Assess underlying need for airway control
Duration of intubation
 Nasal intubation less advantageous for potentially prolonged ventilator requirements
Permanent support
 Underlying advanced intrinsic lung or neuromuscular disease
Temporary support
 Anesthesia
 Presence of reversible intrinsic lung or neuromuscular disease
 Protection of the airway due to depressed mental status
 Presence of reversible upper airway pathology
 Patient care needs (e.g., transport, CT scan, etc.)
 Significant comorbidities
  Aspiration potential or increased respiratory secretions
  Hemodynamic issues such as cardiac disease or sepsis
  Renal or liver failure

Pathophysiology of the respiratory failure
Hypoxic respiratory failure
-    In case of hypoxic respiratory failure, different noninvasive oxygen delivery devices can be used.
-    The severity of hypoxia and presence or absence of underlying disease (such as COPD) will dictate the device of choice.
Hypercapnic respiratory failure
-    The noninvasive device of choice for hypercapnic respiratory failure is BIPAP.

Assessment of above mentioned patient characteristics in conjunction with the mechanism of respiratory distress leads the clinician to proper choice and duration of  invasive or noninvasive options for airway management.

Code status should be clarified prior to proceeding.

Oxygenation
Respiratory rate and use of accessory muscles
-    Is the patient in respiratory distress?
Amount of supplemental oxygen
-    What is the patient’s oxygen demand?
Pulse oximeter or arterial blood gas
-    Is the patient physiologically capable of providing appropriate supply?

Airway
Anatomy
-    Will this patient be difficult to intubate?
Patency
-    Is there a reversible anatomical cause of  respiratory failure as opposed to intrinsic lung dysfunction?
Airway device in place
-    Is there a nasopharyngeal airway or combitube in place?

Oxygen Delivery Devices
Nasal Cannula
4% increase in FiO2 for each 1 L of flow (e.g., 4 L flow = 37% or 6 L flow = 45%)

Face tent
At most delivers 40% at 10-15 L flow

Ventimask
Small amount of rebreathing
8 L flow = 40%, 15 L flow = 60%

Nonrebreather mask
Attached reservoir bag allows 100% oxygen to enter mask with inlet/outlet ports to allow exhalation to escape - does not guarantee 100% delivery.

CPAP is a continuous positive pressure
Indicated in hypoxic respiratory failure and obstructive sleep apnea

BiPAP allows for an inspiratory and expiratory pressure to support and improve spontaneous ventilation
Mainly indicated in hypercapnic respiratory failure and obstructive sleep apnea

If use of noninvasive modes of ventilation does not result in improved ventilation or oxygenation in two to three hours, intubation should be considered

These devices can be used if following conditions are met:
Patient is cooperative with appropriate level of consciousness
Patient does not have increased respiratory secretions or aspiration potential
Concurrent enteral feeding is contraindicated.

Facilitates early extubation, especially in COPD patients
Some devices allow respiratory rate to be set.
Up to 10 L of oxygen can be delivered into the mask for 100% oxygen delivery.
Nasal or oral (full face) mask can be used; less aspiration potential with nasal....

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