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Getting intubations right the first time

How to boost your chances of placing an airway on the first try

September 2016

Published in the September 2016 issue of Today’s Hospitalist

AIRWAY MANAGEMENT “is really easy, except when it’s not,” warned Brian Kaufman, MD. Because a botched intubation can lead to serious complications or even death, he recommends that hospitalists improve their proficiency with intubating and ventilating patients by using bag masks.

At this spring’s Society of Hospital Medicine conference, Dr. Kaufman said the best chance for a successful intubation is on the first try. There are skills doctors can master, equipment they can use and checklists they can adopt to increase their odds of getting it right the first time.

“In the operating room, 
when they can’t get the tube 
in, they wake the patient up 
and come back the next day 
and do it again. We don’t have
 that option,” said Dr. Kaufman, who 
is professor of medicine, anesthesiolo
gy, perioperative care and pain medicine at New York University School of Medicine and New York Harbor VA Hospital. In the ICU, “we have to get the tube in. If we can’t, we start sweating—and if we fail, the coroner may need to be called.”

“Before you start, do 
a rapid assessment of whether this is likely to be an easy or a hard intubation.” 

feature-intubations-kaufman~Brian Kaufman, MD New York University School of Medicine

This difference is clearly illustrated by data about the procedure’s safety. “When you compare the low risk of morbidity and mortality for elective intubations in the OR, what happens to critically ill patients is totally different,” Dr. Kaufman explained. Studies, such as one in the September 2006 issue of Critical Care Medicine, have documented that severe complications of intubations in the ICU occur more than 25% of the time.

“We want to prevent that,” he said. “We want to optimize our initial attempt. Otherwise, we create a vicious cycle where we fail, we get some airway edema and blood, and it gets harder and harder and harder.”

Boosting your chances of success
According to Dr. Kaufman, the key to increasing your odds of getting intubations right the first time is to prepare for the worst. “You want to enhance the conditions for success,” he said. Start by analyzing both the environment (bed height, adequate light, all necessary equipment and team members standing in the proper locations) and the patient, specifically history and anatomy.

“Before you start, do a rapid assessment of whether this is likely to be an easy or a hard intubation,” he said. “That’s very important. You also want to know whether it is going to be hard to mask the patient.” Why? Because if you are having trouble intubating the patient and the oxygen saturation is dropping, “you will have to stop the intubation attempt and bag the patient until saturation improves.”

For patients who you predict will be difficult to intubate or ventilate, Dr. Kaufman urged hospitalists to call for back-up early. “Do not wait too long,” he said, “to call in an anesthesiologist or intensivist, or move on to ask for a surgical airway.”

How can you judge whether a patient is more likely to face difficulties during intubation? Start with medical history. The most important piece of history is whether the person has had trouble before.

“At NYU Langone Medical Center,” Dr. Kaufman pointed out, “if someone has a history of difficult intubation, it goes into the chart. For postop patients, we always look at the anesthesia note, and if there was a difficult intubation, we put a sign up by the patient’s door.” If that patient subsequently deteriorates, “we call the surgical team right away because we know this is a patient who might need a surgical airway.”

Possible physical problems
Also important is anything learned from the patient’s history or a physical exam that points to a possible problem with neck or jaw mobility: a short and wide neck, fused vertebrae, arthritis, or tongue issues. Other potential problems include oral pharynx blockages or obstructions such as tumors, blood, loose teeth or dentures.

Dentures can be tricky. “They get in the way of intubation,” Dr. Kaufman said, “but they make it easier to mask somebody.”

A mnemonic that helps, he said, is LEMON, which stands for:

  • Look at the anatomy.
  • Examine the airway.
  • Mallampati classification score, used by anesthesiologists to judge the size of the tongue vs. the size of the oral pharynx.
  • Obstructions inside the mouth.
  • Neck mobility.

To predict whether a patient may have difficulty with a bag mask, Dr. Kaufman suggested another mnemonic: BONES (Beard; Obese; No teeth; Elderly; Snores). He also noted that the classically difficult-to-mask patients resemble Santa Claus. “This patient may desaturate quickly,” he said, “faster than someone who doesn’t have these features.”

And using the new video and optical laryngoscopes routinely for all intubations “is controversial,” he added, “but they are becoming standard in some institutions.”

But Dr. Kaufman cautioned that hospitalists need to maintain their skills performing direct laryngoscopy “because that’s what saves you most often when you have a failed attempt using video devices.” In addition, many of the new video laryngoscopes are expensive, so there may not be enough available in your hospital at all times, particularly on medicine floors.

And using a checklist—such as the 42-point one published in the January-February 2011 issue of the Journal of Intensive Care Medicine—has also been shown to improve the rate of successful first-attempt emergency endotracheal intubations.

Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.

Tips you can use

HOW CAN YOU maximize your chance of a successful intubation on 
the first pass? Here are four tips from Brian Kaufman, MD, pro
fessor of medicine, anesthesiology, perioperative care and pain medicine at New York University School of Medicine and New York
Harbor VA Hospital.

 Optimize oxygenation. “Get the saturation to at least 90% 
and, if you can, up to 100% before you start the intubating process,” he said, speaking at this spring’s Society of Hospital Medicine conference. “If you have time, you can use noninvasive ventilation for five or 10 minutes before you try to intubate.”

 Keep a “difficult airway cart” at the bedside so you don’t waste time when problems occur. That cart should contain several sizes and types of blades, a video laryngoscope, a gum elastic bougie, a laryngeal airway, a fiber optic bronchoscope, and a cricothyroidotomy kit.

 Know your drugs. For sedation, etomidate is the usual choice. An alternative is propofol, but Dr. Kaufman said hypotension may occur. The two choices of paralytic agents available for rapid sequence intubation are succinylcholine (1 mg/kg bolus) or rocuronium (1.2 mg/kg bolus). This spring, the FDA approved the first direct reversal agent for rocuronium: sugammadix.

 Compressive maneuvers can help, particularly external laryngeal manipulation. A study in the June 2006 Annals of Emergency Medicine showed that visualization improved anywhere from 48% to 86% when such maneuvers of the cricoid cartilage occurred during intubation.

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