Drug-Assisted Intubation - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

Because neuromuscular blocking agents (NMBAs) can cause respiratory arrest, health care team members skilled in intubation must be present and ready at the bedside before the medication is administered. Ensure that an alternative airway is immediately available in case intubation fails.

A personal or family history of malignant hyperthermia is a contraindication to succinylcholine.^{undefined#ref9">9} Relative contraindications include conditions that increase the risk of succinylcholine-induced hyperkalemia (e.g., hyperkalemia; myopathies or neuromuscular disorders; or burns, crush injuries, or recent severe infections).⁹

Obtain a baseline neurological assessment before any NMBA is given.

OVERVIEW

Endotracheal tube (ET) intubation is performed to establish and maintain a patent airway, facilitate oxygenation and ventilation, reduce the risk of aspiration, and assist with the clearance of secretions. Indications for ET intubation include:

• Inadequate oxygenation and ventilation
• Altered mental status (e.g., brain injury, drug overdose)
• Anticipated airway obstruction (e.g., facial burns, epiglottitis, major facial or oral trauma)
• Upper airway obstruction (e.g., secondary to swelling, trauma, tumor, bleeding)
• Apnea
• Respiratory distress or respiratory failure
• Ineffective clearance of secretions
• High risk for aspiration

Drug-assisted intubation (DAI) involves the use of medication to quickly facilitate intubation in patients, often in emergency situations. Common medications used in DAI include NMBAs, sedatives, and analgesics to minimize discomfort and prevent involuntary movements during intubation (Box 1).

Indications for DAI include patients who require definitive airway management but who have an intact gag reflex, especially patients who have sustained a traumatic brain injury (TBI).²

NMBAs are the foundation of emergency airway management. They allow placement of the oral ET tube while minimizing potential complications, such as aspiration. There are two classes of NMBAs.

• One class is the noncompetitive depolarizing agents, of which succinylcholine is the most common; succinylcholine depolarizes the endplates and renders muscles unable to respond to acetylcholine (ACh). Depolarizing agents are rapid in onset and short acting.⁹
• The second class is the competitive, nondepolarizing NMBAs, which compete with and block the action of ACh at the postjunctional nicotinic receptors in the neuromuscular junction. This class includes vecuronium and rocuronium.

Common sedative induction agents and analgesics used in DAI include etomidate, propofol, ketamine, midazolam, and fentanyl.⁹ In some instances, additional medications may be given before sedatives and paralytics. IV lidocaine or fentanyl can be considered in patients with a TBI because it may help to prevent increases in intracranial pressure (ICP) not only from the TBI, but from the effects of succinylcholine, which may exacerbate increased ICP.⁵ Lidocaine or fentanyl can also be used to help mitigate the sympathetic response during intubation.⁹ Atropine may also be considered in pediatric patients less than 1 year old to prevent bradycardia from a vagal response during intubation, as well as reduce oral secretions if ketamine is used as a sedative induction agent.^5,7

The steps of DAI are often conducted according to the seven “Ps”:⁴

• Preparation
• Preoxygenation
• Preintubation optimization
• Paralysis with sedative induction
• Positioning with protection
• Placement with proof
• Postintubation management

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• Reassure the family that the patient’s inability to move is temporary, and any new decrease in level of consciousness are the desired effects of the medications.
• Inform the patient that swallowing may help diminish gagging.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Determine if the patient or family has health literacy needs or requires tools or assistance to effectively communicate. Be sure these needs can be met without compromising safety. This may be deferred until after the procedure.
2. Review the patient’s and family’s previous experience and knowledge of ET intubation and understanding of the care to be provided. This may be deferred until after the procedure.
3. Assess the patient’s immediate history of trauma when a brain or spinal cord injury is suspected.
4. Assess the patient’s nothing-by-mouth (NPO) status.
5. Assess the patient’s level of consciousness, level of anxiety, and respiratory difficulty.
6. Complete a brief neurologic assessment of the patient, including movement of the extremities before the patient receives an NMBA.
7. Assess the patient’s vital signs, including oxygen saturation.
8. Assess the patient’s oral cavity for the presence of dentures, loose teeth, or other possible obstructions and remove if appropriate.
9. Determine the appropriate size ET tube for the patient.
10. Assess the patient’s airway to determine whether a difficult intubation is anticipated.

