Podcast 84 – The Post-Intubation Package

The Post-Intubation Package

There is a ton of stuff to do post-intubation besides confirming the tube and giving the team high-fives. What we do in the ED has ramifications on the patient’s course in the hospital. Preventing badness starts with us.

Achieve Adequate Analgesia and Sedation

I won’t belabor this, because I’ve discussed it in so many other podcasts, such as the one about not leaving your patient in a nightmare

Secure the Tube Well

We use the Hollister Anchor Fast (as always, no conflicts of interest).

Raise the Head of the Bed to at Least 30°

May or may not help prevent VAP, but it definitely helps lung mechanics

Confirm Lung Protective Vent Settings

See the Dominating the Vent Lecture for more on all that

Humidify the Air

Either with a humidification circuit on the vent or a Heat-Moisture-Exchanger (HME)

Place In-Line Suction and then Actually Use It

In-line is probably no better than intermittent with sterile technique, but who is actually going to use sterile technique

Suction the mouth each time you suction the tube as well

Hook Up the ETCO2

You read NAP4 right? Continuous waveform ETCO2 until the ET tube gets pulled

Cuff Pressure

Too low and you risk micro-aspiration and VAP, too high and the patient has the potential for ischemia. The ideal pressure is between 20-30 cm H20. Use a cufflator.

Gastric Tube

Empty the stomach to reduce the chances of aspiration

Nebulizers/MDI

If they were intubated for reactive airway disease, then they need frequent nebs. In some hospitals, all patients get intermittent MDIs. Make sure to remove the HME for nebulizer or MDI treatments.

Prevent Aspiration past the Cuff of the ETT

Cuff Lube

Lube on the tube cuff may help avoid micro-aspiration (Anesthesiology 2001; 95:377–81 & Anaesthesia. 2006 Feb;61(2):133-7.)

Continuous Subglottic Suction ETTs

BestBets: Continuous subglottic suction is effective for prevention of ventilator associated pneumonia

May prevent 4 cases annually if used for all patients in an average US hospital (Critical Care 2012, 16:446)

A listener, Dan Hierholzer, DO (last name:  Here-Hole-Zer) reports on 1 issue with these tubes: they have a wider external diameter so if you are trying to pass them through an intubating supra-glottic airway, you need to go 1 size lower. Dan demanded a shout-out to the residents at Geisinger Medical Center in exchange for this excellent tip.

Get a Blood Gas

I like arterial, but if you want to go venous and you have a sat between 90-95% then knock yourself out.

Check Tube Depth

I start with 21 cm for women and 23 cm for men. Adjust based on size obviously. Then get an ultrasound and/or X-ray. When getting an x-ray make sure the head is in a neutral vertical position (remember the tube follows the nose, nose down-tube deep).

Bonus Meds-SUP and DVT Proph

Have an institutional plan for which meds and when

Bonus-Oral Decontamination

Chlorhexidine

Put a BVM at the Bedside ± PEEP Valve

When something goes wrong you should not need to search for this. Put the mask on the O2 tubing.

Have a Plan for Vent Alarms

Treat them like a cardiac arrest announced overhead.

Additional Reading

This amazing post from my bud Kane Guthrie from LITFL is worth a read stat: Key things to know about ventilator-associated pneumonia (VAP)

This article is geared to the ED prevention of VAP later in the patient’s course: Ventilator-associated pneumonia: the potential

A Checklist

Jeffrey Siegler, an EM PGY1, made the first foray into turning this into a checklist

I received a second one, this one index-card-sized, from Chris Huntley, PA from the University of Washington ED.

Now on to the Podcast…

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Comments

  1. Minh Le Cong says:

    Scott, great stuff as always! One tip to share and this is an old habit from anaesthesia training, I like to reinsert an OPG after intubation as a bite block to guard the ETT

    • Yep, a bite block is nice. If you are going to use an oral airway, critical to position it by the molars and not the incisors as patients have been known to chip a tooth when position up front. I tape to the ETT on one side of the mouth.

    • Speaking from ICU land, we don’t use OPA as a routine – causes too many mucosal pressure injuries and makes oropharyngeal suctioning and proper teeth cleaning difficult.

      Management of biting in the ED/first stages of ICU should be proper analgesia/sedation; the only time I’ve seen tube damage was with attempting to wake TBI patients (always a fun job).

      (Caveat: Reinforced tubes should always have either a properly sedated patient, be a nasal ETT or have a bite block insitu. If they manage to collapse the wire reinforcement via biting, it stays collapsed. Major pain.)

