Trauma 2004; 6: 249–254

Indications for endotracheal intubation

and ventilation
Steve Christian and Mav Manji

The ability of the emergency physician to recognize and manage a patient with a
compromised airway is probably the most important aspect of an individual’s care
in the emergency department. Endotracheal intubation in a critically ill patient is a
potentially hazardous procedure because of the technical difficulties that can be
encountered during emergency airway management and the profound pathophy-
siological changes that the institution of mechanical ventilation can cause. This
review article sets out to illustrate when invasive airway management should be
considered and the potential consequences of attempts to perform endotracheal
intubation and mechanical ventilation.

Key words: endotracheal intubation; emergency airway management; difficult

airway; mechanical ventilation

Introduction although in recent years equipment has been developed

for noninvasive ventilation using tight-fitting face
Airway control and the maintenance of adequate masks (Ram et al., 2003). This review article looks at
pulmonary ventilation is probably the most important the indications for endotracheal intubation and the
aspect in the management of patients in the accident institution of pulmonary ventilation.
and emergency department. Techniques used to secure
a patient’s airway are not without their own serious
consequences, therefore difficult decisions often have Endotracheal intubation
to be made as to which patient needs emergency
intervention to control a compromised airway. A wide In general the conditions requiring endotracheal
variety of devices have become available to assist the intubation are actual or impending (AARC Clinical
emergency physician in re-establishing a patient’s air- Practice Guidelines, 1995):
way, each with its own advantages and disadvantages  Airway obstruction.
(Benson et al., 1996).  Inability to protect airway.
Endotracheal intubation, however, remains the  Respiratory failure.
‘gold standard’ in securing an airway and protecting
the lungs from contamination in an emergency situa- In addition intubation of the trachea enables tra-
tion because of its proven safety record in experienced cheal toilet and allows control of respiratory function
hands. The institution of mechanical ventilation is by enabling mechanical ventilation to be instituted.
often directly linked to endotracheal intubation,
Airway obstruction
Airway obstruction can either be partial or complete.
University Hospital Birmingham NHS Trust, Birmingham, UK. Partial obstruction can be identified by stridor or
snoring, caused by turbulent gas flow in the upper
Address for correspondence: Mav Manji, Department of Critical
Care Medicine, University Hospital Birmingham NHS Trust, airway. Complete obstruction is silent because gas flow
Edgbaston, Birmingham B15 2TH, UK. E-mail: mav.manji@ is no longer occurring and is recognized by paradoxical
uhb.nhs.uk chest and abdominal movement to produce a see-saw

