Pulseless and apneic or severely obtunded patients can (and should) be intubated without pharmacologic assistance. Other patients are given sedating and paralytic drugs to minimize discomfort and facilitate intubation (termed rapid sequence intubation).
(See also Overview of Respiratory Arrest, Airway Establishment and Control, and Tracheal Intubation.)
Pretreatment before intubation
Pretreatment typically includes
100% oxygen
If time permits, patients should be placed on 100% oxygen for 3 to 5 minutes; this measure may maintain satisfactory oxygenation in previously healthy patients for up to 8 minutes. Noninvasive ventilation (NIV) or high-flow nasal cannula (HFNC) can be used to aid preoxygenation (1). Even in apneic patients, such preoxygenation has been shown to improve arterial oxygen saturation and prolong the period of safe apneic time (2). However, oxygen demand and safe apnea times are very dependent on pulse rate, pulmonary function, red blood cell count, and numerous other metabolic factors.
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Sedation and analgesia for intubation
Laryngoscopy and intubation are uncomfortable; in conscious patients, a short-acting IV drug with sedative or combined sedative and analgesic properties is mandatory.
Drugs to cause paralysis for intubation
Skeletal muscle relaxation with an IV neuromuscular blocker markedly facilitates intubation.
> 1 to 2 days old, spinal cord injury, neuromuscular disease, renal failure, or possibly penetrating eye injury. About 1/15,000 children (and fewer adults) have a genetic susceptibility to malignant hyperthermia
Alternative nondepolarizing neuromuscular blockers have longer duration of action (>
Topical anesthesia for intubation
Post-intubation sedation and analgesia
3).
General references
1. Higgs A, McGrath BA, Goddard C, et al: Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth 120:323–352, 2018. doi: 10.1016/j.bja.2017.10.021
2. Mosier JM, Hypes CD, Sakles JC: Understanding preoxygenation and apneic oxygenation during intubation in the critically ill. Intensive Care Med 43(2):226–228, 2017. doi: 10.1007/s00134-016-4426-0
3. Devlin JW, Skrobik Y, Gélinas C, et al: Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU. Crit Care Med 46(9):e825-e873, 2018. doi:10.1097/CCM.0000000000003299
