1578185 - McGraw-Hill Professional ©CHAPTER 122Arterial

1578185 - McGraw-Hill Professional ©
CHAPTER 122
Arterial Blood Gas and Placement of A-
line
Joseph J. Miaskiewicz, Jr., MD
Critically ill patients require arterial blood gas (ABG) analysis
to assess oxygenation and
ventilation due to limitations of noninvasive oximetry
measurements. Below a pO2 of 60
mm Hg corresponding to an O2 saturation of 80%, the
oxyhemoglobin saturation curve is
steep and large changes in oximetry may mean small changes in
oxygenation. Below this
level oximetry may not correlate with oxygenation, and an
arterial blood gas (ABG) should
be obtained (Table 122-1).
TABLE 122-1 Obtaining an Arterial Sample and Placement of
an Arterial Line
ABG A-Line
Indications In hospitalized medical patients,
an ABG is primarily obtained to
confirm the severity and likely
cause of the disturbance
• Level of oxygenation, especially

in settings when the oximeter
measurements are thought to be
unreliable or difficult to obtain
• Need for intubation: refractory
hypoxemia (pO2 < 55 on 100% O2
Usually in the ICU setting
for
• Frequent ABG sampling
• Continuous blood
pressure monitoring in
use of inotropic or
vasopressor agents
NRB mask) or hypercapnic
respiratory failure (pCO2 > 55
with acidemia pH < 7.25)
• Severity metabolic acidosis and
adequacy of respiratory
compensation when ↑ work of
breathing
• Contribution of ↑pCO2 versus
other causes in somnolent
patient
Contraindications Impaired collateral circulation
• Raynaud
• Thromboangiitis obliterans

• Cyanosis
Impaired collateral
circulation
Preparation Allen test: occlusion of the radial
and ulnar arteries by firm pressure
while the fist is clenched followed
by opening of the hand and
release of the arteries one at a time
to assess adequacy of returning
blood flow to the hand
Assess collateral
circulation with Allen test
Avoid brachial and
femoral arteries
(inadequate collateral
supplies)
Technical Tips
The radial artery at the
wrist best site (near the
surface, relatively easy to
palpate, and stabilize
with good ulnar collateral
supply)
Apply local anesthetic with 1%
lidocaine in the conscious patient
Immobilize hand on a wrist board
or towel and dorsiflex wrist
Same as for ABG
If lose ability to palpate
pulse, likely arterial

spasm precluding
successful cannulation.
Wait until subsides or
choose another site
If unsuccessful, apply
pressure for several
minutes to avoid
hematoma formation
(which will make
subsequent attempts
more difficult) and
consider use of
ultrasound to visualize
vessel
Reassess perfusion of
hand after placement
Complications Transient obstruction of blood flow
may ↓ arterial flow in distal tissues
unless adequate collateral arterial
vessels available in the setting of
Remove catheter
immediately if any sign
of vascular compromise
• Spasm
• Intraluminal clotting
• Bleeding and hematoma
formation

Use nondominant hand
preferred
By measuring both oxygenation and ventilation ABG analysis
assesses the effects of
the cardiopulmonary system in oxygen delivery. ABG analysis
directly measures the pH,
pCO2, and pO2. The normal range for the pH is between 7.36
and 7.44 corresponding to a
normal range of 36 to 44 torr for the pCO2. The normal range
for the pO2 is between 80
and 100 torr. However, age and the pCO2 also determine
alveolar O2.
Oximetry does not measure pCO2 and does not reflect
ventilation or acid-base status.
Ventilation may be defined in terms of movement of a volume
of air into and out of the
lungs, removing carbon dioxide from the blood and providing
oxygen. Alveolar ventilation
is defined in terms of ventilation of CO2. High oxygen
saturation may be falsely reassuring
in patients whose respiratory drive is compromised by an
increase of oxygenation due to
supplemental O2. Assessment of alveolar ventilation is the key
to determining whether a
patient is receiving enough oxygen. A raised PaCO2 reflects
reduced alveolar ventilation.
See Chapter 238 (Acid Base Disorders). An approach to
interpreting arterial blood gases is
essential when caring for hospitalized patients (Table 122-3).
Respiratory failure is classified as hypoxemic respiratory failure
(hypoxemia without
carbon dioxide retention [SaO2 < 95%, PaO2 < 80 on room air])
or hypercarbic respiratory

