Knowing when you need to intubate a patient in respiratory distress is a key skill you will use regularly as a nurse. This skill applies across the board…not just ED or ICU. Nurses in all settings come into contact with patients who decompensate, and knowing when you need to intubate can mean the difference between life and death.
So what are the general signs of respiratory compromise? First, let’s review the normal findings you’d expect to see in a patient who is doing just fine.
- Respiratory rate 12-20 times per minute (though to be honest, I often would see mid 20-s and the patient was fine)
- No accessory muscle use
- O2 saturation > 90% on RA
- ABG within normal limits
- P/F ratio > 300
- Clear lung sounds
- Protecting airway like a champ
OK, now that we’ve reviewed what’s normal, let’s talk about what warrants intubation and when you can “wait and see.”
- Increased respiratory rate…note that this isn’t as easy as just stating a number. You’d need to look at how the RR is correlating with other factors…O2 sat and WOB are the main ones. But, in general, a RR in the 30s-40s is generally a sign that an intervention needs to be done. Whether it’s intubation depends on the O2 sat mostly. Sometimes patients will be put on BiPAP in hopes this does the trick. The thing about an elevated respiratory rate is that the patient will tire out eventually, and then the spiral down is swift. You need to keep a close eye on anyone who is tachypneic.
- Decreased respiratory rate. If the patient is breathing 7 times a minute but their O2 and CO2 are okay, you may just use BiPAP and wait and see what happens…you’ll want to keep an eagle-eye on their CO2 though, so expect to monitor capnography or do another ABG. If the respiratory rate is low (and especially if also shallow) and the O2 is low or the CO2 is high, then this is time to get more assertive.
- Increased work of breathing occurs when the patient is hungry for air and using all those accessory muscles to try to get more air in. Watch the muscles of the neck, chest and belly…if these are in high gear, note that the patient will wear out, so you need to hop on this quick.
- Dropping O2 sats. Note that “normal” is greater than 90%…but what if your patient has been 98% on RA all day, and is suddenly 91%? Even though this is “normal” you need to check into it. Not that they need to be intubated, but something in their status clearly changed, and you should go figure it out. Chances are, it will continue to trend downward…a good nurse will catch it before it gets serious. Try some coughing and deep breathing to start (could just be atelectasis), listen to lung sounds (could be fluid overload) or check for problems swallowing (could be aspiration). Do a little detective work and solve this mystery before it becomes an issue.
- If your patient becomes somnolent, checking an ABG is always a good idea. Hypercapnia (elevated CO2) is a very common cause of somnolence, and the cure is usually BiPAP. If the O2 is low, then the cure is usually intubation…BiPAP in some cases, but if the patient isn’t super responsive, they’ll need the extra support.
- If you’ve done an ABG, you’ll be able to calculate your P/F ratio. For more on this, check out my post on this very topic! In general…a P/F ratio that is too low indicates that your patient is in either Acute Lung Injury (ALI) or Acute Respiratory Distress Syndrome (ARDS). ARDS is serious business and your patient will definitely need to be intubated if this condition is confirmed.
- Adventitious lung sounds could indicate a need for intubation. A few crackles can usually be dealt with by giving Lasix or encouraging coughing and deep breathing. However, if your patient’s lungs sound REALLY wet and their O2 sats are dropping, and their WOB is increasing, you are going to intubate this patient before she codes.
- Inability to protect airway. This occurs when your patient has some kind of neurological deficit either from stroke, drugs or they are really really really sick. If your patient is unable to protect his/her airway, then you need to intubate.
Your need to intubate…now what?
So now that you know what to watch for, what do you DO in an emergent intubation? The first thing you want to do, is get your team ready. Call the Respiratory Therapist, tell your charge nurse and grab a couple of other nurses…typically you won’t have a problem getting someone to help, especially in ICU or ED…critical care nurses thrive on emergent situations. Obviously, the doc will be notified so your job as the nurse is to make sure everything goes smoothly.
Ask the doc what meds they want…if the patient is conscious, you’re going to need RSI (rapid sequence intubation) meds. These are meds that relax the patient so the doc can shove an ET down their gullet. If the patient is so compromised that they have no response to noxious stimuli, you may not need this at all. But, most of the time you are going to be using meds…so find out what the doc wants ASAP so you can hustle over to the med room and get it. Note that the MD may ask about the patient’s K level. IF the patient is hyperkalemic, and the doc doesn’t ask…make sure s/he knows…one of the commonly used intubation meds is succinylcholine which causes a transient hyperkalemia. In a patient with a normal K level, this is no biggie…but if it’s already high, this could be an issue and they’ll want to order a different paralytic instead.
The next thing you’ll want to do is make sure someone has prepped a liter bolus of NS…the meds used for RSI cause hypotension, AND the change to positive pressure ventilation causes hypotension due to decreased venous return. Both of these issues can usually be mitigated with a quick fluid bolus.
If the patient is in a really bad way, your room could be a bit chaotic. There’ll be an RT bagging the patient, a doc at the head of the bed (make sure you know how to remove the headboard…and move the bed away from the wall so the doc can get back there). There will be another RT at the ready to hand the doc the necessary intubation equipment. There will be a nurse pushing the meds, another watching the monitor and then you…making sure the whole scene plays out as it should. Hopefully the charge nurse was available to talk to the family, and in most cases everything will go absolutely smoothly.
Your patient is intubated…now what?
Once your patient is intubated, you’ll want to get an order right away for sedation and pain control…when the RSI drugs wear off, you don’t want the patient rousing and pulling their ET. So, get that order for a propofol gtt and fentanyl gtt right away so it’s hanging and ready before the patient needs it. Get an order for restraints if you’re going to need it, and don’t forget to grab the oral care supplies from the clean utility room!
Note that when your patient is first intubated, they’ll be on 100% FiO2…the RT will come by to slowly wean them down to the appropriate oxygen level…and you’ll likely do a repeat ABG to see how your patient is responding to this therapy. Your role as the nurse at this point is to protect the patient from Ventilator Acquired Pneumonia (VAP) and get them off the vent as soon as possible. This means daily or twice daily spontaneous breathing trials, sedation holidays and aggressive weaning. You got this!
So, speaking of VAP…how do you prevent it? You’ll initiate the VAP prevention bundle…and yes, it’s as fun as it sounds! Note that a “bundle” is a group of interventions that, when done together as a whole, drastically improve outcomes. To improve patient outcomes who are on a ventilator, you will ensure…
- HOB 30-45 degrees.
- Oral care q 2-4 hours (depends on what you’re using and hospital policy). Chorhexadine is the main thing here…it has shown to significantly reduce pneumonia.
- Suction all the secretions off the ET cuff…you can use a long, thin and flexible catheter for this, a Yankauer usually won’t do the trick as it’s so big.
- Peptic ulcer disease prophylaxis. Not directly related to pneumonia, but it is directly related to patient outcomes.
- DVT prophylaxis. Again, not directly related to pneumonia, but a huge factor in patient outcomes.
- Daily sedation vacations and assessment for readiness to extubate…get that tube out ASAP!
I hope this helps you understand WHEN to intubate your patient and how to take care of them once this occurs. You may be interested in learning about Acute Respiratory Distress Syndrome, so if you are…you can check that out here.
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