Preparation

Preparation (DAI step 1)

1. Attach the patient to a pulse oximeter, cardiac monitor, and blood pressure monitoring device.
2. Ensure that the patient has patent IV access.
3. Notify the respiratory therapist of impending intubation so that a ventilator can be set up.
4. Set up the suction apparatus and connect the rigid tonsil-tip suction catheter to the tubing.
5. Check equipment.
6. Ensure that alternative airway equipment is available in case intubation fails.
   1. Supraglottic airway (laryngeal mask airway, intubating laryngeal mask airway, i-gel^® supraglottic airway)²
   2. Retroglottic airway (laryngeal tube airway [King airway, LTA], intubating laryngeal tube airway [ILTA])²
   3. Surgical airway equipment
   4. Needle cricothyroidotomy equipment (not recommended in patients less than 12 years old)
   5. Fiberoptic scope
   6. Eschmann tracheal tube introducer (gum elastic bougie)²
7. Ensure that all necessary medications, needles, and syringes are close at hand, whether in a kit (Box 2) or assembled separately.

PROCEDURE

Preoxygenation

1. Preoxygenate the patient for 3 to 5 minutes with high-flow oxygen via a nonrebreather mask or high-flow nasal cannula if ventilations are adequate or via a manual resuscitation bag (MRB) with a face mask connected to a high-flow oxygen source if the patient is not adequately ventilating.³ Provide frequent and gentle breaths.
2. Elevate the head of the bed slightly during preoxygenation if the patient is not in spinal motion restriction. If the patient is in spinal motion restriction, place the patient in reverse Trendelenburg position.⁴

Preintubation optimization

1. Give premedications as indicated.
   1. Give lidocaine or fentanyl as ordered to mitigate the sympathetic response and increase in ICP in patients with a suspected TBI.⁵
   2. Give atropine as ordered to pediatric patients less than 1 year old to mitigate and treat vagally-induced bradycardia during intubation.⁷

Paralysis with sedative induction

1. Give the sedative induction agent as ordered (Box 1).

   The induction agent should always be administered before the NMBA.

2. Administer the NMBA as ordered.

   Adequate muscle relaxation may take 90 seconds or longer after administration of an NMBA.⁹

3. Insert an oral or nasal airway, as needed while waiting for medications to take effect.

Positioning with protection

1. Maintain a patent airway by using the head tilt-chin lift or jaw thrust maneuver.
2. Administer high-flow supplemental oxygen by nonrebreather mask or high-flow nasal cannula (passive oxygenation). If the patient has been sufficiently preoxygenated, oxygen will continue to diffuse into the bloodstream regardless of diaphragmatic movement.⁵

   Bag-mask ventilation after paralysis and induction may result in vomiting and aspiration, and should be avoided unless adequate oxygenation cannot be obtained during preoxygenation.⁶

3. Position the patient’s head by flexing the neck forward and tilting the head (sniffing position [only if neck trauma is not suspected]) (Figure 1). Adjust the bed height as needed.
   1. If necessary, place a small towel under the patient’s occiput to elevate it, allowing for proper neck flexion.
   2. If spinal trauma is suspected, request that an assistant maintain the head in a neutral position with inline spinal motion restriction and stabilize the cervical spine.

      Do not flex or extend the neck of a patient with a suspected spinal cord injury.

4. Suction the patient’s mouth and oropharynx as needed.

Placement with proof

1. The intubator orally intubates the patient.
2. Verify the ET tube placement:⁴
   1. Attach an exhaled carbon dioxide detector and look for evidence of exhaled carbon dioxide.
   2. Look for symmetric rise and fall of the chest while auscultating over the epigastric area to detect any gurgling sounds.
   3. Auscultate for bilateral breath sounds.
3. Inflate the cuff, and ventilate and oxygenate the patient with high-flow oxygen while manually maintaining the tube placement.¹

Postintubation management

1. Secure the ET tube.
2. Initiate continuous waveform capnography to monitor ET tube placement.^8,10
3. Confirm ET tube location with a chest radiograph.
4. Be sure there is adequate sedation and analgesia in conjunction with NMBAs.
5. Insert an orogastric tube as indicated.