failure (pCO2 > 45 mm Hg). Calculation of the gradient
between the alveolar and arterial
oxygen tensions (the A-a gradient) in respiratory failure will
help to determine whether the
patient has associated lung disease or just reduced alveolar
ventilation (Table 122-2). See
Chapter 138 (Acute Respiratory Failure).
TABLE 122-2 Calculation of the A-a Oxygen Gradient from the
ABG
The Alveolar-Arterial Oxygen Gradient
The A-a oxygen gradient = PAO2 – PaO2
Estimated normal gradient ∼ (Age/4) + 4
The Alveolar Gas Equation
PAO2 = (FiO2 × [Patm – PH2O]) – (PaCO2/R)
• Inspired air at sea level, the FiO2 of room air = 0.21
• Atmospheric pressure, Patm = 760 mm Hg
• PH2O at 37 F = 47 mm Hg
• Respiratory quotient, R = 0.8
Hypoxemic Respiratory Failure with Normal A-a Oxygen
Gradient
• Alveolar hypoventilation (oversedation, obesity
hypoventilation syndrome, muscular
weakness, neurologic disease)
• High altitude (low inspired FiO2)
Hypoxemic Respiratory Failure with ↑ A-a Gradient
file://view/books/9780071843140/epub/EPUB/xhtml/286_Chapt
er238.html
file://view/books/9780071843140/epub/EPUB/xhtml/173_Chapt
er138.html

• Ventilation-perfusion mismatch (pulmonary embolism, COPD,
ARDS, pulmonary artery
vasospasm)
• Right-to-left shunt (anatomic: cardiac, pulmonary AVM,
hepatopulmonary syndrome;
physiologic due to fluid preventing ventilation of perfused
alveoli: pneumonia,
atelectasis)
Disorders of the lung structure reduce the efficiency of oxygen
transfer and widen the A-a
gradient. The prolonged respiratory depression may lead to
collapse of some areas of
lung and an increase in the A-a gradient.
Hypercarbic Respiratory Failure, Hypoxemia from Impaired
Ventilation with Normal A-a
Oxygen Gradient
• Inadequate alveolar ventilation (without shunting from fluid or
collapse of alveoli)
• Ventilatory pump failure (respiratory muscle weakness,
neurolgic disease, thoracic cage
issues)
TABLE 122-3 Blood Gas Interpretation
Step 1: Acid-base (ventilation)
pH PaCO2 Interpretation
↓ ↑ In acute respiratory failure the change in pH will be
accounted
for by the high carbon dioxide concentration.

↓ ↓ A severe metabolic acidosis or some limitation on the
ability
of the respiratory system to compensate.
Normal ↑ Alveolar hypoventilation (raised PaCO2) with a
normal pH
most likely a primary ventilatory change present long enough
for renal mechanisms to compensate. Increased serum
bicarbonate may also be a clue of chronic CO2 retention.
A similar picture may result from carbon dioxide retention due
to reduced ventilation compensating for a metabolic
alkalosis, although such compensation is usually only partial.
Normal ↓ A primary metabolic acidosis in which the respiratory
system
has normalized the pH. Calculate the anion gap.
↑ ↓ Acute alveolar hyperventilation if the pH is appropriately
raised for the reduction in PaCO2.
Chronic alveolar hyperventilation if the pH is between 7.46
and 7.50 as the renal system seldom compensates
completely for an alkalosis.
Step 2: Oxygenation (pO2, %saturation)
pO2 PaCO2 pH
Normal Normal ↑ A primary metabolic alkalosis
to which the ventilatory
system has not responded.
↓ Normal ↓ Hypoxemia: when patients

with chronic CO2 retention
increase usual level of
ventilation (acute pulmonary
embolism in chronic lung
disease).
Step 3: Calculate the A-a gradient to determine whether carbon
dioxide retention is
related to an intrapulmonary cause
A-a Explanation Etiology
Gradient Calculating the A-a gradient is
most useful for determining
the severity of the underlying
disorder and whether there is
a component of
hypoventilation.
Especially for hospitalized
patients who are prescribed
medications that may
suppress respiration, the A-a
gradient is used to determine
the relative contribution of
hypoventilation to hypoxia
due to underlying lung
disease.
Normal A normal A-a gradient is ∼10-
15 torr. Advancing age results
in increases of the normal A-a
gradient. A-a gradient = 2.5 +
0.21 × age in years.
The ABG abnormality is all
due to hypoventilation.