      • Yep, by the time they get to ICU, they better have had their sedation and analgesia optimized to the point where they are not going to clench.

      • Great tip on the reinforced tubes, I can see that being a nightmare.

        • Reinforced/flexible tubes are a problem for three main reasons.

          1 – As mentioned above, once they have been deformed, they do not return to their previous shape, which can cause significant obstruction of the tube.

          2 – The cuffs are usually high pressure, low volume cuffs, which can potentially cause musocal inflammation and ischaemia in the trachea.

          3 – The tip of the ETT is often made of especially soft and compliant material to facilitate nasal intubation, and easier passage of the larynx when attached to a fibrescope. The tip usually also incorporates the Murphy eye. Once at body temperature the tip is very susceptible to compression, which can result in complete obstruction of the tube.

          For any period of prolonged ventilation, patients should never be left with a reinforced/flexible tube if it can be avoided. The tube should be exchanged for one with a low pressure, high volume cuff, and a normal tip.

      • David Hersey says:

        Hello,

        From my ICU expereince we don’t use OPA as bite blocks for the reasons noted above. On rare occassions we use bite blocks that slide over the tube.

        The caveat about the reinforced or armoured tubes is an excellent point. Just seen an airway issue with a posterior fossa tumor patient that bent the armoured tube.

        I assume the reinforced tube that comes with the iLMA could have the same issue?

        Great stuff,
        David
        Life Flight NS

        • I don’t often use bite blocks, but when I do need one in the field I will use an OPA a size or two smaller than the patient would have needed inserted backwards. (The flange that is normally on the lips is just behind the teeth and the curved part is sticking up in the air.) I tape it to the ETT, with a tab for easy removal of course.

  2. Jeremy M says:

    Hey Scott,

    Not sure what your thoughts are on regular usage of a respirator filter. But for our local standard we also make sure we are using a inline filter so we decrease cross contamination and provider contamination. We acutally are lucky enough to use a HME/respiratory filter combo from Covidien (no conflicts).

    • all our circuits have two filters between the ventilator and the tubing. If you have yours on the Y, does this mean you resuse vent tubing?

      • Jeremy M says:

        I work pre hospital in a rural setting so we do not have vents available unless we are doing inter facility transports. Even though when we arrive at the hospital we have ventilators (we work closely with our facility’s) we may not have a Dr available after arriving in the ED for 20-30minutes(or longer) depending on time of day and unless a qualified paramedic or Dr that is comfortable with a ventilator is there they are not used and patients are ventilated with a BVM only(no attachments) for an unfortunate amount of time. Our hospital ventilators now that we have real ones (were quite lucky in this sense) only have a single ventilation hose and blue and white sampling tubes (drager oxylog 3000) as it stands no protocol or standard exists for the “post intubation package” so needless to say I am forwarding this podcast to the facility director.

        • This sounds like one of the systems I used to work in…
          Is there any chance your agency would invest in PEEP valves for the BVMs? If not, can you tactically acquire some from your friendly neighborhood hospital?

          I share your frustration with a lack of vent training in EMS. I ran all of the ventilator education (both initial and continuing) at one of my jobs and I struggled with both the lack of background knowledge of our (non critical care) paramedics and the infrequency with which they managed vented patients. I believe, in the hands of an inexperienced operator, even with all its flaws and inconsistencies, BVM ventilation (with PEEP) is the safer option.

          • Jeremy M says:

            Rebecca I am acutally pretty lucky, were very progressive in the prehospital realm here. We have everything in the post minus the ABG, oral decontamination and cuff meter. But they are relative to our situation and we make do. I get alot of grief from our uppers over the christmas tree I make every time I set up a BVM. If any one is interested pre hospital tree from our evac ett up Inline Suction/MDI adaptor, Etco2, HME/Resp Filter, Manometer, BVM with peep. I digress.. My question was more to our hospital setting as we frequent are called in to intubate. As the HME was mentioned for regular use I wasnt sure if it was a case by case basis of use of the the filter.

  3. This is great Scott! As far as filtration goes, is there a consensus on what type to use in ED as first line of defense within a Hospital. My recommendation has always been a N99 or N100, especially post SARS.

  4. Sean Marshall says:

    Fellow RTs, help our friend Scott out… He’s a good guy, don’t leave him hanging in his ED without adequate RT support! Most of the steps he mentions here would be done by an RT as a matter of routine within seconds of intubation at my hospital, including the A.line and the intubation itself.

    Unfortunately, the powers that be in my hospital haven’t invested in continuous capnography or subglottic suction ETTs.

