The document discusses optimizing peri-intubation physiology for a critically ill patient. It recommends: 1) Pre-oxygenating with non-invasive ventilation to maximize oxygen reserves. 2) Using rapid sequence intubation with apneic oxygenation via nasal cannula to prevent hypoxemia during intubation. 3) Inserting a bougie on the first intubation attempt to improve first pass success. 4) Having protocols to prevent hypotension during intubation to optimize hemodynamics.

1. Optimise, Don’t Compromise:
Peri-Intubation Physiology
Todd W. Rice, MD, MSc
Associate Professor of Medicine
Vanderbilt University School of
Medicine

2. Mort, TC, et al. J of Cli Anes, 2004
Jaber S, et al. Int Care Med, 2010
Cook TM, et al. BJA, 2011Severe Complications = cardiac arrest, death, new SBP <65, new hypoxemia <80%
ICU Intubation
Severe Complication
Rate
OR Intubation
Severe Complication
Rate
ICU Intubations are
Complicated

3. Death or
Neurologic
Injury
1 in 3 Complication Rate
Procedure Variables
• Multiple Attempts
• Poor oxygenation strategy
• No airway evaluation
• Inexperienced Operators
• Lack of equipment
• No capnography use
Patient Variables
• Critically ill
• Severe physiologic
derangements
• Acute decompensation
Interventions
• Video
Laryngoscopy
• Apneic
Oxygenation
• Drug Selection
• Experts only
• Pre-procedure
Checklists
• Patient Positioning
Out-of-OR Endotracheal
Intubations
Cook TM, et al. BJA, 2011

4. Case:
45 y.o. male presents with H1N1 ARDS and
worsening hypoxia. His oxygenation deteriorates and
he is currently saturating 89% on 100% non-rebreather
mask.
You make the decision to intubate him:
How will you optimise peri-intubation physiology?

5. Is this patient at risk for peri-
intubation complications?

6. Case:
45 y.o. male presents with H1N1 ARDS and
worsening hypoxia. His oxygenation deteriorates
and he is currently saturating 89% on 100% Non-
Rebreather Mask.
You make the decision to intubate him:
How will you optimise peri-intubation physiology?
Will You use VL or DL?

7. Video Laryngoscopy Improves Glottic
Visualization
Janz DR, et al. Crit Care Med. 2016.

8. Video Laryngoscopy Does NOT Increase
First Attempt Success
Janz DR, et al. Crit Care Med. 2016.

9. Lascarrou JB, et al. JAMA. 2017.
OR 1.12;
(95% CI: 0.71-1.78)
P=0.63

10. Lascarrou JB, et al. JAMA. 2017.

11. Huang HB, et al. Chest. 2017.
First Pass Success
RR: 1.08 (0.92-1.26); P=0.35

12. Huang HB, et al. Chest. 2017.
Time to Intubation
Mean Difference: 4.12 (-15.86-24.09);
P=0.69

13. Huang HB, et al. Chest. 2017.
Complications
RR: 0.72 (0.30-1.70); P=0.45

14. Is it better to have seen
and failed, or never to
have seen at all?
http://www.criticalcares.com/2017/01/
25

16. Case:
45 y.o. male presents with H1N1 ARDS and
worsening hypoxia. His oxygenation deteriorates
and he is currently saturating 89% on 100% non-
rebreather mask.
You make the decision to intubate him:
How will you optimise peri-intubation oxygenation?
How Will You PreOxygenate?

17. Casey JD, et al. Lancet Resp Med. 2019;Epub March 18, 2019.

18. Baillard C, et al. AJRCCM. 2006;174:171-177.
Baillard C, et al. Br J Anesth. 2018;120:361-367.
Frat J-P, et al. Lancet Resp Med. 2019;epub March 19, 2019

19. Case:
45 y.o. male presents with H1N1 ARDS and
worsening hypoxia. His oxygenation deteriorates
and he is currently saturating 89% on 100% non-
rebreather mask.
You make the decision to intubate him:
Once you push meds, how will you prevent
hypoxemia during the procedure?
Will You Use RSI or Bag Mask Ventilation?

20. Casey JD, et al. NEJM. 2019; 380:811-821.

21. Casey JD, et al. NEJM. 2019; 380:811-821.

22. Apneic Oxygenation:
Physiology
FRC 2L
O2
Weingart SD, et al. Ann Emerg Med, 2012

23. Silva LOJ, et al. Ann Emerg Med. 2017; 70:483-494.
Lowest Oxygen Saturation
Mean Diff: 2.21 (0.81-3.61);
P=0.002

24. First Pass Success
OR: 1.59 (1.04-2.44); P=0.03
Silva LOJ, et al. Ann Emerg Med. 2017; 70:483-494.

25. SpO2 < 93%
OR: 0.66 (0.52-0.84); P=0.007
Silva LOJ, et al. Ann Emerg Med. 2017; 70:483-494.

26. Case:
45 y.o. male presents with H1N1 ARDS and
worsening hypoxia. His oxygenation deteriorates
and he is currently saturating 89% on 100% non-
rebreather mask.
You make the decision to intubate him:
You’ve pushed meds, how will you optimise first
pass success?
Will You Use Bougie On First Attempt?

27. Driver BE, et al. JAMA. 2018; 319:2179-2189.

28. Driver BE, et al. JAMA. 2018; 319:2179-2189.

29. Case:
45 y.o. male presents with H1N1 ARDS and
worsening hypoxia. His oxygenation deteriorates
and he is currently saturating 89% on 100% non-
rebreather mask.
You make the decision to intubate him:
How will you optimise peri-intubation
hemodynamics?
Will You Try to Prevent Hypotension?

30. 1. Have a plan
2. Have a back up plan
3. Have a back up to the back up plan
4. Pre-oxygenate with NIV
5. Use laryngoscope you are comfortable with (VL
for view)
6. If able, bag-mask ventilate b/w induction &
laryngoscopy
7. Routine use of bougie will improve first pass
Summary

31. QUESTIONS????
todd.rice@vanderbilt.edu
@toddrice_icu