Elevated An elevated A-a gradient
represents ↑ difficulty in
getting O2 from the alveoli to
the blood.
A higher FiO2
disproportionately increases
the PAO2 more than the PaO2.
• Diseases that affect the
pulmonary interstitium
including interstitial lung
disease, pneumonia, and
CHF.
• Pulmonary vascular disease:
pulmonary emboli, shunts,
pulmonary hypertension.
• Ventilation/perfusion
mismatches of large vessels
(pulmonary or tumor
emboli) and small vessels
(pulmonary hypertension,
vasculitis, interstitial lung
disease and emphysema).
• When breathing 100%
oxygen, older patients may
normally have an A-a
gradient as high as 80 torr
and younger patients as
high as 120 torr.

Step 4: Does the result correlate with the clinical setting?
Possible Source of Error Prevention
Presence of heparin in
syringe
Express any heparin out of syringe prior to sampling
Air bubbles (resulting in
equilibrium between air
and arterial blood:
↓PaCO2, ↑PaO2
Inspect sample and remove air bubbles
Inadequate sample Obtain at least 3 mL aterial blood
Metabolically active
cellular constituents of
blood (resulting in
changing arterial gas
tensions over time)
Cool sample on ice
Analyze sample within 1 h
Sampling of venous
blood
Pay attention to technique
Neither oximetry nor ABGs will detect the presence of a
reduced O2-carrying capacity
because anemia, and carbon monoxide (CO) poisoning, and
methemoglobinemia do not
affect the alveolar pO2. When there is CO poisoning, the

oximeter cannot differentiate
between hemoglobin molecules with CO attached and those with
O2 attached and will
report normal O2 saturation. ABGs will also report normal
values because the PaO2 is a
measurement of the oxygen dissolved in the blood and not the
number of O2 molecules
attached to hemoglobin molecules. In CO poisoning an elevated
carboxyhemoglobin will
be required to make the diagnosis. Nonsmokers may have levels
up to 3, smokers 10 to
15, and CO poisoning levels above 15. Likewise, the presence
of abnormal hemoglobins,
such as sickle cell, fetal hemoglobin, and methemoglobin, will
not affect the ABG results.
Oximetry may also not correlate with oxygenation with falsely
low results when there is
poor blood flow and perfusion to the fingertips,
vasoconstriction due to hypothermia or
sepsis
BCO212 Business Finance 1 Final Exam Makeup
Task brief & rubrics
Task
· individual
· upload word document or pdf with solutions
Formalities:
· Wordcount: 900 words maximum, 600-900 words normal
· Cover, Table of Contents, References and Appendix are
excluded of the total wordcount.
· Font: Arial 12,5 pts.
· Text alignment: Justified.

· The in-text References and the Bibliography have to be in
Harvard’s citation style.
Submission:
Weight:
It assesses the following learning outcomes:
· To be able to conduct equity valuation
· Understand the idea of valuation using comparables
Exercise 1 (20 points):
XYZ tech is based in European Union. Share price of XYZ is
traded at 62 euro per share. Company is paying dividends once
a year. Expected dividend next year is about 1.25 euro per
share. Return on equity is equal to 0.12.
Question 1.1:
Using Gordon model find implied growth rate of the company
XYZ (10 points)
Question 1.2:
You are worrying that company might be overvalued. Forward
P/E ratio in tech sector is about 20. Analysts (whom you trust)
expect that earnings per share will be 2 euro per share. Use
relative (multiples) valuation method to estimate “fair” share
price. Compare your estimate to the actual share price and make
a conclusion whether company is overvalued or no? (10 points)
Procter & Gamble will pay an annual dividend of $1 one year
from now. Analysts expect this dividend to grow at 12% per
year thereafter until the fifth year. After then, growth will level

