RESUSCITATE before INTUBATE

Before proceeding with intubation, be aware of factors that can cause peri-intubation complications. Always think C.R.A.S.H.:

• Consumption (increased oxygen demand)
• Right Ventricular Failure
• Acidosis
• Saturation
• Hypotension

 

C – Consumption

Increased oxygen consumption can occur in situations such as pediatric patients, pregnancy, sepsis, thyrotoxicosis, and other high metabolic states.

Management:

• Optimize preoxygenation (100% FiO2, denitrogenation).
• Utilize apneic oxygenation during intubation (nasal cannula at 15L/min).
• Anticipate a shorter apnea time—intubate quickly and avoid delays.

 

 

R – Right Ventricular (RV) Failure

Patients with RV dysfunction or failure are at high risk of decompensation during intubation due to their limited ability to handle increased afterload and pressure changes.

Management:

• Use cardiac ultrasound to assess fluid status and guide resuscitation.
• Consider early vasopressors (e.g., norepinephrine).
• Use inhaled pulmonary vasodilators (e.g., nitric oxide or epoprostenol) if available.
• Optimize preoxygenation to avoid desaturation and worsening RV strain.

 

 

A – Acidosis

Intubation in patients with severe metabolic acidosis (e.g., DKA, lactic acidosis) can worsen acidosis due to the interruption of compensatory hyperventilation.

Management:

• Avoid intubation if possible.
  • If intubation is necessary, use ventilator-assisted pre-oxygenation (VAPOX) to support spontaneous breathing and avoid further CO2 retention.
  • Ventilator Settings (SIMV + PSV) before induction:
    • RR: 0
    • Tidal Volume: 8 mL/kg of IBW
    • FiO2: 1.0
    • PS: 5-10 cmH2O
    • PEEP: 5
    • Inspiratory Flow: 30 L/min
  • After induction: Set RR to 12 breaths/min, perform jaw thrust to maintain airway patency
  • Post-intubation: Increase RR to 30 breaths/min to maintain adequate ventilation and prevent worsening acidosis.

 

 

S – Saturation

Optimizing oxygen saturation is critical to ensure a safe apneic interval during intubation. Preoxygenation should address:

• Denitrogenation
• Improving Functional Residual Capacity (FRC)
• Reducing ventilation/perfusion mismatch

 

Management:

i. NO.D.E.S.A.T (Nasal Oxygen During Effort Securing A Tube)

• Use nasal cannula at 15 L/min along with high-flow oxygen (HFMO2) or bag-valve mask (BVM) during preoxygenation.
•  Rule of 15:
  • ​Nasal oxygen at 15 L/min + HFMO2/BVM at 15 L/min ± 5-15 cmH2O PEEP.

ii. Improve BVM technique:

• Use the EV (Two-Provider) Technique for better seal and ventilation.
• For facial hair, consider applying Tegaderm to improve mask seal.

iii. Delayed Sequence Intubation (DSI):

• Use procedural sedation to facilitate preoxygenation in an agitated hypoxic patient.

 

iv. Proper Positioning:

• BUHE (Back Up Head Elevation): Elevating the head improves preoxygenation efficacy, prolongs safe apnea time, and increases oxygen reserve by shifting weight off the chest.

 

 

H – Hypotension

Critically ill patients are at significant risk of peri-intubation hypotension due to volume depletion, vasoplegia, or cardiomyopathy. Positive pressure ventilation (PPV) increases intrathoracic pressure, reducing venous return and cardiac output.

 

Management:

i. IV Access:

• Secure two peripheral IV lines before intubation.

ii. Fluid Resuscitation:

• Administer fluid boluses if the patient is fluid-responsive and not volume-overloaded.

iii. Aim Higher BP

• Aim for a higher BP before intubation, ideally SBP ≥ 140 mmHg.

• Consider delaying intubation until BP is optimized.

iv. Lower the Sedatives, Higher the Paralytics:

• Use low-dose sedatives and high-dose paralytics to minimize vascular tone reduction.

v. Push-Dose Pressor: 

• Prepare for push-dose pressors or start a peripheral vasopressor infusion:    

  • Adrenaline (1:100,000) (10 mcg/mL), administer 0.5-2 mL IV every 2-5 minutes to maintain adequate BP.

vi. Awake Trachel Intubation:

• Consider awake tracheal intubation in hemodynamically unstable patients with a high risk of difficult airway management.