    • Ahhh, Sean to work in a center with RTs like that is pure bliss.

      • Sean, remember that RTs are a very American creature. In Australasia/UK and I think Europe there is no such thing and all of what Scott has gone through is done by docs and nurses.

        Scott, when you talk about running to vent alarms like a cardiac arrest alarm, do you mean that you have ventilated patients who aren’t being continuously cared for 1:1 by an experienced doc or RN (or RT)?

        I must say I almost tune out ventilator alarms (indeed, I had the drager tone as my text message alert for a while) because in ANZ all ventilated patients have 1:1 nursing 24/7 by an experienced bedside RN, so docs rarely have to pay attention to alarm. Even intubated patients in ED have 1:1 or at most occasionally 1:2 nursing until transfer to ICU.

        I’m sad to say I don’t know much about nursing ratios in US EDs/ICUs but is 1:1 nursing not mandatory for ICU level patients?

        • Sean Marshall says:

          Yep, I understand that RTs mostly exist in Canada and US, and that Scott’s talk may resonate more with docs and nurses that have to take care of the vent and airway as part of a much larger overall job. But seriously guys… get some RTs down under, it would expand my travel options :)

          I would echo your sentiments about vent alarms to some extent. Most critical care vents have different tones for high and low priority alarms… I think there’s a happy medium between running to the bedside because the pt coughed and triggered an alarm and ignoring a loud and persistent vent disconnect alarm (which I have still seen with 1:1 nursing).

    • Minh Le Cong says:

      what you can insert an A line and perform RSI but dont have access to continuous capnography?

      • Sean Marshall says:

        Sad but true. We have the colour change EtCO2 detectors of course for tube confirmation and in ICU we have one crummy handheld capnometer that mostly collects dust.
        I get depressed when we get an EMS crew bringing in a pt and I have to sneak a glance at their monitor for EtCO2 before they get disconnected and hooked up to our monitors without that capability.

        • Alexander Sammel says:

          Sean,

          I feel with you, mate! Not having cont. waveform EtCo2 in the ED is very frustrating and if not on the receiving side when I bring them in sometimes I wonder if not only we need “Upstairs care downstairs” but “Outside care inside”!

          Dreaming of better managing critical patients in the ED…

      • Seth Trueger says:

        not that rare!

  5. Minh Le Cong says:

    On the subject of ETT securing in prehospital setting. This all comes down to simplicity and diligence. We use plain old cloth tape to tie knots and secure tube in my service. I do double ties..that is two pieces of tape with two knots each so there are two ties securing the ETT. I place an oral airway too to guard the tube. And the real key is to watch the ETT like a hawk and use waveform capnography. This is what sets a safe standard for ETT care in the prehospital setting.
    The commercial ETT holders are fine but we do not use them. I guess this all harks back to anaesthesia training where commercial holders are not de rigeur.

  6. Here’s a mnemonic that I made up a while back because I found that I was forgetting to do things after the intubation. I modified it a bit to include a couple of the things you covered in the podcast.
    cheers,
    Brian

    PC FAXES
    Prophylaxis- DVT/GI
    Cuff pressure- CO2 monitoring
    Foley
    ABG
    X-ray for tube position
    Elevation- of the head of bed
    Sedation/Analgesia- Settings for vent- Suctioning

  7. Geoffrey says:

    I’ve been using the subglottic suction devices for the past few months in my rotations at LAC+USC, though I have yet to see one on continuous suction. I have been hooking the subglottic port to suction port up to wall suction each time I perform inline suction, and even with pretty vigilant oral suctioning, I consistently get a bunch of nasty secretions up from the subglottic port.

    For me, this shows that the vigilant oral suctioning alone really isn’t doing the job. The cost of these damn things is incredible, but they’ve made a believer out of me.

  8. David Hersey says:

    Hello,

    I only have antidotal experience with subglottic suction ETTs (mainly the EVAC tube). But, from my experience they don’t work very well for a couple of reasons.

    1) With very think oral secretions the subglottic suction line plugs up. The lumen of the suction tubing is too small. When you do suction the mouth you find the secretions that the subglottic suction ETTs is missing.

    2) Staff keep cranking up the pressure on the subglottic suction and this cause tissue damage (due to reason #1)

    3) If they work well and all the secretions are cleared the subglottic suction will make a gurgling noise similar to a cuff leak. In addition to being irritating they may make staff assume it is the EVAC tube and actually miss a cuff leak (saw this twice).