off at 2% per year. What is the value of a share of Procter &
Gamble stock if the firm’s equity cost of capital is 10%?
(a&b 10 points each):
Exercise 4 (12 points): Theoretical question (150 words
maximum)
Explain what are the pros and cons of the comparable/multiples
valuation of the stocks? What are the most popular
multiplicators for stock valuation?
Exercise 5* (8 points): Practical valuation using P/E ratio.
Pick a stock of the publicly traded US-based company of your
choice. What is the industry of the company? Use average
industry P/E ratio and EPS (earnings per share) of the company
to define the “fair” price of the stock.
Hint: you might find this data useful:
http://pages.stern.nyu.edu/~adamodar/New_Home_Page/datafile
/pedata.html
Rubrics
Exceptional 90-100
Good 80-89
Fair 70-79
Marginal fail 60-69
Knowledge & Understanding (20%)
Student demonstrates excellent understanding of key concepts
and uses vocabulary in an entirely appropriate manner.
Student demonstrates good understanding of the task and
mentions some relevant concepts and demonstrates use of the

relevant vocabulary.
Student understands the task and provides minimum theory
and/or some use of vocabulary.
Student understands the task and attempts to answer the
question but does not mention key concepts or uses minimum
amount of relevant vocabulary.
Application (30%)
Student applies fully relevant knowledge from the topics
delivered in class.
Student applies mostly relevant knowledge from the topics
delivered in class.
Student applies some relevant knowledge from the topics
delivered in class. Misunderstanding may be evident.
Student applies little relevant knowledge from the topics
delivered in class. Misunderstands are evident.
Critical Thinking (30%)
Student critically assesses in excellent ways, drawing
outstanding conclusions from relevant authors.
Student critically assesses in good ways, drawing conclusions
from relevant authors and references.
Student provides some insights but stays on the surface of the
topic. References may not be relevant.
Student makes little or none critical thinking insights, does not
quote appropriate authors, and does not provide valid sources.
Communication (20%)
Student communicates their ideas extremely clearly and
concisely, respecting word count, grammar and spellcheck
Student communicates their ideas clearly and concisely,
respecting word count, grammar and spellcheck
Student communicates their ideas with some clarity and
concision. It may be slightly over or under the wordcount limit.
Some misspelling errors may be evident.
Student communicates their ideas in a somewhat unclear and
unconcise way. Does not reach or does exceed wordcount
excessively and misspelling errors are evident.

CHAPTER 121
Intubation and Airway Support
Bisan A. Salhi, MD
Todd A. Taylor, MD
Douglas S. Ander, MD
INTRODUCTION
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 (Table 121-1). 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.
TABLE 121-1 Overview of Emergency Airway Management
Technique Description Notes
Rapid Sequence
Intubation (RSI)

Defined by the
simultaneous
administration of a
Avoids insufflation of the stomach
sedative and paralytic
agent to assist in
endotracheal intubation,
usually via direct
laryngoscopy
Minimizes risk of aspiration with
assisted BVM ventilation
Bag-Valve-Mask (BVM)
Ventilation
The ability to ventilate a
patient can be an
effective bridge prior to
intubation and is a
requirement prior to use
of any paralytic agents
Prior to ventilating with a BVM,
place an airway adjunct to
maintain patent airway and to
optimize ventilation:
• Nasopharyngeal airway if

patient’s airway (gag) reflexes
intact
• Oropharyngeal airway if absent
airway reflexes
If patient has dentures, they
should be left in place during BVM
ventilation and removed just prior
to insertion of laryngoscope
If the operator is having problems
maintaining a seal or ventilating,
two-hand BVM should be
attempted
Endotracheal Intubation Airway control
established usually
through direct
laryngoscopy and
orotracheal intubation
Any operator attempting
intubation, particularly if using
paralytic agents, should be very
comfortable with the technique,
equipment, rescue devices, and
with other resources for
assistance, have a plan to address
any contingency
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. For those performing endotracheal intubation, it is
important to maintain this

