The Post-Intubation Package

There is a ton of stuff to do post-intubation besides confirming the tube and giving the team high-fives. What we do in the ED has ramifications on the patient's course in the hospital. Preventing badness starts with us.

Achieve Adequate Analgesia and Sedation

I won't belabor this, because I've discussed it in so many other podcasts, such as the one about not leaving your patient in a nightmare

Secure the Tube Well

We use the Hollister Anchor Fast (as always, no conflicts of interest).

Raise the Head of the Bed to at Least 30°

May or may not help prevent VAP, but it definitely helps lung mechanics

Confirm Lung Protective Vent Settings

See the Dominating the Vent Lecture for more on all that

Humidify the Air

Either with a humidification circuit on the vent or a Heat-Moisture-Exchanger (HME)

Place In-Line Suction and then Actually Use It

In-line is probably no better than intermittent with sterile technique, but who is actually going to use sterile technique

Suction the mouth each time you suction the tube as well

Hook Up the ETCO2

You read NAP4 right? Continuous waveform ETCO2 until the ET tube gets pulled

Cuff Pressure

Too low and you risk micro-aspiration and VAP, too high and the patient has the potential for ischemia. The ideal pressure is between 20-30 cm H20. Use a cufflator.

Gastric Tube

Empty the stomach to reduce the chances of aspiration

Nebulizers/MDI

If they were intubated for reactive airway disease, then they need frequent nebs. In some hospitals, all patients get intermittent MDIs. Make sure to remove the HME for nebulizer or MDI treatments.

Prevent Aspiration past the Cuff of the ETT

Cuff Lube

Lube on the tube cuff may help avoid micro-aspiration (Anesthesiology 2001; 95:377–81 & Anaesthesia. 2006 Feb;61(2):133-7.)

Continuous Subglottic Suction ETTs

BestBets: Continuous subglottic suction is effective for prevention of ventilator associated pneumonia

May prevent 4 cases annually if used for all patients in an average US hospital (Critical Care 2012, 16:446)

A listener, Dan Hierholzer, DO (last name:  Here-Hole-Zer) reports on 1 issue with these tubes: they have a wider external diameter so if you are trying to pass them through an intubating supra-glottic airway, you need to go 1 size lower. Dan demanded a shout-out to the residents at Geisinger Medical Center in exchange for this excellent tip.

Get a Blood Gas

I like arterial,