When and How to

Intubate and Ventilate

in Shock
Heart Lung Interaction
Navy Lolong
iNTUBATION in CRITICALLY iLL or APNEU patient
COULD BE TOO LATE
 Too much
questions, like….
•Intubate or not ?
•Now or wait ?
•Who will do it ?
•Me or anesthesiologist?
When to intubate ?
Is there failure of airway
maintenance or protection?
The decision
Simple
to intubate is
based on Is there failure of oxygenation or
three ventilation?
Just answer
fundamental
this 3 questions
assesments : Is there an anticipated need for
intubation (ie, what is the
expected clinical course)?
In shock…

Respiratory muscle need Venous return is

more blood perfusion decreased
 In shock

Lactate acidosis ↑

Increase Work of Breathing for Hyperventilation

Increased need of Respiratory Muscle Blood Perfusion

Redistribute Blood Flow from more

important organ
 Flow darah akan di
pertahankan ke arah
jantung dan otak,
 juga otot pernafasan
Spontaneous Breathing

Mechanical Ventilated
 Mechanical ventilation
in shock

Decrease Work of Breathing

Decrease need of Respiratory Muscle

Blood Perfusion

Redistribute Blood Flow to more

important organ
 Penurunan konsumsi oksigen otot
pernafasan oleh ventilasi mekanik

Konsumsi O2
otot nafas

Pemahaman sapih ventilator

Normal Gagal Nafas Ventilasi mekanik

 Endotracheal
Rivers Protocol Intubation and
Rivers Protocol Mechanical Ventilation
Intubation and Ventilation in Shock will…

•Protected patent airway

•Increase Oxygenation
•Decrease Work Of Breathing
HOW TO INTUBATE
in Shock
Totally DIFFERENT with intra-
operating room intubation
 In SHOCK …

Low Sepsis Induced

Low Cardiac
Intravascular Vasoplegia Myocardial
Contractility
Volume Depression
In WORST Condition ..
• Is the patient in arrest or an agonal state?

appropriate
CRASH
•  If so, direct intubation without medications is

• Is the patient likely to respond to direct laryngoscopy (ie,

gag, thrash, vomit)?

airway
• If not, then the patient is unlikely to benefit from the
time required to administer sedative and paralytic
medications.
• Direct laryngoscopy, without medications, is indicated
CRASH Airway Algorithm

CRASH Airway Bag Valve

Indicated ? Mask INTUBATE
Ventilation

EXCEPTION : the patient who is unresponsive because

of a critical intracranial insult
In BETTER THAN WORST Condition ..
•Resuscitation as optimal as it can be
•Prepare for the exhaust endogenous
cathecolamine reserve condition
•To avoid Post Intubation Hypotension
(PIH)
Post Intubation Hypotension (PIH)
• a decrease in systolic blood pressure (SBP) to ≤ 90 mmHg, a decrease in
SBP of ≥ 20% from a baseline, a decrease in mean arterial pressure (MAB)
to ≤65 mmHg, or the initiation of vasopressors within the 30-min following
intubation
• Green RS. CJEM. 2012 Mar; 14(2):74-82
• A brief (</= 10 minutes) episode of hypotension was associated with
increased mortality that increased with duration of hypotension (p =
0.0001)
• Zenati. J Trauma. 2002 Aug; 53(2):232-6
• occurred in 22% of patients
• Heffner AC. J Crit Care. 2012 Dec; 27(6):587-93
Intubation Sequence in Shock Condition
1. Start correcting hypotension with fluid resuscitation and
vasopressor on the same time.
2. Start rapid-continuous monitoring
3. When the targeted MAP reached, give premedication
4. Adjust the vasopressor
5. Bag Valve Mask Assist-Ventilation with Sellick Maneuver
6. Induction
7. Laryngoscope
8. Adjust the vasopressor
Sellick’s
Manuever
Drug for Intubation in Shock
• Lidocain spray
• Midazolam 0,01-0,05 mg/kg iv
• Fentanyl 1-2 mcg/kg iv
• Ketamin 0,5-1,5 mg/kg iv titration 0,5 mg/kg
• Propofol 10% normal dosage (Avoid Propofol if could)
• Rocuronium 1,3-1,5 mg/kg iv
• Miller. Ann Emerg Med 2016
HOW TO VENTILATE
in SHOCK
• Pre-hospital endotracheal intubation in trauma patients is associated
with hypotension and decreased survival. This may be mediated by
the effect of positive pressure ventilation during hypovolemic states
HEART-LUNG INTERACTION
Positive pressure

• Rise in:
• Intrathoracic pressure
• Intra-abdominal
pressure
• Lung volumes
Normal, Venous return
• In volume-loaded patient
• ↑ intra-thoracic pressure
• ↑ intra-abdominal pressure
• Pressure gradient maintained
• Venous return constant
EDV vs EDP

EDP

EDV
Pulmonary vascular resistance
Hypoxic pulmonary vasoconstriction
In Cardiac Shock …
•Positive Pressure Ventilation will :
•Decrease LV preload
•Increased stroke volume
•Decrease LV afterload
•Decrease myocardial oxygen consumption
In other SHOCK condition…
• Positive pressure ventilation before fluid resuscitation
increases intra-thoracic pressure, and may compromise
venous return.
• Auto-PEEP, created by stacking of large, rapid breaths during
bagging of an intubated patient, may further increase intra-
thoracic pressure.
• studies have shown that pre-hospital personnel frequently
provide inadvertently high ventilatory rates, resulting in
hyperventilation
Pulmonary vascular resistance
Venous return
• In volume-depleted patient
• ↑ intra-thoracic pressure
• ↑ intra-abdominal pressure
• Venous collapse/narrowing
• Venous return obstructed/limited
 preload
So, Ventilation in shock :
•Low Tidal Volume Ventilation
•6 mL/kg IBW
•Pplat <30 mLH2O
AVOID HyperINFLATION & HyperVENTILATION

•Start RR 12 breaths/minute
•Use pulse oximetry and Blood Gas Analysis
•Adjust vasopressor
•Adjust sedation
CONCLUSION
• Intubate the shock patient when :
• Secured patent airway is impaired, or
• Oxygenation / ventilation is impaired, or
• Shock is severe
• Avoid Post-Intubation Hypotension with special
intubation maneuver
• Ventilate with Low Tidal Volume Ventilation
• Avoid Hyperinflation or Hyperventilation
MAKASE