essential skill, and to be aware of their own practices 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.
Successful intubation requires not only knowledge of the basic
procedural steps, but
also knowledge of airway anatomy, landmarks, and locations of
various airway structures
relative to each other.
INDICATION FOR INTUBATION
All indications for endotracheal intubation can be classified as
(1) failure to maintain a
patent airway, (2) failure of oxygenation and/or ventilation, and
(3) anticipation of a
rapidly deteriorating clinical course (Table 121-2).
TABLE 121-2 Indications for Intubation
Indication Suggestive Signs Comments
Failure to maintain a
patent airway
• Inability to phonate
• Inability to swallow or handle

secretions
• High risk of aspiration
• The presence/absence
of a gag reflex does
NOT effectively assess
airway patency
• The gag reflex is
physiologically absent
in 20% of normal adults
• Stimulation of the gag
reflex increases risk of
vomiting/aspiration
Failure to oxygenate or
ventilate
• Unresponsiveness to noninvasive
oxygenation or ventilation
methods
• Assess patient’s clinical
appearance including
vital signs, mentation
• Monitor oxygenation
with continuous pulse
oximetry and/or ABG
analysis
• Monitor ventilation with
capnography, ABG, or
VBG analysis.

Anticipate deterioration in
clinical condition
• Patient must be unaccompanied
for testing
• Patient unable to maintain
current work of breathing
• Likely further studies or surgery
etc
• Consider clinical factors
such as severe
metabolic acidosis with
inadequate respiratory
compensation;
neuromuscular
weakness (impaired
maximal inspiratory
pressure); etc
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. 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 predicts poorer

outcomes; thus, a backup plan is necessary if initial intubation
attempts are not
successfully executed. The LEMON rule is one popular rule for
assessment for difficult
intubation (Table 121-3).
TABLE 121-3 Assessment for Difficult Intubation (Mnemonic:
LEMON)
Look Injury, large incisors, large tongue, beard, receding
mandible, obesity, abnormal face or neck pathology
or shape
Evaluate the 3-3-2 rule Mouth opening < 3 fingers, mandible
length < 3
fingers, or larynx to floor of the mandible < 2 fingers
Mallampati Class III (see base of uvula) and class IV (soft
palate
is not visible)
Obstruction Any upper airway pathology that causes an
obstruction (abscess, edema, masses, epiglottitis)
Neck mobility Limited mobility of neck (eg, trauma with
cervical
spine immobilization, arthritis, congenital defect)
BAG-VALVE-MASK (BVM) VENTILATION
The most important skill required for inpatient clinicians in
airway management is use of

a BVM and airway adjuncts to ventilate and oxygenate the
patient. BVM ventilation can
effectively maintain airway patency while an alternative plan is
developed and
implemented. However, patients with a high risk of failing
BVM ventilation may require
more rapid and definitive airway evaluation and management.
Predictors of difficult BVM
are summarized in Table 121-4.
TABLE 121-4 Assessment for Difficulty with Bag-Valve-Mask
(BVM) Ventilation
(Mnemonic: MOANS)
Mask seal Inadequate mask seal (beard, blood/emesis, facial
trauma, operator small hands)
Obesity BMI > 26 kg/m2
Age >55 y
No teeth No teeth (impairs BVM effectiveness)
Stiff ventilation Asthma, COPD, ARDS, term pregnancy
ARDS, acute respiratory distress syndrome; BMI, body mass
index; BVM, Bag-valve-mask; COPD,
chronic obstructive pulmonary disease.
PROCEDURAL STEPS
Rapid sequence intubation (RSI) is now the predominant and
preferred method in
managing the emergent airway, precluding the apneic patient
requiring a crash airway (ie,

