Key messages

• Intubation offers four advantages: protection of the airway relief of obstruction tracheal toilet enables mechanical ventilation. Introduction

Indications for intubation are airway protection, access to secretions, bypassing obstruction, control of respiratory function, anesthesia, and transportation. Airway protection

Protective laryngeal reflexes may be impaired if there is any reduction in level of consciousness. In the absence of an adequate cough reflex, aspiration of gastric contents or blood may contaminate the lung, or airway obstruction may occur leading to hypoxia and hypercarbia.

Head injury, brain tumor, cerebrovascular accident, drug overdose, epilepsy, or syncope are commonly associated with a failure of protective reflexes and thus a need for intubation. Occasionally bulbar palsy or neuromuscular weakness may result in impairment of airway control, necessitating intubation.

Loss of airway control is associated with a Glasgow Coma Scale score of 8 or less. Clinical signs of partial airway obstruction are noisy breathing or snoring. Total obstruction is soundless as no air traverses the larynx. Both partial and complete obstruction are associated with a characteristic paradoxical respiratory pattern in which the chest moves inward on inspiration with marked indrawing of the suprasternal notch. Signs of an obstructed airway may not be noticed by the casual observer.

Patients with weakness (e.g. Guillain-Barre syndrome or myasthena gravis), can be difficult to assess. A vital capacity below 15 ml/kg may be associated with ineffective cough and protective reflexes. If in doubt it is better to err on the cautious side and intubate.

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