Guidelines on intubation and extubation in the ICU were released in January 2019 by the French Society of Anaesthesia and Intensive Care Medicine (SFAR) and the French-Speaking Intensive Care Society (SRLF). [14]
Complicated ICU intubation
Consider all patients admitted to ICUs at risk of complicated intubation.
In order to reduce the risk of a complicated intubation, use careful preparation and take steps to maintain oxygenation and cardiovascular stability, which will help anticipate and prevent respiratory and hemodynamic complications.
Differentiate risk factors for a complicated intubation from predictive factors of a difficult intubation.
An additional recommendation for pediatric patients is to consider all patients to be at risk for complicated intubation.
Equipment for difficult intubation
To confirm the correct position of the endotracheal tube, supraglottic device, or direct approach through the trachea, capnographic control is necessary.
A difficult airway trolley and a bronchoscope (conventional or single use) are needed for emergent management of a difficult intubation.
To improve the success rate of endotracheal intubation, use metal blades for direct laryngoscopy.
Videolaryngoscopes should be used initially or after failure of direct laryngoscopy in order to limit intubation failures.
For oxygenation and to facilitate intubation under bronchoscopic control, use supraglottic devices.
For pediatric patients, laryngoscopic blades used should be suited to the habits of the practitioners (eg, Miller straight blade, Macintosh curved blade). Exposition failure warrants a change in the type of blade used. Additionally, oral intubation is preferred, as are cuffed tubes to limit reintubations due to leakage.
Drugs in difficult intubation
Hypnotic agents (eg, etomidate, ketamine, propofol) facilitate rapid sequence induction. The choice of agent depends on patient history and clinical situation.
Succinylcholine can be used in critically ill patients to facilitate tracheal intubation during rapid sequence induction. If succinylcholine is contraindicated, rocuronium dosed above 0.9 mg/kg (1-1.2 mg/kg) is an alternative. Note that sugammadex should be available for possible emergent use if rocuronium is used.
An additional recommendation for pediatric patients is the use of atropine before intubation and during induction for those older than 28 days up to age 8 years, particularly in children with septic shock or hypovolemia or if suxamethonium is used.
Protocols and algorithms in difficult intubation
Noninvasive ventilation should be used for preoxygenation of hypoxemic patients. For patients who are not severely hypoxemic, high-flow nasal oxygen can be used.
Include a respiratory component in the intubation protocol in order to decrease respiratory complications. Integrate a postintubation recruitment maneuver into the respiratory component for hypoxemic patients.
After intubation of hypoxemic patients, a positive end-expiratory pressure of at least 5 cm water is recommended.
A cardiovascular component to the protocol to address fluid challenges and early administration of amines to decrease cardiovascular complications is recommended.
Extubation prerequisites
To decrease the risk of extubation failure, a spontaneous breathing trial is recommended before any extubation in ICU patients ventilated for greater than 48 hours.
However, the spontaneous breathing trial is not adequate as a lone method for detecting extubation failure risk. As such, it is suggested that screening be conducted for other risk factors, such as excessive tracheobronchial secretions, swallowing disorders, ineffective cough, and altered consciousness.
Extubation failure
To predict the occurrence of laryngeal edema, perform a cuff leak test before extubation. If the patient has at least one risk factor for inspiratory stridor, the cuff leak test is recommended before extubation to reduce the risk of failure related to laryngeal edema.
During mechanical ventilation, it is recommended to institute measures to prevent and treat laryngeal pathology.
In the event the leak volume is low or zero, corticosteroids can be prescribed to help prevent extubation failure related to laryngeal edema. If corticosteroid therapy is selected, the recommendation is to start it at least 6 hours before extubation.
For pediatric patients, corticosteroid therapy should be started 24 hours pre-extubation in order to be effective.
Extubation and respiratory therapy
Suggested prophylactic measures include high-flow oxygen therapy via a nasal cannula (1) after cardiothoracic surgery, (2) after extubation in hypoxemic patients, and (3) in patients at low risk of reintubation. Additionally, noninvasive ventilation is suggested as a prophylactic measure in patients at high-risk of reintubation, especially hypercapnic patients.
Noninvasive ventilation is suggested as a therapeutic measure to treat acute postoperative respiratory failure, especially after lung resection or abdominal surgery.
Noninvasive ventilation is not suggested as treatment for acute respiratory failure after extubation in the ICU unless the patient has underlying COPD or if blatant cardiogenic pulmonary edema is present.
For pediatric patients, noninvasive ventilation is not recommended in low-risk patients.
Physiotherapist treatment is likely required before and after endotracheal extubation following mechanical ventilation for more than 48 hours to reduce weaning duration and risk of extubation failure. A physiotherapist also should probably attend endotracheal extubation; this may help limit immediate complications (eg, bronchial obstruction in patients at high risk for extubation failure).