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250 S Christian and M Manji

type appearance as well as the lack of breath sounds on  Neuromuscular junction (e.g., drugs acting on
auscultation of the chest. Causes of sudden airway the neuromuscular junction, organophosphates,
obstruction that may be encountered in the emergency myasthenia gravis) (Varelas et al., 2002).
department include:  Chest wall and pleurae (e.g., flail chest, haemo-
thorax, pleural effusion, myopathies) (Bach et al.,
 Inhaled foreign body (AARC Clinical Practice 1997).
Guidelines, 1995).  Lungs and airways (e.g., pneumonia, pulmonary
 Trauma (e.g., laryngotracheal trauma, facial oedema, asthma, COPD, pulmonary embolism)
trauma) (Eggen and Jorden, 1993; Thaller and (Zimmerman et al., 1993; Adnet et al., 2001).
Beal, 1991).
 Upper airway burns (e.g., smoke inhalation, inges-
tion of corrosive chemicals) (Williams and Dymock, When to intubate?
1993).
 Infection (e.g., acute epiglottitis, retropharyngeal The judgement of when to perform endotracheal
abscess) (Mayo-Smith, 1993). intubation can either be straightforward or extremely
 Obstructive angioedema (Roy et al., 1993). difficult, depending on the cause of airway compro-
 Upper airway tumours (AARC Clinical Practice mise, the severity of respiratory failure and the general
Guidelines, 1995). state of the patient. One of the few guidelines pub-
lished, indicating specifically when to intubate a
patient concerns those with acute traumatic head
Inability to protect airway
injury (Gentleman et al., 1993). The advice on when
Patients lose the ability to maintain their airway when
to intubate differs depending upon whether the patient
they become comatosed, lose their gag reflex or cease to
is about to be transferred to another site or to an
have the ability to cough. When the airway is no longer
isolated area of the hospital such as the radiology
protected, the patient presents an increased risk of
department. There is a much lower threshold for
aspiration into the lungs of any fluid or particulate
intubating patients if a transfer is planned. The pur-
matter that may be present in the upper airway. A large
pose behind this is to minimize the risk of having to
number of conditions can precipitate the above effects,
intubate a patient during a transfer, in the less than
although perhaps the most important ones seen in
ideal conditions that this situation may involve.
everyday practise are the following:
Indications for immediate intubation and ventilation
 Drugs and toxins (Sporer, 1999).
following a head injury
 Traumatic head injury (Gentleman et al., 1993).
 Cerebrovascular accident (Berrouschot et al., 2000).  Coma (GCS  8).
 CNS infection (e.g., meningitis, encephalitis).  Loss of protective laryngeal reflexes.
 Ventilatory insufficiency:
Respiratory failure  PaO2 < 9 KPa on air or <13 KPa on oxygen;
Respiratory failure can either be relative, in respiratory  PaCO2 > 6 Kpa.
distress or complete in the form of apnoea (respiratory
 Spontaneous hyperventilation to a PaCO2 < 3.5 KPa.
arrest). Respiratory distress is often manifested by an
 Respiratory arrhythmias.
elevated respiratory rate, low tidal volumes, hypercap-
nia and hypoxaemia. The causes of acute respiratory Indication for intubation and ventilation
failure are too numerous to mention in full although it prior to transfer
is best to describe them in relation to the normal  Significantly deteriorating conscious level, even if
mechanisms involved in respiration. not in coma.
 Bilaterally fractured mandible.
 Central nervous system (e.g., CVA, traumatic head  Copious bleeding into mouth.
injury, spinal cord injury infection, drugs and toxins)  Seizures.
(Berrouschot et al., 2000).
 Peripheral nervous system (e.g., Guillain-Barré syn- A senior physician who has adequate experience in
drome) (Sharshar et al., 2003). the technique of intubation should ideally decide when

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 Endotracheal intubation and ventilation 251

