critical care medicine
Tracheal Intubation
Before Intubation
Maneuvers to create a Clearing and Opening the Upper Airway and to ventilate and oxygenate the patient are always indicated before attempting tracheal intubation. Once a decision to intubate has been made, preparatory measures include Correct patient positioning (see figure) Ventilation with 100% oxygen Preparation of necessary equipment (including suction devices) Sometimes drugs Ventilation with 100% oxygen denitrogenates healthy patients and significantly prolongs the safe apneic time (effect is less in patients with severe cardiopulmonary disorders). Strategies to predict difficult laryngoscopy (eg, Mallampati scoring, thyromental distance testing) are of limited value in emergencies. Practitioners should always be prepared to use an alternate technique (eg, Laryngeal Mask Airways (LMA) , During Cardiac Arrest , chest compressions should not be halted for intubation attempts. If practitioners cannot intubate while compressions are being done (or during the brief pause that occurs during compressor changes), an alternate airway technique should be used. Suction should be immediately available with a rigid tonsil-tip suction device to clear secretions and other material from the airway. Anterior cricoid pressure (Sellick maneuver) has previously been recommended before and during intubation to prevent passive regurgitation. However, this maneuver may be less effective than once thought and may compromise laryngeal view during laryngoscopy. Drugs to Aid Intubation , including sedatives, muscle relaxants, and sometimes vagolytics, are typically given to conscious or semiconscious patients before laryngoscopy. 1.Apfelbaum JL, Hagberg CA, Connis RT, et al: 2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway.Anesthesiology136(1):31-81, 2022. doi:10.1097/ALN.0000000000004002 2.Difficult Airway Society: DAS guidelines for management of unanticipated difficult intubation in adults 2015. 