cardiac or respiratory arrest). Rapid sequence intubation is
defined as the simultaneous
administration of a sedative and paralytic agent to assist in
endotracheal intubation,
usually via direct laryngoscopy (Table 121-5). Central to the
concept of RSI is the
avoidance of assisted BVM ventilation to avoid insufflation of
the stomach and minimize
the risk of aspiration. Outcomes evidence supports RSI as a safe
and effective technique
for emergency airway management that maximizes the patient
and physician likelihood of
timely, successful airway management (Table 121-6).
TABLE 121-5 Equipment for Endotracheal Intubation
Endotracheal tubes (assortment of sizes) with stylet
Intubation blade (direct or video)
Oxygen
Bag-valve-mask
Suction with Yankuer tip
Airway adjuncts (oral and nasal)
Confirmation device (end-tidal CO2 detector)
Stethoscope
Lubricant
TABLE 121-6 Procedural Steps of Rapid Sequence Intubation
(RSI)
Preparation
Assessment of the
airway, adequate IV
access, continuous
oxygenation monitoring,
RSI medications (sedative

and paralytic)
Equipment
Laryngoscope with
functioning light & blades of
multiple sizes,
working suction, oxygen,
Medications (code cart
nearby),
Backup airway devices, BVM,
Monitors (telemetry, pulse
oximetry, BP)
Medical Team
Engage team of appropriately
trained staff; backup nearby,
Utilize the assistance of
respiratory therapists early,
Call for help early
Preparation
Anticipate a difficult
airway (a complex or
challenging intubation)
with a backup plan such
as fiberoptic intubation
Risk Factors
Congenital
Pierre Robin syndrome, Down
syndrome, anterior epiglottis
Acquired
Ludwig angina, abscess,
epiglottis;
RA, AS, scleroderma,
temporomandibular joint

dysfunction;
Assessment
Look for injury, large incisors,
large tongue, receding
mandible, obesity, abnormal
face or neck pathology or
shape
Evaluate the 3-3-2 rule
(LEMON rule)
Mouth opening <3 fingers
Mandible length <3 fingers
Adenomas, goiter, lipoma,
hygroma, carcinoma tongue,
larynx, thyroid;
Facial injury, cervical spine
injury;
Obesity, acromegaly;
Active burns, inhalation injury;
Subglottic stenosis
Larynx to floor of mandible <2
fingers
Mallampati
Class III (see base of uvula)
Class IV (soft palate not
visible)
Obstruction
Any upper airway pathology
that causes an obstruction
Neck Mobility

Limited neck mobility
Preparation
Assess difficulty with
bag-valve-mask (BVM)
ventilation
Five Independent Risk
Factors (MOANS):
1. Inadequate mask seal
(beard, blood, emesis,
facial trauma, operator
small hands)
2. Obesity (BMI > 26
kg/mm3)
3. Age > 55 y
4. Absence of teeth
5. Stiff ventilation (asthma,
COPD, ARDS, term
pregnancy)
Difficult oxygenation—the
inability to maintain oxygen
saturation >90% despite BVM
and 100% oxygen
RSI by trained operators
preferred, but other techniques
and backup methods should
be considered if difficulty with
BVM is predicted
Preoxygenation 100% supplemental oxygen to

induce nitrogen washout and
maximize time for intubation
without oxygen desaturation
Patients will have 7-9 min
prior to desaturation in
normal, healthy adult; less
time in ill patient with
comorbidity or critically ill
Premedication (Optional) Administration of drugs 3-5
min before induction and
paralysis
To blunt effects of direct
laryngoscopy, including
bronchospasm and a strong
sympathetic response. This
step is often omitted
Paralysis
Sedatives for induction;
paralytics for intubation
Sedative regimen should
provide reliable amnesia;
paralytics ↓ metabolic
demands, ↓CO2
production, ↑chest
compliance
Sedatives
Etomidate
…Onset 45-60 s for 5-10 min
Propofol
…Onset 45-60 s for 5-10 min
…Short-acting, allows frequent

monitoring of neurologic
status
Midazolam (Versed)
Side Effects
Etomidate
Minimal hypotension,
possible adrenal insufficiency
Propofol
Hypotension, depresses
myocardial contractility;
↑triglycerides, pancreatitis
Midazolam (Versed)
Unless contraindicated,
commonly etomidate for
sedation and
succinylcholine for
paralysis
…Often used in combination
with fentanyl bolus
…Anticonvulsant properties
Fentanyl
…Used to reduce pain from
laryngoscopy, not always
required
…Higher potency, faster onset,
shorter duration than
morphine
Less hypotension than

