Emergency Medicine · Year 3 · from Emergency Medicine

Case 1: Emergent Intubation - The Crashing Patient

Patient Demographics

  • Age: 56 years
  • Sex: Male
  • Occupation: Restaurant manager

Chief Complaint

"He can't breathe!"

History of Present Illness

A 56-year-old male with history of COPD presents in severe respiratory distress. Wife reports progressive shortness of breath over 3 days with increasing sputum production (green/yellow). He ran out of his inhalers last week. Over the past hour he has become increasingly lethargic and "can't catch his breath." He uses home oxygen at 2L/min.

Initial Assessment

ESI Level: 1 - Respiratory failure requiring immediate intervention

First Impression:

  • Appearance: Severely distressed, tripod positioning, diaphoretic, cyanotic
  • Work of breathing: Severe - accessory muscle use, paradoxical breathing
  • Circulation: Pale, diaphoretic

Vital Signs:

  • Heart rate: 128 bpm
  • Blood pressure: 168/96 mmHg
  • Respiratory rate: 36 breaths/min (labored)
  • SpO2: 78% on 2L NC
  • Temperature: 38.2C
  • GCS: 11 (E3V3M5) - Decreasing

Indications for Intubation

Classic Indications (3 F's and an A):

  1. Failure to oxygenate - SpO2 78% despite supplemental O2 ✓
  2. Failure to ventilate - Hypercarbic, tiring ✓
  3. Failure to protect airway - Decreasing mental status ✓
  4. Anticipated clinical course - Will only worsen without intervention ✓

Decision: Emergent endotracheal intubation indicated

Pre-Intubation Assessment

Difficult Airway Predictors (LEMON):

  • Look externally: Obese, short neck, beard
  • Evaluate 3-3-2: Mouth opening adequate, thyromental distance short
  • Mallampati: Unable to assess (distress)
  • Obstruction: No obvious obstruction
  • Neck mobility: Adequate

Anticipated Difficulty: MODERATE (obese, short neck)

Preparation (7 P's of RSI):

  1. Preparation - Equipment, personnel, monitoring
  2. Preoxygenation - Critical before paralysis
  3. Pretreatment - Consider for specific indications
  4. Paralysis/Induction - RSI medications
  5. Positioning - Optimize for success
  6. Placement - Laryngoscopy and tube insertion
  7. Post-intubation - Confirm, secure, ventilate

Equipment Setup

Airway Equipment:

  • Laryngoscope (direct AND video available)
  • ETT sizes 7.0, 7.5, 8.0 (cuffed)
  • Stylet
  • Bougie (gum elastic)
  • BVM with PEEP valve
  • Suction (Yankauer)
  • End-tidal CO2 detector
  • Backup: LMA, surgical airway tray

Medications:

  • Induction: Ketamine 2 mg/kg (bronchodilator, preserves BP)
  • Paralytic: Succinylcholine 1.5 mg/kg (rapid onset)
  • Push-dose epinephrine available

Personnel:

  • Provider for intubation
  • Respiratory therapy (BVM, ventilator)
  • Nurse (medications, monitoring)
  • Second physician (backup, cricothyrotomy if needed)

Preoxygenation

Critical in COPD/Hypoxic Patient:

  • High-flow nasal cannula at 15L/min + non-rebreather mask
  • Apneic oxygenation: Maintain nasal cannula during laryngoscopy
  • Goal: SpO2 >93% before paralysis
  • Patient preoxygenated 3 minutes; SpO2 improved to 88% (best achievable)

Procedure - Rapid Sequence Intubation

Positioning:

  • Ramped position (elevation of head/shoulders) - optimizes obese airway
  • External ear canal aligned with sternal notch

Induction:

  • Ketamine 150mg IV push (2 mg/kg)
  • Patient sedated within 30 seconds

Paralysis:

  • Succinylcholine 120mg IV push (1.5 mg/kg)
  • Fasciculations noted
  • Paralysis achieved at 45 seconds

Laryngoscopy:

  • Video laryngoscopy used (Glidescope)
  • Grade II view (arytenoids visible)
  • Bougie passed through cords
  • ETT 7.5 passed over bougie
  • Cuff inflated
  • ETT secured at 23cm at lip

Confirmation of Tube Placement

Multiple Methods Required:

  1. End-tidal CO2 (ETCO2): Waveform present - MOST RELIABLE
  2. Bilateral breath sounds: Present and equal
  3. Chest rise: Symmetric
  4. Misting in ETT: Present
  5. SpO2 improvement: 88% → 94%
  6. Chest X-ray: ETT tip 3-5cm above carina (confirms position, not placement)

Post-Intubation Management

Immediate Actions:

  • Secure tube with commercial holder
  • Ventilator settings:
  • Mode: Volume control
  • Tidal volume: 6-8 mL/kg IBW
  • Rate: 12-14 (allow for prolonged expiration in COPD)
  • PEEP: 5 cmH2O
  • FiO2: 100% initially, wean to target SpO2 >92%
  • Sedation: Propofol infusion + fentanyl PRN
  • Gastric decompression: OG tube
  • Arterial line for monitoring

Post-Intubation Vitals:

  • HR: 98 bpm
  • BP: 128/78 mmHg (improved with positive pressure)
  • SpO2: 96%
  • ETCO2: 58 mmHg (will need to improve with ventilation)

Secondary Survey

SAMPLE History (from wife):

  • Symptoms: Progressive dyspnea, cough, sputum
  • Allergies: Sulfa
  • Medications: Albuterol, tiotropium (ran out), prednisone PRN
  • PMH: COPD (severe), CAD, HTN
  • Last Meal: Last night
  • Events: COPD exacerbation

Diagnosis

COPD Exacerbation with Acute Hypercarbic Respiratory Failure requiring emergent intubation

Diagnostic Testing

ABG Post-Intubation:

  • pH: 7.22
  • pCO2: 72 mmHg
  • pO2: 118 mmHg
  • HCO3: 28 mEq/L

Interpretation: Acute on chronic respiratory acidosis

Chest X-ray:

  • ETT in good position
  • Hyperinflation
  • Right lower lobe infiltrate (possible pneumonia trigger)

Management

COPD Exacerbation Treatment:

  • Albuterol/ipratropium nebulizers via ETT
  • Methylprednisolone 125mg IV
  • Antibiotics: Azithromycin + ceftriaxone (CAP coverage)
  • Optimize ventilator for COPD (longer expiratory time)

Disposition

  • Medical ICU admission
  • Weaning protocol initiated day 2
  • Extubated day 3
  • Step-down unit day 4
  • Discharged day 7 with inhaler teaching and pulmonology follow-up

Teaching Points

  1. Recognize indications early: Don't wait until crash to decide on intubation
  2. Preparation prevents disaster: Equipment, personnel, backup plans ready
  3. Preoxygenation is critical: Maximizes safe apnea time
  4. Ketamine for bronchospasm: Bronchodilator and maintains hemodynamics
  5. Video laryngoscopy improves first-pass success: Especially in difficult airways
  6. Confirm placement multiple ways: ETCO2 waveform is gold standard
  7. Anticipate post-intubation hypotension: Especially in hypovolemia, sedation
  8. Ramped positioning: Critical for obese patients - ear to sternal notch alignment

Clinical Image

Image Description: Illustration of Cormack-Lehane laryngoscopic view classification from Grade I (full glottic opening visible) to Grade IV (no glottic structures visible), used to describe the view during direct or video laryngoscopy.

Attribution: Image from Wikimedia Commons, Cormack Lehane classification. Licensed under CC BY-SA 4.0. Source: https://commons.wikimedia.org/wiki/File:Cormack-Lehane_classification_system.svg

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