this technique should be instituted. This is particularly variety of conditons that involve deformities of the
important because a relatively high number of the upper airway (e.g., large thyroid goitre) (AARC Clinical
endotracheal intubations undertaken in the emergency Practice Guidelines, 1995). In managing the airway it
department are difficult, even if the need to secure the is vital to have a plan B and a plan C, if plan A fails to
airway is obvious. A recently published study illustrated secure the airway. Many ‘failed intubation drills’ and
this point by reporting an incidence of difficult intuba- difficult airway algorithms have been published to
tion of 3–5.3% in English emergency departments provide a plan of action in the event of being unable
(Morton et al., 2000). The reasons why intubation is to secure the airway (Tunstall, 1976; ASA, 1993).
challenging in the emergency department are plentiful. Management of the predicted difficult airway in the
Emergency patients often have a full stomach, are operating department will often involve the use of
uncooperative, haemodynamically unstable and may awake fibre-optic intubation in the first instance.
have traumatic damage to the upper airway. All of This is often not a practical proposition for patients
these factors can make the induction of anaesthesia, in the emergency department because they are often
which is necessary to facilitate endotracheal intubation hypoxic and confused, making it difficult to control the
in all but the most deeply comatosed patients, a patient and anaesthetise the upper airway within a
hazardous procedure. The risk of being unable to short period of time. There may also be copious
secure the airway and being unable to ventilate a blood in the airway making visualization of the larynx
patient in the emergency department is significantly impossible.
higher than in a theatre environment (Nolan and Clancy, Other techniques that have been described to secure
2002). Complications of intubation are numerous; an airway when direct laryngoscopy and endotracheal
however, serious complications are fortunately rare intubation are not possible include the insertion of a
in experienced hands. This list represents some combitube airway, cricothyroidotomy, percutaneous
of the more common and most serious immediate tracheostomy and surgical tracheostomy (Morton
complications seen in intubated patients. et al., 2000). Despite all of these methods to create a
definitive airway, it has to be remembered that the
 Failure to establish an airway (Shwartz et al., 1995). priority is always to ventilate the patient. Methods to
 Failure to intubate the trachea (Shwartz et al., 1995). maintain ventilation without protecting the airway
 Failure to recognize failed intubation (Shwartz et al., from contamination include bag and mask ventilation
1995). (with or without an oropharngeal or nasopharyngeal
 Pulmonary aspiration (Shwartz et al., 1995). airway) and the insertion of a laryngeal mask airway.
 Hypertension and tachycardia (Kihara et al., 2003). The beneficial effects of ventilation are often sec-
 Hypotension and bradycardia due to vagal stimula- ondary to a significant reduction in oxygen consump-
tion (Winston et al., 1987). tion. Ventilation decreases the work of breathing and is
 Dental damage (Butron and Baker, 1987). effective at reducing respiratory muscle exhaustion.
 Cervical spine trauma (Muckart et al., 1997). The options available to the physician managing a
 Laryngeal trauma (Usui et al., 2001). patient who is unable to protect his airway are simple.
 Pneumonia (Montravers et al., 2002). The patient should be woken up where possible, for
 Increased intracranial pressure. example, administering naloxone to a patient with an
opioid overdose (Sporer, 1999). If this is not possible it
is essential to protect the patient’s lungs from aspira-
Difficult intubation tion by means of a definitive airway, usually with
endotracheal intubation. In a patient with upper air-
A wide variety of scoring systems and tests have been way obstructions the choices are similar. Either the
developed to determine on which patients it is likely to obstruction is removed or a definitive airway is made.
be difficult to perform direct laryngoscopy and endo- Patients who are awake, able to protect their own
tracheal intubation (Cormack and Lehane, 1984). airway but present to the emergency department with
Although many of these tests are highly sensitive, the acute respiratory failure may not need intubation in
specificity is generally poor. Clinical features that order to be ventilated. For quite some time, patients
would indicate direct laryngoscopy may be difficult with exacerbations of COPD have been successfully
include a receding mandible, prominent maxillary treated with noninvasive ventilation (NIV) via a tight
incisors, short neck, reduced neck movement and a fitting facemask (Ram et al., 2003; Plant et al., 2000).

