Is intubation really needed? Consider risks, alternatives

There may be other options

Not every patient experiencing shortness of breath needs to have definitive airway intervention such as intubation, says Sybil Murray, RN, an ED nurse at St. Anthony's Medical Center in St. Louis, MO.

"Sometimes, coaching the patient through deep breathing and relaxation techniques, along with proper comfort positioning, may be just enough to forego an emergent intubation," she says.

Chronic obstructive pulmonary disease patients often try to treat themselves at home and arrive at the ED tired, out of breath, pale, and diaphoretic, says Orchid Quiton Chefalo, RN, CEN, CCRN, charge nurse of the ED at San Joaquin Community Hospital in Bakersfield, CA. "It is probably best to intubate them at that time," she says.

On the other hand, if your patient has altered mental status but is still keeping his or her airway and there is no obstruction, "then make sure you do everything first before intubation," says Chefalo. "Sometimes you may need to put them on a BiPAP [bilevel positive airway pressure] to see if they turn around."

Use as last resort

Risks of intubation include perforation of the esophagus, notes Chefalo. "We want to prevent intubation, but sometimes we do have to. If they've been working hard to breathe for a long time, the patient may need to take a rest," she says.

Endotracheal intubation and laryngeal mask airways are "last resort efforts" to improve the patient's oxygenation perfusion, says Chris Ruckman, RN, MBA, CEN, manager of adult emergency services at Vanderbilt University Hospital in Nashville, TN.

"These advanced airway techniques allow for more precise delivery of oxygen to the patient's lung fields," he says. Bag mask ventilation is an option if you need to deliver direct oxygenation to a patient who has developed an airway compromise or has an episode of oxygen desaturation, adds Ruckman.

"This type of oxygen delivery is non-invasive," says Ruckman. "It can provide the patient with ample oxygen while preparing for an advanced airway, such as an endotracheal intubation."

Look for these signs

"There are some basic signs that you can observe when you walk in the room and first lay eyes on the patient," says Nicole Walkinshaw, RN, an ED nurse at St. Elizabeth Regional Medical Center in Lincoln, NE.

She says to see if the patient is awake, alert, swallowing secretions, if he or she is able to speak to you, whether there are any obvious obstructions, and to check the color of his or her skin and membranes.

Walkinshaw says to consider these items when assessing intubation necessity:

  • Is there failure of airway maintenance, or failure of protection of the patient's airway?
  • Is there failure of ventilation? "Sometimes a patient with a chronic airway disease process such as chronic obstructive pulmonary disease acclimates to altered gas tension," she says. "But if there is an acute change in carbon dioxide retention, that can indicate ventilation failure."
  • Is there failure of oxygenation?

"If hypoxic, the patient may appear restless, agitated, cyanotic, confused, or obtunded," Walkinshaw she says. (See related stories on assessment, and a question to ask patients, below.)

Sources

For more information on assessing the need for intubation, contact:

  • Wendy L. Callan, RN, MSN, TNS, Trauma Nurse Coordinator, Advocate Condell Medical Center, Libertyville, IL. Phone: (847) 990-5016. Fax: (847) 573-4281. E-mail: wendy.callan@advocatehealth.com.
  • Chris Ruckman, RN, MBA, CEN, Manager, Adult Emergency Services, Vanderbilt University Hospital, Nashville, TN. Phone: (615) 875-4606. Fax: (615) 322-1494. E-mail: christopher.ruckman@Vanderbilt.edu.
  • Sybil Murray, RN, Emergency Department, St. Anthony's Medical Center, St. Louis, MO. Phone: (314) 525-1906. Fax: (314) 525-4148. E-mail: Sybil.Murray@samcstl.org.
  • Nicole Walkinshaw, RN, Emergency Department, St. Elizabeth Regional Medical Center, Lincoln, NE. Phone: (402) 219-7142. E-mail: nwalkinshaw@stez.org.

Assessing airway? Don't overlook these things

When assessing a patient's airway, do you look for tracheal deviation and subcutaneous emphysema around the neck and clavicle? Do you compare the right lung and left lung fields with alternating side auscultation?

These items are frequently forgotten by ED nurses, according to Chris Ruckman, RN, MBA, CEN, manager of adult emergency services at Vanderbilt University Hospital in Nashville, TN. "Never listen to lung fields through clothing. Sounds get distorted," he says. Use these clinical practices for airway assessment:

Don't go by lab values alone.

The general appearance of your patient tells you a lot, especially skin color and level of consciousness, says Orchid Quiton Chefalo, RN, CEN, CCRN, charge nurse of the ED at San Joachin Community Hospital in Bakersfield, CA. "Take a closer look. Be comfortable with telling the physician, 'I need you to look at this patient again.'"

Get an accurate pulse oximeter reading.

If a patient has chronic obstructive pulmonary disease (COPD) and you place the pulse oximeter on his or her fingernails, you may get misleading information because of the thickened nails that are common with COPD, says Chefalo.

"It may give you a false reading," she says. "Good placement is really important because the treatment is based on the trend of the oxygen saturation." Instead, place the oximeter on the patient's forehead, earlobe, or other extremities, says Chefalo.

"You'll want to see an even waveform — a good pleth that coincides with the QRS complex on the cardiac monitor. If it's not reading correctly, you won't see that nice, pretty waveform," she says. "It's not capturing what it's supposed to."

Consider non-invasive positive pressure ventilation.

This alternative avoids the complications associated with invasive ventilation, says Wendy L. Callan, RN, MSN, TNS, trauma nurse coordinator at Advocate Condell Medical Center in Libertyville, IL, and is used for patients with cardiac disease, exacerbations of chronic pulmonary disease, sleep apnea, and neuromuscular diseases.

"This assists ventilation without the use of an endotracheal tube, using either a nasal mask, oronasal mask, or mouthpiece," says Callan.

Simply greet the patient and watch how he or she responds.

When the patient begins to speak, you can quickly assess the use of accessory muscles, nasal flaring, the ability to speak in full sentences without dysphonia, mental status, skin color, obvious trauma to the nasal airway, and posture, says Ruckman.

Do continous reassessment.

If the patient is put on a bilevel positive airway pressure machine, assess whether he or she is tolerating it and comfortable, and listen to the patient's breath sounds, says Chefalo.

Consider hypoxia if the patient appears restless, anxious, or combative, and consider hypercardia if the patient appears drowsy or lethargic, says Callan. "If the patient goes from restless to lethargic, this is not a good sign!" she warns.


Clinical Tip

Ask patients this key question

Ask your ED patient with respiratory difficulty, "Have you ever been intubated before?" recommends Leah M. Gehri, RN MN CCRN, director of emergency and trauma services at MultiCare Good Samaritan Hospital in Puyallup, WA.

"This is a key indicator of how severe their illness has been," says Gehri. "If patients have been intubated multiple times in the past, they can get sick very quickly and require a high level of attention."