    4) They take up a suction port which can be an issue with patients with a large number of chest tubes (weak reason I know!).

    5) They are expensive and the evidence is mixed so save the money for some other equipment needs.

    Thank you,

  9. Jacob Avila says:

    Hi Scott, and greetings from Chattanooga, Tn!

    Thanks for the great podcast. I had a question about something you mentioned when confirming the ETT placement post-intubation. You mentioned an option would be to advance the ETT until you stopped seeing SLS on the left, then pull back a few sonometers. Is this method something that has been described in the EM literature? Thanks!

  10. anandan sps says:

    I have a couple of things to say

    1) It is essential to remove the HME filter while giving nebs, otherwise it will be ineffective

    2) Swab the port on the cuff with chlorhexidine before connecting it to the pilot balloon

    3) I think it is ideal to take abg’s after 20 to 30 mins of fio2 change

  11. anandan sps says:

    I have a couple of things to say

    1) It is essential to remove the HME filter while giving nebs, otherwise it will be ineffective

    2) Swab the port on the cufflator with chlorhexidine before connecting it to the pilot balloon

    3) I think it is ideal to take abg’s after 20 to 30 mins of fio2 change

  12. Beg to differ with the sequence. Anesthesiologist for 40+ years. First step is ET CO2-not there, neither is the tube unless it part of CPR where levels may be nearly undetectable. The desire to believe in correct positioning is overwhelming but ET CO2 is THE reality check

    • Thanks so much for commenting. I hope I was clear on the podcast: these steps are post tube placement and confirmation. Levels are never undetectable on waveform capnography even during CPR. The location of ETCO2 in the post-tube package is for places using coloremtric for confirmation and then having to find/call for cont waveform for tube monitoring. Of course tube confirmation occurs prior to a post-intubation package.

  13. Gregory Burns, RRT says:

    Hi Scott, I’m an RT at a university/county trauma center in San Francisco and have been listening to your podcast for a few years now. I thoroughly enjoyed this podcast as it dealt with things we routinely do at our institution, and I only wanted to comment on the topic of ETCO2 and the importance of understanding the PaCO2-PETCO2 gradient, especially with the hypoperfused trauma/medical patient. Often, we (RTs) find ourselves asked by our anesthesia/EM colleagues to “aim for x ETCO2″ and they request maxing out the respiratory rate to achieve this, and often time resulting in a considerable amount of air trapping. As a result of the decreased E time the PETCO2 often will drop, but only because of an increase in airway dead space; furthermore, in the volume depleted patient I can only assume that their alveolar dead space will increase as well due to hyperinflation and decreased preload secondary to the intrinsic PEEP. So in targeting a PETCO2 with the intentions of ventilating the patient more, you end up doing the opposite: decreasing alveolar ventilation in return for an increased VD/VT and PEEPi! I think the epitome of bringing ICU level care to the ED is to offer our patients the smartest rather than the most aggressive ventilator management. Just my thoughts, thanks!

    • The fact that ETCO2 doesn’t = PaCO2 is a consistent meme on the podcast. Thanks for reinforcing this point yet again. The reason we are monitoring ETCO2 is for tube disconnection.

  14. Noone has mentioned the most important thing in this post

    - that really groovy “laryngoscope-as-bottle-opener” in the main photo

    I’ve got one. Great for cracking open a beer after a difficult case…

  15. Bit of piyush ( kuwait ) paper & the possibly a video clip will demonstrate ‘ what happens possibly better !

    During spontaneous breathing trail ….

  16. Scotty F says:

    Hi Scott, fantastic podcast. I practice as a critical care flight paramedic in Ontario Canada and this lecture (and indeed most of your lectures) is very much in keeping with our practice. I will be forwarding this podcast to our education department as I think it very nicely summarizes the many facets involved in post intubation care.

    In response to your tube securing question we have a few approaches that we use. Our call profiles are on scene trauma, modified on scene (pick up from er closest to the incident), or interfacility. I find no gross deviance between rotor and fixed wing practice. If intubating on scene we generally use a waterproof tape to secure as it is fast and easy. A few of my colleagues do prefer a commercially available tube restraints however. During our modified, or interfacility calls we will very frequently use a commercial device unless the taping appears well place, tube secured, isn’t covering the patients lips, or encircling the head.