propofol,
delirium, slower onset,
respiratory depression, long
half-life; contraindications:
narrow-angle glaucoma
Fentanyl
Respiratory depression,
constipation;
contraindications: end-stage
liver disease, severe
respiratory disease if not
intubated
Succinylcholine
Bradycardia, ↑ICP, histamine
release; contraindications:
Paralytics
Succinylcholine
…First-line for RSI outside of
ICU
…Rapid onset, short acting
Rocuronium
…Alternative to
succinylcholine
…Rapid onset, minimal CV
effects
…Hyperkalemia (ESRD,
rhabdomyolysis, burns >10%
BSA, crush injury)
…Neurologic (stroke, spinal
cord injury, ALS, MS,↑ICP,
history of malignant
hyperthermia, eye injury)
…Prolonged immobility >48-72
h

Rocuronium
Caution with difficult airway:
longer acting than
succinylcholine
Proper Positioning to
Optimize Visualization of
Vocal Cords
Place a folded towel under the
occiput to raise head by ~ 3-7
cm
This “sniffing” position lines
up the oral, pharyngeal, and
laryngeal axes, thereby
optimizing the view of the
cords during laryngoscopy
Visualize the arytenoids and
the vocal cords prior to
insertion of endotracheal tube
(ETT) by elevating epiglottis
which lies just above larynx
and vocal cords
Placement of ETT
Typically advanced to 23
cm marker at the lip of
adult male, 21 cm adult
female
Multiple methods to confirm
correct placement:
…Condensation of ETT
…Bilateral breath sounds
…Absence of breath sounds

over epigastrium
…End-tidal CO2 detection
Gold standard for confirming
appropriate tube placement:
use of end-tidal carbon
dioxide detection
…CXR (ETT tube 2-3 cm above
carina)
Postintubation Care Proper stabilization of ETT to
prevent movement or
accidental dislodgment.
Patients who are medically
paralyzed require sedation
and pain control
Placement of a nasogastric or
orogastric tube can help
decompress any insufflated
air that occurred during BVM
use and will help ↓risk of
emesis and aspiration
In general, RSI is safer and more successful than awake
intubation. However, RSI is not
advised if difficulty with BVM is predicted or the ability to
intubate via direct laryngoscopy
is in question (eg, upper airway obstruction, stridor,
angioedema, head and neck cancers).
In select patients in which awake intubation is indicated, it

should be approached with
caution, and may require backup rescue airway methods and/or
the involvement of
consultants (eg, anesthesiology or otolaryngology).
COMPLICATIONS OF RSI (TABLE 121-7)
TABLE 121-7 Endotracheal Intubation Complications
Directly Related to Laryngoscopy Notes
Hemodynamic changes including
hypertension, hypotension,
tachycardia, and bradycardia
A pneumothorax needs to be considered in a patient
with hypoxia and hypotension and should be
evaluated for all patients with postprocedure chest
radiography
Hypoxemia Routine preoxygenation with high flow oxygen via
non-rebreather mask is standard in healthy,
nonobese adults. Consider using noninvasive
ventilation in critically ill patients with ill patient with
compromised lungs or abnormal body habitus.
Consider apneic oxygenation
Airway trauma/perforation
Laryngospasm and bronchospasm
Trauma to teeth, lips, and tongue
Proper technique is essential to avoid any local
trauma to oral anatomy and airway structures
Right mainstem bronchus
intubation

Evaluate with postprocedure chest radiography
Raised intracranial and intraocular
pressure
Unclear clinical significance
Esophageal intubation Prompt recognition of an esophageal
intubation will
allow immediate removal of the ETT and
reventilation and oxygenation with a BVM prior to
reattempting intubation
Failed intubation Clinicians should assess patients for a
difficult
airway in an effort to prevent a failed intubation
attempt. When a difficult intubation is predicted,
consultation should be initiated early and backup
equipment should be readily available
Related to Endotracheal Intubation
Tension pneumothorax A pneumothorax needs to be considered
in a patient
with hypoxia and hypotension and should be
evaluated for all patients with postprocedure chest
radiography
Aspiration Placement of a nasogastric (NG) or orogastric (OG)
tube following endotracheal intubation can help
decompress any insufflated air that occurred during