MONITORING AND CARE

1. Assess and adjust the level of sedation, as ordered and indicated.
2. Continue to monitor ET tube placement, pulse oximetry, and continuous waveform capnography. Reassess tube placement every time the patient is moved.

EXPECTED OUTCOMES

• Effective ET tube placement

UNEXPECTED OUTCOMES

• Esophageal intubation
• Vasodilation, resulting in profound hypotension
• Dislodgment of the ET tube
• Trauma to teeth, nasal mucosa, posterior pharynx, or larynx

DOCUMENTATION

• Name and dose of medications administered
• Patient’s response to the medication, including any adverse reactions
• Patient’s vital signs, oxygenation, and ventilation before, during, and after the procedure
• Size of ET tube placed
• Position of the ET tube in relation to the teeth or gums (in centimeters)
• Description of the method used to secure the tube
• Validation of ET tube placement
• Unexpected outcomes and related interventions
• Education

PEDIATRIC CONSIDERATIONS

• Cuffed endotracheal tubes are preferred over uncuffed tubes in pediatric patients.⁷
• Routine use of cricoid pressure is not recommended during ET intubation of pediatric patients. If cricoid pressure is used, it should be discontinued if it interferes with ventilation or intubation.¹⁰

REFERENCES

1. American College of Surgeons (ACS). (2018). Appendix G: Skills: Skill station A: Airway. In ATLS: Advanced trauma life support: Student course manual (10th ed., pp. 335-375). Chicago: Author.
2. American College of Surgeons (ACS). (2018). Chapter 2: Airway and ventilatory management. In ATLS: Advanced trauma life support: Student course manual (10th ed., pp. 22-41). Chicago: Author.
3. Driver, B.E., Reardon, R.F. (2019). Chapter 4: Tracheal intubation. In J.R. Roberts and other (Eds.), Roberts and Hedges’ clinical procedures in emergency medicine and acute care (7th ed., pp. 62-110). Philadelphia: Elsevier.
4. Edminster, E. (2024). Chapter 5: Airway and ventilation. In TNCC: Trauma nursing core course: Provider manual (9th ed., pp. 63-87). Burlington, MA: Jones & Bartlett Learning.
5. Kempema, J.M., Trust, M.D., Brown, C.V.R. (2021). Chapter 14: Management of the airway. In D.V. Feliciano, K.L. Mattox, E.E. Moore (Eds.), Trauma (9th ed., pp. 215-238). New York: McGraw-Hill.
6. Milici, J.J. (2024). Chapter 11: Respiratory emergencies. In A. Foley (Ed.), Sheehy's manual of emergency care (8th ed., pp. 105-127). St. Louis: Elsevier.
7. Nagler, J., Donoghue, A.J., Yamamoto, L.G. (2021). Chapter 8: Airway. In K.N. Shaw, R.G. Bachur (Eds.), Fleisher & Ludwig's textbook of pediatric emergency medicine (8th ed., pp. 34-42). Philadelphia: Wolters Kluwer.
8. Panchal, A.R. and others. (2020). Part 3: Adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 142(16 Suppl. 2), S366-S468. doi:10.1161/CIR.0000000000000916 Retrieved December 16, 2024, from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000916
9. Schwartz, R.B., McCollum, D. (2019). Chapter 5: Pharmacologic adjuncts to intubation. In J.R. Roberts and others (Eds.), Roberts and Hedges’ clinical procedures in emergency medicine and acute care (7th ed., pp. 111-126). Philadelphia: Elsevier.
10. Topjian, A.A. and others. (2020). Part 4: Pediatric basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 142(16 Suppl. 2), S469-S523. doi:10.1161/CIR.0000000000000901 Retrieved December 16, 2024, from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000901

Clinical Review: Justin J. Milici, MSN, RN, CEN, CPEN, CPN, TCRN, CCRN, FAEN

Published: January 2025