In this episode, I’ll discuss how to tell if a patient is about to be intubated.
When a physician makes the decision to intubate a patient, there is a delay between the time they share the decision and the time the team is ready to facilitate intubation. The nurse and respiratory therapist need time to prepare the patient, equipment, and medications. The more time that passes during the preparation phase, the greater the risk to the patient.
One area that a pharmacist can have a positive impact on a critical care team is by being able to anticipate and identify when intubation is likely. When the pharmacist is able to obtain medications for intubation in advance, dose calculations and other pharmacotherapy decisions can be made in a period of less urgent stress. Then, when the physician makes the decision to intubate, the lag time between the decision and the intubation can be shortened. Also, when the pharmacist assumes responsibility for preparing the medications, the rest of the team can remain hands-on with the patient ensuring adequate pre-oxygenation, IV access, and supportive care.
Traditional training does little to prepare a pharmacist to identify a patient who needs intubation. Having some idea of a physician’s decision-making process can help let a pharmacist know what to look for to identify a patient needing intubation.
Making the decision
The decision to intubate is often based on clinical experience as much as it is based on objective data. Three questions are often considered to make the decision:
1. Can the patient protect their airway?
2. Can the patient adequately oxygenate?
3. What is the anticipated clinical course?
Can the patient protect their airway?
To decide if a patient can protect their airway or not, the physician will consider the patient’s level of consciousness, whether the patient can swallow, and the patient’s ability to clear secretions.
Some examples of conditions where patients may be unable to protect their airway include:
- Seizure
- Stroke
- Airway obstruction
- Bleeding into the airway
Can the patient adequately oxygenate?
To decide if a patient can adequately oxygenate, the physician will look at oxygen saturation, blood gas results, response to non-invasive respiratory support, respiratory rate, and accessory muscle use.
Some examples of conditions where patients may be unable to oxygenate include:
- COPD exacerbation
- Asthma exacerbation
- Acute pulmonary edema
What is the anticipated clinical course?
If the natural course of a patient’s disease makes it likely they will experience respiratory failure, the physician will elect to intubate the patient before they experience respiratory failure.
Some examples of conditions where a patient may be intubated based on their anticipated clinical course include:
- Sepsis from pneumonia
- Burn victims with evidence of smoke inhalation
- Overdose
- Trauma
- Extreme agitation requiring high doses of sedatives
- Respiratory compromise and patient requires endoscopy, bronchoscopy, operating room procedure, or need to leave the unit for a test that will change management of the patient
Pharmacist’s Role
Knowing all of this information, I am better able to predict when a given patient is going to need intubation, so I can complete medication-related preparations ahead of time. I’ll still have a few false alarms, where I take medications out of the automated dispensing cabinet before they are needed. But it is worth it because most of the time I have the pharmacotherapy needs of the patient and team ready to go by the time the decision to intubate is made.
There is much more to the pharmacology of airway management than predicting when the patient will be intubated. Members of my Hospital Pharmacy Academy have access to my Airway Pharmacology Masterclass, where I cover paralytic and sedative choices for the 6 different types of airway scenarios, as well as how to anticipate and deal with complications related to intubation.
If you are listening to this podcast before 10 pm EST on January 21, 2018, you can try out the Hospital Pharmacy Academy for a full 7 days for only 1 dollar by going to pharmacyjoe.com/trial. You’ll get access to my Airway Pharmacology Masterclass as well as over 20 additional, practical trainings that cover the topics of critical care, infectious disease, emergency medicine, and general hospital pharmacy. You’ll also get access to over 60 weekly literature digests, and the members-only forums to connect with me and other Academy members. To sign up go to pharmacyjoe.com/trial.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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