How to determine who needs to be intubated.
- RT Jaime
- Apr 8, 2021
- 4 min read
Mechanical Ventilation:
Who needs to be intubated?
About
In this blog post my goal is to explain what to look for in order to identify a patient who requires mechanical ventilation based on diagnostic and patient assessment tools.
Who
Really any patient who is admitted to the hospital can decompensate while they are in the hospital. That is why there are crash carts everywhere and knowledgeable staff ready to intubate and perform CPR to save their lives. These patients can be in the ICU, ER, outpatient clinics, and other acute care floors. Be prepared to jump into action to save their life.
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Patient History
Like Dr. Bailey said in Grey’s Anatomy as she grilled her Residents, “what is the most important piece of information we can gather about a patient?” Many of them replied
CT Scan
Ultrasound
MRI
Lab Tests
EKG’s
AND THE LIST GOES ON!
None of which were the correct answer. She went on to say that “The patient’s history is the most valuable piece of information we can gather about a patient.”
This piece of information is going to point you in the right direction of where you are going to take this set of diagnostics, etc. For example if you know the patient is a CHF patient who just had a bunch of salt over Labor Day weekend, we can deduce that the patient is fluid overloaded and needs BiPAP. Of course we can assess, get a CXR, confirm our suspicions, etc and give the proper treatment of lasix and positive pressure. Once again, the patient’s history is the most important piece of information you can use to direct your care optimally and efficiently.
Patient Assessment
Usually you will see some signs of fatigue and shortness of breath before proceeding to intubation for a patient, however don’t always count on this. There can be patients who go apneic or have a syncopal episode without warning especially in the ICU. Let’s face it they are in the ICU for a reason. Your assessment skills are going to be the first line of defense in identifying who needs to be intubated. What to look for:
Shortness of breath - How hard is the patient working to breath?
Nasal flaring, tripoding, orthopnea, dyspnea on exertion.
Color - Is the patient cyanotic, pale, flushed, diaphoretic, etc?
Vitals - HR, RR, BP, O2 saturation?
Respiratory Muscles - accessory muscle use, retractions (Intercostal, Subcostal, Suprasternal) abdominal paradox, etc.
Auscultation - (Wheezing, Rhonchi, Coarse, Diminished)
Click on the image and download the Free eBook with Cliff Notes from this blog post!
Diagnostics
After you identify a patient who is exhibiting any of these signs of respiratory distress, you can advocate for further diagnostic testing such as ABG’s and Chest X-Ray’s. The ABG will be the gold standard in my opinion in identifying who meets solid criteria for intubation. This is where your arterial stick skills will come in handy (I hope you practice this plenty of times as a new grad). Once you have the ABG, run it and make a mental note of how much Oxygen they are on, it will matter in terms of the PaO2.
ABG Reading: pH, PaCO2, PaO2, HCO3-
ABG Normal Values: 7.35-7.45, 35-45, 60-100, 22-26
If the patient has a respiratory acidosis of pH less than 7.2, and a high PaCO2 you have textbook criteria and plenty of evidence to recommend intubation to the team. For sure you should increase your respiratory support to Non-Invasive Ventilation (NIV) at least, but if the patient looks like they are about to crash, go ahead and push for intubation. Remember some patients may compensate with deep breathing, nasal flaring, and retractions in order to have a normal ABG result, but they will eventually tire out and crash. So ALWAYS look at your patient and use your clinical skills to guide you with the diagnostic tests AND with your patient assessment skills.
The next diagnostic tool you can use is the Chest X-Ray (CXR). You may already have enough information from your patient assessment and ABG to strongly recommend intubation, but it is not abnormal to also include a CXR in the diagnostic testing bundle. This will give more information as to WHY the patient is experiencing respiratory distress. If we go back to our CHF patient we will most likely see Pulmonary Edema on the CXR. We can see if the patient has pneumonia, a pleural effusion, a pericardial effusion, a pneumothorax, a foreign body, just to mention a few.
In closing these are the three extremely important tools you can use when identifying who needs to be intubated:
Patient History
Patient Assessment
Diagnostics (ABG, CXR)
This is a short blog post about how to determine who needs intubation, but it is not the only resource out there. If you are not sure, please use your fellow RT’s and leadership RT’s to help you grow in your assessment skills and ask plenty of questions so you can continue to learn and add to your repertoire of experience as an RT. I hope you enjoyed this post!
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