Duration of intubation
Nasal intubation less advantageous for potentially prolonged ventilator requirements
Underlying advanced intrinsic lung or neuromuscular disease
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.)
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.
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?
- Will this patient be difficult to intubate?
- 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
4% increase in FiO2 for each 1 L of flow (e.g., 4 L flow = 37% or 6 L flow = 45%)
At most delivers 40% at 10-15 L flow
Small amount of rebreathing
8 L flow = 40%, 15 L flow = 60%
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....