Which intubation modality should I choose?
There are more options to intubate a patient besides our standard RSI techniques. I’ll be giving a brief overview of some other options below & an excellent flowchart from WJEM. Since this is a POTD, I will not be going in depth into each modality. However, I’ll try and include major indications & pitfalls when going through them.
Delayed Sequence Intubation (DSI): Primarily used in patients who are preventing you from oxygenating them (i.e. pulling off their bipap, agitated etc…). This is basically procedural sedation where the “procedure” is preoxygenation.
Begin by giving a dissociative dose of IV Ketamine (1-2 mg/kg) and once the patient is properly sedated, preoxygenate them as you wish. Ketamine usually preserves their respiratory drive, but you may need to step in and intubate earlier than you anticipate if the patient were to experience respiratory depression. When the patient is adequately preoxygenated, you can give the paralytic and intubate the patient as you normally would.
Sometimes, just forcing the patient to tolerate Bipap without interruption may result in the patient’s respiratory status improving and avoiding intubation.
Ketamine Only Breathing Intubation (KOBI): KOBI is a great choice in physiologically challenging intubations where patients cannot tolerate a moment of apnea such severe acidosis.
Begin by giving a dissociative dose of IV Ketamine. The patient will then be sedated, but still breathing. Then proceed with your intubation modality of choice. Beware, the patient may be a little rigid, have a higher risk of vomiting, and the vocal cords will still be moving. Either the vocal cords can be “timed” or a paralytic given shortly before passing the endotracheal tube. Even if a paralytic is not used, it should be readily available incase of complications such as jaw rigidity.
Awake Intubation: Awake intubations are the ideal choice for cooperative patients that may be difficult intubations, but the intubation is less urgent. The advantage lies in that it is incredibly safe (the patient is breathing the whole time) and the procedure can be aborted if the intubation cannot be completed. An example could be a patient with Ludwig’s angina, where the loss of airway reflexes in RSI could lead to dire consequences if the patient is unable to be intubated. It would likely be difficult to oxygenate & ventilate a patient with Ludwig's angina, especially with all the soft tissue collapse after induction & paralysis in RSI, leading to disastrous consequences.
Begin by drying out the oropharynx (gauze, glyopyrrolate). Then, the goal will be to topicalize extensively. 4% Nebulized lidocaine should be used. Atomized lidocaine should also be given via the nose and mouth (usually in awake intubations, nasotracheal intubation via fiberoptic bronchoscope is better tolerated than orotracheal intubation). Lastly, the patient can also gargle viscous lidocaine. The patient can also be given anxiolysis (such as versed) and may need soft restraints depending on the clinical scenario. Proceed with either orotracheal or nasotracheal intubation. Once you have passed the cords, the patient can be fully sedated since the airway is then secured.
Merelman, A. H, Perlmutter, M. C, & Strayer, R. J. (2019). Alternatives to Rapid Sequence Intubation: Contemporary Airway Management with Ketamine. Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 20(3). http://dx.doi.org/10.5811/westjem.2019.4.42753 Retrieved from https://escholarship.org/uc/item/4b27s3ks
https://www.emdocs.net/awake-endotracheal-intubation/