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252 S Christian and M Manji

This has resulted in a significant reduction in the

number of patients from this particular group requir-
ing endotracheal intubation. The advantage of this
technique is that the normal anatomy of the upper
airway is maintained and the patients subsequently
have lower incidences of nosocomial pneumonia,
shorter intensive stays and improved outcome (Ram
et al., 2003). It has become clear that other groups of
patients who present with respiratory failure may
benefit from NIV although the results of trials in
these patients has been less encouraging. In our opi- Figure 1 Intrapleural pressure and ventilation in
nion it would be reasonable to attempt a trial of NIV upright lung
on a patient with respiratory distress in the emergency
department who is awake, cooperative and able to
maintain their own airway. pressure are greatest in the dependent areas making
In an ideal situation endotracheal intubation and this part most compliant and hence causing it to receive
conventional ventilation should be instituted by a the most ventilation.
senior physician, experienced in the technique, who Similarly, blood flow is also unevenly distributed,
will subsequently take over the patients continuing mainly influenced by gravitational forces. The lungs
care (almost invariably on the intensive care unit). can be divided into arbitrary zones in order to under-
Following this guideline helps ensure the appropriate- stand the effect of gravity and influence of alveolar
ness of ventilation for the each individual patient and pressure on the blood flow (Figure 2).
also guarantees an adequate level of competence from The upper region of the lungs (zone I) may receive
the physician performing these potentially dangerous very little blood as alveolar pressure may exceed arterial
interventions. The main problem adhering to this and venous pressures. Zone II lung arterial pressure is
policy is that in UK hospitals, an experienced anaes- greater than the alveolar pressure which in turn is greater
thetist may not be available (Walker and Brenchley, than the venous pressure. Blood flow is thus dependent
2000), which has led to an increase in emergency on alveolar pressure. In zone III, both arterial and
department staff performing endotracheal intubation. venous pressures exceed alveolar pressure and it
This is in line with other developed countries such as is in this region that the best alveolar blood flow is seen.
the USA and Australia where emergency physicians In zone IV, the interstitial pressure may physically
undertake most of the tracheal intubations in the compress arterioles and reduce the blood flow.
emergency department (Nolan and Clancy, 2002). In a state of low cardiac output, blood flow can
almost cease in zone I. This is due to a decrease in
pulmonary artery pressure whilst the alveolar pressure
Pathophysiological consequences of remains unaffected, effectively increasing dead space.
mechanical ventilation
Achieving a ventilation=perfusion balance
Each lung unit consists of approximately 150 million
alveoli, which are ventilated according to their posi-
tion on the pressure-volume curve (Figure 1). Trans-
pulmonary pressure is defined as airway pressure
minus pleural pressure. The dependent regions of
the lungs are subject to a lower transpulmonary
pressure. This region is therefore positioned on the
lower steeper part of the pressure–volume curve.
When a negative intrathoracic pressure is generated
during normal spontaneous ventilation, the transpul-
monary pressure is increased to an equal extent all Figure 2 Distribution of pulmonary blood flow in the
over the lungs. Thus the changes in transpulmonary zone model of the lung

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 Endotracheal intubation and ventilation 253

The change from normal breathing to mechanical  Increase in intrathoracic pressure leading to impair-
ventilation can cause profound alterations in respira- ment of venous return and elevation of venous
tory physiology. Ventilated patients are typically pressure.
nursed in a supine position, which results in a decrease  Shearing injury may leading to modification of local
in total lung volume and functional residual capacity vasoactive status.
(Figure 3).
Closing capacity encroaches on tidal ventilation
meaning airways start to close during normal ventila- Conclusions
tion (Figure 3). This effect causes an increase in the
amount of physiological shunting and potentially a It is clear that endotracheal intubation and ventilation
worsening hypoxaemia. Mechanical ventilation can are important skills in the management of critically ill
also adversely affect ventilation=perfusion matching patients in the emergency department. The manage-
because ventilation occurs predominantly in non- ment of patients requiring these advanced airway skills
dependent areas whereas blood flow is concentrated requires an adequate understanding of the potential
in dependent regions. benefits as well as the pitfalls that we occasionally
Cardiovascular changes are extremely common observe with these techniques. We believe it is essential
when a patient is initially placed on a ventilator and that physicians who decide to perform endotracheal
these are predominantly caused by an increase in intubation in the emergency department retain an
intrathoracic pressure leading to a reduction in venous insight into their own skill levels and act within their
return to the heart. This reduction in ‘preload’ can own limitations to avoid the potentially disastrous
cause a dramatic reduction in cardiac output leading to consequences of failed airway management. Perhaps
profound hypotension, especially in a patient who is the most important message from this review is to
hypovolaemic before ventilation is instituted. These recognize the symptoms and signs of airway compro-
changes may cause a paradoxical increase in cardiac mise and respiratory failure rapidly, then to request
output in patients with heart failure due to a beneficial experienced assistance early if there is any doubt as to
instant reduction in preload. whether these problems can be rectified.
Mechanical ventilation should not be taken lightly
as elevated intrathoracic pressure affects regional
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