    Our pediatric practice for on scene’s is the same as that used for adults. During modified scenes, or interfacility calls our medical direction has very clearly directed us to remove whatever is currently holding the tape and replace that with our approved taping technique. We use a silk suture to wrap around and tie to the tube and place on the patient’s upper lip (soaked in mastisol). We then use an ultra adhesive two inch tape cut into pant legs to wrap around the tube in both directions. Many of us find this process cumbersome and frequently not as adequate at securing a tube as whatever is currently holding the tube. Further to the ackwardness of this process it is also very time consuming. This is what we are told we must do however.

    That’s my two cents as an air provider. Please keep these podcasts coming we enjoy them as a great means of learning.

    Scotty.

    • Yep, I remember the 2″ pants leg. Awkward to do in real time! I used to premake them, which at least saves time, but I am a huge fan of the commercial devices. Nothing more disheartening than finishing a 5 minute tape job and then finding the tube needs to be pulled back 2 cm.

  17. Ray Allen says:

    Hey Dr. Scott! I love your podcast!! Just a quick note on your comments regarding cuff pressures following placing an ETT. For the last several years, I’ve used my own version of a “poor man’s manometer.” It requires no additional equipment and I have had great results. I am a flight nurse and paramedic. Obviously, adding additional equipment to our limited arsenal of airway equipment is limited. So here a poor man’s method of achieving 10-30mmHg in the ETT cuff…

    After passing the tube through the cords, begin ventilating the patient with a BVM or vent. Put your ear next to the patients mouth and listen for air exchange while slowly filling the cuff. Once the air exchange is no longer present, add 1cc of air, and secure the tube. Simple procedure which takes a few seconds.

    One caveat…if you add or change PEEP then you must re-adjust the volume (pressure) of air within the cuff. Otherwise your vent’s low pressure alarms will go crazy!

    • Ray, It is a great tip. I’m worried that your method would guarantee that the cuff pressure is not too high, but it may be too low as it is basically obtaining the minimum sealing pressure.

  18. Great summation. Confirms and reinforces actions I have taken as my standard practice from other sources. What was really cool for me was listening to the dominating the vent lectures and intubating metabolic acidosis patients about three times each. Now it is incorporated in both my practice and my teaching of medical students, MLP’s, RT’s and RN’s. Good stuff.

  19. Scott,

    I work in both an aeromedical transport environment as well as at a quaternary referral centre in Canada. MY site uses EVAC tubes (subglottic suction tubes) routinely and overall we are quite happy with them. The only real concern is as you mentioned on the podcast, the outer diameter. These tubes can be considerably bigger than an equivalent sized inner diameter tube. Usually this is not a concern in adults but in children we have gone away from using them as it can be the difference between a tube that is almost a full size or more bigger.

  20. Do you normally start enteral feeding at a trophic dose in the ED? Giving the controversy of PPI with VAP and C. difficile colitis, it seems a better choice for preventing stress ulcer.

  21. David Marquez, RN says:

    Scott, great post intubation package. Like you, I’ve been through the era of umbilical and cotton tape to secure ET tubes. I couldn’t agree more with the use of commercial ET tube holders. Additionally, please consider the use of a hard cervical collar (Stiff neck, Miami J, Aspen, Philly) on any intubated patient in the ED, not just trauma patients. By controlling the head movement, whether onto a CT table or during the transfer for ground or air transport you significantly decrease the probability of tube displacement. I have used this for many years doing air transport and have never had an accidental extubation or even had the tube move much more than a millimeter or two. I must admit that I have had some strange looks from the receiving MD/RN’s but once I explained my rational I’ve seen eyes widened and heads nodding in agreement. It’s a cheap way to insure a patent airway and you can remove it in less that thirty seconds.

    • It’s a great point during transfers in-house and probably for when radiology is shooting their chest x-rays. I see the patients head flopping back and forth every time they shoot one.

  22. Great podcast as always (yes I’m a little behind)! I’m going to try and get my residency to create a “post-intubation” order set for our EMR that will incorporate much of what you listed.

    Question about lubing up the ETT cuff… is this commonly done? I’m a 4th year EM resident and I’ve never heard of this. I checked out the article and it looks legit, I’ll try it next time. To be honest I’ve often wondered why we don’t just lube the whole tube.

Trackbacks

  1. [...] you may have heard The Master of the Critical Care Universe, Scott Weingart put out an episode on The Post Intubation Package.  In this episode he briefly mentions using ultrasound during your intubation and commented that [...]

  2. [...] you may have heard The Master of the Critical Care Universe, Scott Weingart put out an episode on The Post Intubation Package.  In this episode he briefly mentions using ultrasound during your intubation and commented that [...]

  3. […] EMCrit Podcast 84 – The Post-Intubation Package […]

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