in 42% of cases.
Many ABG tests were ordered as part of a clinical
routine or to monitor parameters that can be
assessed clinically or through less invasive testing.
Implementation of practice guidelines may prove
useful in controlling test utilization and in
decreasing costs

 No national organization explicitly states a policy

on the utilization of ABG tests to assess whether a
patient is ready for extubation.
Two recent studies examined the usefulness of
ABG tests in conjunction with a spontaneous
breathing trial to predict successful extubation.
Both studies concluded that ABG values affected
extubation decisions in relatively few patients.

 These results corroborate our clinical opinion that

an ABG test is not necessary before and after each
intubation or extubation or for every change in
ventilator settings.
The aforementioned reasons for ordering ABG
tests were indicated by approximately 40% of the
clinicians.
In all of those cases, an ABG test may not have
been necessary to supplement or justify a clinical
assessment.

 ABG tests should be ordered to assess a significant

physiologic change in the patient.
Education about the usefulness of ABG tests and
the implementation of practice guidelines could
prove helpful.
Removal of arterial lines according to developed
guidelines may prevent overutilization of ABG
tests.
Reminding clinicians about redundant or
inappropriate orders.

SUMMARY AND RECOMMENDATIONS

When the need for intubation is unclear,
emergency clinicians assess the patient by asking
four questions to identifies the need for
intubation in nearly all emergency scenarios:
Is there failure of airway maintenance or
protection?
Is there failure of ventilation?
Is there failure of oxygenation?
Is there an anticipated need for intubation ?
(ie, what is the expected clinical course)

 The quickest test of airway patency and

maintenance is to listen to the patient's speech.
The gag reflex has no role in determining the
need for intubation or the patient's ability to
protect their airway.
The gag mechanism does not contribute to
laryngeal closure and airway protection.
The ability to sense and swallow secretions is a
more reliable sign of the patient's capacity for
airway

 Clinicians should not rely on arterial blood gases

(ABG) in the emergent setting to determine the
immediate need for intubation.
Despite the absence of overt signs of respiratory
distress, some patients need early intubation,
because of their anticipated clinical course,
particularly
the
possibility
of
respiratory
decompensation when outside the ED, or the
progression of upper airway compromise.

TERIMA KASIH