I. Problem/Challenge.

Tracheal intubation is a procedure that requires continued practice to maintain a competent skill set. It has been estimated that 57 intubations are necessary to achieve the 90^th percentile of success. Although there are many hospitalists that routinely treat patients that require airway management and intubation, there remains a fair amount of practitioners that do not often encounter this patient population. This lack of practice may lead to complications, especially in patients with difficult airways in emergent situations.

II. Identify the Goal Behavior.

The hospitalist should be able to identify when endotracheal intubation is appropriate. Knowledge regarding airway anatomy, patient positioning, appropriate equipment, and oxygenation/ventilation are required. When endotracheal intubation is unsuccessful, the hospitalist must be familiar with the use of alternative airway devices, such as laryngeal mask airway (LMA).

III. Describe a Step-by-Step approach/method to this problem.

1. Identify the indications and contraindications to endotracheal intubation. Indications may include acute respiratory failure, altered mental status with inability to protect the airway, or need for sedation/paralysis secondary to other causes. Contraindications include severe airway trauma or obstruction.

2. Use Bag-Valve mask (BVM) to provide 100% supplemental oxygen to patient prior to intubation.

3. Gather appropriate equipment for intubation:

Equipment list:

• Cardiac monitoring device for heart rate, blood pressure, oxygen saturation

• Suction device

• Endotracheal tubes (ETT)- 7f-8.5f for adults

• Sylet

• Mask, goggles, gown, gloves

• Laryngoscope Handle with functional lighting

• Laryngoscope blades (Macintosh or Miller)

• Rescue airways if available - including nasal airway and LMA

• Tape or commercial device for securing ETT

• Stethoscope for airway auscultation

• Syringe for cuff inflation

• End-tidal CO2 monitor

Medications for rapid sequence intubation (RSI) if patient is awake:

Medication list:

• Sedation: midazolam 1-2 mg IV, etomidate 0.3 mg/kg IV, lorazepam 1-2 mg IV.

• Paralysis (neuromuscular blockade): succinylcholine 1.5 mg/kg IV, vecuronium 0.1 mg/kg IV.

• Always administer sedation prior to neuromuscular blocking agents!

4. Administer intravenous medications for sedation if patient is awake or combative.

5. Position patient in a supine position with flexion of the cervical spine to maximize visualization of the epiglottis. If flexion is contraindicated secondary to cervical spine instability, the cervical spine must be maintained in a neutral position. Manual manipulation of the thyroid cartilage with the dominant hand may improve visualization.

6. Use left hand to insert laryngoscope blade and visualize the epiglottis and vocal cords. The left hand should be used to insert the blade, as the vast majority of laryngoscopes contain the visualization light on the right. If the blade is used with the right hand, this may obstruct view. Insertion of the blade is best done using gentle forward, upward pull and sweeping tongue laterally to the left. Do not pull the laryngoscope backward at an angle, as this may cause dental damage. When placing a curved Macintosh blade, the tip should advance into the vallecula, thus revealing the opening to the trachea. When using a straight Miller blade, the tip should advance into the laryngeal inlet. At this point, the blade tip is used to lift the epiglottis anteriorly to reveal the trachea. Use right hand for suction as necessary. A small, randomized controlled trial demonstrated that providing apneic oxygen through a nasal cannula during laryngoscopy does not appear to increase arterial oxygen saturations over not using supplemental oxygen.

7. Once vocal cords are visualized, use right hand to advance ETT tube into the trachea. Proper position is estimated at three times the ETT size (If 7 french ETT, advance tube to 21 cm at the lip).

8. Secure tube with tape or commercial device.

9. Verify positioning by auscultation of bilateral breath sounds, verification of exhaled CO2, and by obtaining chest radiograph for verification.

IV. Common Pitfalls.

Common complications of endotracheal intubation include inability to visualize the vocal cords. This causes a delay in intubation and oxygenation. Multiple attempts at tracheal intubation increases the frequency of complications including hypoxemia, hypotension, bradycardia, aspiration of gastric contents, and cardiac arrest.

Other complications include endobronchial intubation, pneumothorax, and lip or dental trauma. All of these complications can be reduced by maintaining an adequate skill set, thus reducing the need for multiple laryngoscopy attempts. Activities used by practitioners needing to maintain competency in airway management include use of mannequins, cadavers, and simulators. In addition, some institutions require additional exposure with operating room intubations and ED practice time. Other resources for continued practice include difficult airway workshops.

V. National Standards, Core Indicators and Quality Measures.

As of 2015, no national standards/benchmarks established yet. In 2012, the Eastern Association for the Surgery of Trauma (EAST) published guidelines for emergency tracheal intubation following traumatic injury.

Quality indicators regarding endotracheal intubation that have been used within individual health systems include number of attempts, confirmation of ETT placement, and complication rates post intubation.