BVM use and will help reduce the risk of emesis and
aspiration
Obstruction of endotracheal tube Suction the endotracheal tube
Accidental extubation Accidental dislodgment of the ETT
should be
avoided by proper stabilization of the tube with
appropriate sedation of the patient
Various complications can occur during the course of accessing
an advanced airway in a
patient.
CONTRAINDICATIONS (TABLE 121-8)
TABLE 121-8 Contraindications to Endotracheal Intubation
Notes
Absolute Total airway obstruction
(eg, angioedema)
Total loss of facial or
oropharyngeal landmarks
(eg, blunt or penetrating
trauma to the face)
During cardiac or respiratory arrest,
oxygenation and ventilation are of
paramount importance, and therefore the
use of BVM, intubation, or both should be
attempted despite any contraindications. In
these patients it is advised to perform an
early cricothyrotomy as endotracheal
intubation will be extremely difficult

Relative Anticipated difficult
airway
If a difficult airway is anticipated early
consultation is strongly advised. Other
options include awake intubation, video
laryngoscopy or use of the difficult airway
adjuncts
Contraindications to endotracheal intubation can be divided into
either absolute or relative
but these need to be tailored to the specific clinical situation.
NONINVASIVE VENTILATION (TABLE 121-9)
TABLE 121-9 Noninvasive Positive Pressure Ventilation
(NIPPV)
Indications Contraindications Notes
COPD (moderate
to severe
exacerbation)
Acute CHF
exacerbation,
Asthma,
Pneumonia in
some selected
cases
Impending circulatory or
pulmonary arrest
Altered mental status

Inability to handle
secretions
Recent facial trauma or
surgery
Recent upper airway or GI
surgery (gastric
distention)
Inability to properly fit
mask
Inability to adequately
monitor patient for
decompensation
BIPAP preferred to intubation: ↓need for
intubation, ↓LOS, ↓mortality
BIPAP, CPAP ↓wall stress, ↓afterload,
↑oxygenation
↓mortality (likely due of ↓VAP)
NIPPV not shown to be helpful and may be
harmful in following situations:
ALI, ARDS
Postextubation respiratory failure
(↑mortality by delaying intubation)
Failure of ABG to improve after 1 h of
therapy also highly predictive of
subsequent impending respiratory failure
In select patients, NIPPV may result in decreased need for
intubation, serious
complications, decreased hospital length of stay, and/or
improved likelihood of survival to
hospital discharge.
SUGGESTED READINGS
Bair AE, Filbin MR, Kulkarni RG. The failed intubation attempt
in the emergency

department: analysis of prevalence, rescue techniques, and
personnel. J Emerg Med.
2002;23:131-140.
Caplan RA, Benumof JL. Practice guidelines for management of
the difficult airway: an
updated report by the American Society of Anesthesiologists
Task Force on
management of the difficult airway. Anesth. 2004;101:565.
Cattano D, Paniucci E, Paolicchi A, Forfori F, Giunta F,
Hagberg C. Risk factors assessment
of the difficult airway: an Italian survey of 1956 patients.
Anesth Analg. 2004;99:1774-
1779.
Kheterpal S, Han R, Tremper KK, et al. Incidence and
predictors of difficult and impossible
mask ventilation. Anesthesiology. 2006;105:885-891.
Masip J, Roque M, Sanchez B, Fernandez R, Subirana M,
Exposito JA. Noninvasive
ventilation in acute cardiogenic pulmonary edema: systematic
review and meta-
analysis. JAMA. 2005;294:3124-3130.
Pistoria M, Amin A, Dressler D, McKean S, Budnitz T. Core
competencies in hospital
medicine. J Hosp Med. 2006;1(S1):87.
Ram FSF, Picot J, Lightowler J, Wedzicha JA. Non-invasive

positive pressure ventilation for
treatment of respiratory failure due to exacerbations of

1578185 - McGraw-Hill Professional ©CHAPTER 122Arterial

Recommended

Recommended

More Related Content

More from KiyokoSlagleis

More from KiyokoSlagleis (20)

1578185 - McGraw-Hill Professional ©CHAPTER 122Arterial