[PCL] Owning the Airway (when you don't own the airway)


How do you set up the room for a patient to be intubated if you aren't credentialed for airway management? What do you do while you're waiting for someone to come in and tube the patient?

Step 1: Decide the patient needs to be intubated

  • General indications:

    • Patient should be intubated when you're thinking about intubating (shoutout to Marino).

      • Intubate AHEAD of the curve to prevent physiologically difficult airway

    • Refractory hypoxemia/hypercapnia, clinical course, increased WOB, severe encephalopathy

    • Algorithms: ABCDEF, etc

Step 2: Prepare the Room

  • Not necessarily hard to do but you need help. Recruit your colleagues! Nurse, RT, etc

  • Optimize IV access

Step 3: Preoxygenate

  • Not just NRB! Most aren't true 100% NRB

  • Best bets: NRB + NC (both turned to "flush rate"), HFNC + NRB, pure BVM, BiPAP

    • NRB doesn't have complete seal so room air is going to entrain in mask, reducing FiO2

  • GOAL: denitrogenation of the lungs to ensure more time to intubate, not necessarily SaO2 100%

Step 4: Plan, Develop Shared Mental Model

  • Verbalize/brief the room about the patient - get whole room on same mental model to move like well oiled machine

    • "This is emergent" vs "this is non-emergent", expectations

  • Difficult airway predictors: physiologically (i.e. PHTN) or anatomically

  • What do anticipate can go wrong? (I.e. worsening shock, etc)

Step 5: Call Airway Manager

  • Use "James Bond" moment - "Do you have preference on medications you want to draw up to be prepared on your arrival?", know patients last potassium for contraindications to sux

  • Run through formal checklist or "STOPMAID" - a mental checklist to know you have everything is ready


Is suction working on wall? Prevent airway disaster


VL or DL? ETT? Difficult airway box (scalpel, bougie)? LMA? OPA/NPA? PEEP valve?


Oxygenating and denitrogenating appropriately


Sniffing position at head of bed



Blood pressure cycling every two min (esp w/o a line), SaO2 probe on other arm


Roles are clear and defined, you know who will be helping intubator

IV Access

Should have been optimized; at least 2+ good PIVs, IO at bedside if needed


If you communicated with airway provider, should be drawn up and ready to go

stopmaid graphic.jpg

Step 6: Verbalize plans A, B, C to room

"There is no such thing as an emergent intubation; only emergent oxygenation followed by slow controlled intubation" - Scott Weingart

Step 7: Post Intubation Management

  • Illusion of success: highly recommend staying in room as long as possible (5-10 min) to look for post intubation hypotension, desaturating, PTX, evidence of R main stem, etc

  • Orders

    • Vent order set

    • First ventilator settings

    • P/A/D strategy

    • CXR, ABG (1 hour post-intubation)



Longing by Joakim Karud https://soundcloud.com/joakimkarud
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