Chapter 122. Intubation and Airway Support

1. What are the indications for rapid sequence intubation?

2. What are the predictors of a difficult airway?

3. When is “awake intubation” indicated?

4. What are the alternative methods available for intubation and/or ventilation?

Airway management can significantly affect outcomes for hospitalized critically ill patients. Failure to deliver adequate oxygen may cause irreversible brain damage or preclude successful resuscitation. Options for management may range from assisted ventilation with a bag-valve-mask (BVM) to noninvasive ventilation (NIV) support to endotracheal intubation. A successful outcome in any intubation demands proficiency in patient assessment, knowledge of the equipment (basic and advanced), requisite technical skills, appreciation of individual limitations, and an alternative plan to deal with the difficult or failed airway.

In 2006 the Society for Hospital Medicine published the Core Competencies in Hospital Medicine, which listed endotracheal intubation as one of the procedural competencies for hospitalists. However, a small survey published in 2010 noted that individual hospitalists (n = 175) performed on average only 10 endotracheal intubations in the previous year with a range of 3 to 20. This limited clinical experience with advanced airway management highlights the importance of a valuable educational program for the hospitalists as well as clinicians' understanding of their own practice and skill limitations. Depending on their clinical environment and work setting, the expectations for different hospitalists in advanced airway management will vary. However, all hospitalists should be versed in initial airway management and stabilization, including effective use of oral and nasal airway and BVM devices.

Airway Anatomy

Successful intubation requires knowledge of basic airway anatomy landmarks and locations of various airway structures relative to each other to identify the glottic opening and successfully intubate. The larynx and in particular the vocal cords lie just below the epiglottis, and proper elevation of the epiglottis should allow the clinician to visualize the arytenoids and the vocal cords prior to insertion of the endotracheal tube (ETT) (Figure 122-1).

Predictors of a Difficult Airway

A difficult airway refers to complex or challenging BVM or endotracheal intubation. Difficult oxygenation is the inability to maintain the oxygen saturation > 90% despite using a BVM and 100% oxygen. A failed airway refers to the inability to either ventilate or intubate a patient after three intubation attempts by the same operator using multiple blades. Experienced operators uncommonly encounter this problem. Difficult ventilation occurs in 1 in 50 anesthesia cases. In one study of emergency department cases 2.7% were deemed failed intubation attempts due to unsuccessful first attempts requiring rescue techniques. A higher rate of poor clinical outcomes occurs when the airway is managed as an emergent (rather than elective) procedure. In addition, an increased number of airway attempts ...