Chapter 35

• The choice between noninvasive ventilation via mask versus ventilation via translaryngeal tracheal intubation is an increasingly critical branch point in the management of patients with respiratory failure.
• Shock, a failed trial of extubation, inability to protect and maintain one's own airway, need for larger minute ventilations or larger transpulmonary pressures, and transport of an unstable patient all remain indications for tracheal intubation.
• Assessment and adequate preparation of the patient prior to intubation are crucial to ensuring successful and safe intubation.
• Awake tracheal intubation with topical anesthesia remains the preferred technique, although skilled operators can perform rapid sequence induction and intubation with a high degree of success. General anesthesia and paralysis are associated with substantial risks in critically ill, hemodynamically unstable patients.
• The appropriate timing of tracheostomy remains poorly defined. Improved endotracheal tubes allow for prolonged intubation with a low risk of associated traumatic injury.
• Percutaneous tracheostomy and conventional tracheostomy are increasingly performed at the bedside to minimize the hazards associated with transporting a critically ill patient.

Tracheal intubation remains one of the most common and important procedures performed in the intensive care unit (ICU). When done well, tracheal intubation can be a lifesaving procedure. When done poorly, it may initiate a cascade of events that can lead directly or indirectly to trauma, severe complications, and death. The widespread adoption of noninvasive ventilation in the management of patients with type II acute-on-chronic respiratory failure (ACRF) and high-pressure pulmonary edema has created a population of patients who have failed moderate levels of ventilatory support and require emergent airway management (see Chap. 33). It is imperative that those who manage the airways in these patients have a high degree of knowledge, skill, and comfort in managing patients with little physiologic reserve. It is imperative that ICU physicians have knowledge and understanding of the indications for tracheal intubation, the assessment of the patient for tracheal intubation, the devices and techniques available for tracheal intubation, and the consequences and complications of tracheal intubation.1

The decision about whether to intubate a critically ill patient requires that a practitioner at the bedside synthesize all of the information they have at their disposal about a patient, compare it to their institutional practice patterns and resources, and decide how to proceed. These decisions are rarely clear-cut; reasonable practitioners can arrive at different decisions in identical circumstances. Patients who require intubation as part of the initial management of their respiratory failure include but are not limited to those with cardiopulmonary arrest, respiratory arrest, acute respiratory distress syndrome (ARDS) of almost any cause, and any patient who is unlikely to respond to noninvasive ventilation (Table 35-1). The decision to intubate a patient after noninvasive ventilation is even more difficult to make. Triggers to convert to an invasive airway include progressive hypercapnia in spite of adequate levels of support (such as a patient with sleep apnea who is worsening on biphasic positive airway pressure [BIPAP]), unacceptably high airway pressure, ...

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