Trauma 2004; 6: 249–254

Indications for endotracheal intubation

and ventilation
Steve Christian and Mav Manji

The ability of the emergency physician to recognize and manage a patient with a
compromised airway is probably the most important aspect of an individual’s care
in the emergency department. Endotracheal intubation in a critically ill patient is a
potentially hazardous procedure because of the technical difficulties that can be
encountered during emergency airway management and the profound pathophy-
siological changes that the institution of mechanical ventilation can cause. This
review article sets out to illustrate when invasive airway management should be
considered and the potential consequences of attempts to perform endotracheal
intubation and mechanical ventilation.

Key words: endotracheal intubation; emergency airway management; difficult

airway; mechanical ventilation

Introduction although in recent years equipment has been developed

Airway control and the maintenance of adequate
pulmonary ventilation is probably the most important
aspect in the management of patients in the accident
and emergency department. Techniques used to secure
a patient’s airway are not without their own serious
consequences, therefore difficult decisions often have
to be made as to which patient needs emergency
intervention to control a compromised airway. A wide
variety of devices have become available to assist the
emergency physician in re-establishing a patient’s air-
way, each with its own advantages and disadvantages
(Benson et al., 1996).
Endotracheal intubation, however, remains the
‘gold standard’ in securing an airway and protecting
the lungs from contamination in an emergency situa-
tion because of its proven safety record in experienced
hands. The institution of mechanical ventilation is
often directly linked to endotracheal intubation,
University Hospital Birmingham NHS Trust, Birmingham, UK.
Address for correspondence: Mav Manji, Department of Critical
Care Medicine, University Hospital Birmingham NHS Trust,
Edgbaston, Birmingham B15 2TH, UK. E-mail: mav.manji@
uhb.nhs.uk
for noninvasive ventilation using tight-fitting face
masks (Ram et al., 2003). This review article looks at
the indications for endotracheal intubation and the
institution of pulmonary ventilation.
Endotracheal intubation
In general the conditions requiring endotracheal
intubation are actual or impending (AARC Clinical
Practice Guidelines, 1995):
 Airway obstruction.
 Inability to protect airway.
 Respiratory failure.
In addition intubation of the trachea enables tra-
cheal toilet and allows control of respiratory function
by enabling mechanical ventilation to be instituted.
Airway obstruction
Airway obstruction can either be partial or complete.
Partial obstruction can be identified by stridor or
snoring, caused by turbulent gas flow in the upper
airway. Complete obstruction is silent because gas flow
is no longer occurring and is recognized by paradoxical
chest and abdominal movement to produce a see-saw

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250 S Christian and M Manji
type appearance as well as the lack of breath sounds on
auscultation of the chest. Causes of sudden airway
obstruction that may be encountered in the emergency
department include:
 Inhaled foreign body (AARC Clinical Practice
Guidelines, 1995).
 Trauma (e.g., laryngotracheal trauma, facial
trauma) (Eggen and Jorden, 1993; Thaller and
Beal, 1991).
 Upper airway burns (e.g., smoke inhalation, inges-
tion of corrosive chemicals) (Williams and Dymock,
1993).
 Infection (e.g., acute epiglottitis, retropharyngeal
abscess) (Mayo-Smith, 1993).
 Obstructive angioedema (Roy et al., 1993).
 Upper airway tumours (AARC Clinical Practice
Guidelines, 1995).
Inability to protect airway
Patients lose the ability to maintain their airway when
they become comatosed, lose their gag reflex or cease to
have the ability to cough. When the airway is no longer
protected, the patient presents an increased risk of
aspiration into the lungs of any fluid or particulate
matter that may be present in the upper airway. A large
number of conditions can precipitate the above effects,
although perhaps the most important ones seen in
everyday practise are the following:
 Drugs and toxins (Sporer, 1999).
 Traumatic head injury (Gentleman et al., 1993).
 Cerebrovascular accident (Berrouschot et al., 2000).
 CNS infection (e.g., meningitis, encephalitis).
Respiratory failure
Respiratory failure can either be relative, in respiratory
distress or complete in the form of apnoea (respiratory
arrest). Respiratory distress is often manifested by an
elevated respiratory rate, low tidal volumes, hypercap-
nia and hypoxaemia. The causes of acute respiratory
failure are too numerous to mention in full although it
is best to describe them in relation to the normal
mechanisms involved in respiration.
 Central nervous system (e.g., CVA, traumatic head
injury, spinal cord injury infection, drugs and toxins)
(Berrouschot et al., 2000).
 Peripheral nervous system (e.g., Guillain-Barré syn-
drome) (Sharshar et al., 2003).
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 Neuromuscular junction (e.g., drugs acting on
the neuromuscular junction, organophosphates,
myasthenia gravis) (Varelas et al., 2002).
 Chest wall and pleurae (e.g., flail chest, haemo-
thorax, pleural effusion, myopathies) (Bach et al.,
1997).
 Lungs and airways (e.g., pneumonia, pulmonary
oedema, asthma, COPD, pulmonary embolism)
(Zimmerman et al., 1993; Adnet et al., 2001).
When to intubate?
The judgement of when to perform endotracheal
intubation can either be straightforward or extremely
difficult, depending on the cause of airway compro-
mise, the severity of respiratory failure and the general
state of the patient. One of the few guidelines pub-
lished, indicating specifically when to intubate a
patient concerns those with acute traumatic head
injury (Gentleman et al., 1993). The advice on when
to intubate differs depending upon whether the patient
is about to be transferred to another site or to an
isolated area of the hospital such as the radiology
department. There is a much lower threshold for
intubating patients if a transfer is planned. The pur-
pose behind this is to minimize the risk of having to
intubate a patient during a transfer, in the less than
ideal conditions that this situation may involve.
Indications for immediate intubation and ventilation
following a head injury
 Coma (GCS  8).
 Loss of protective laryngeal reflexes.
 Ventilatory insufficiency:
 PaO2 < 9 KPa on air or <13 KPa on oxygen;
 PaCO2 > 6 Kpa.
 Spontaneous hyperventilation to a PaCO2 < 3.5 KPa.
 Respiratory arrhythmias.
Indication for intubation and ventilation
prior to transfer
 Significantly deteriorating conscious level, even if
not in coma.
 Bilaterally fractured mandible.
 Copious bleeding into mouth.
 Seizures.
A senior physician who has adequate experience in
the technique of intubation should ideally decide when

this technique should be instituted. This is particularly
important because a relatively high number of the
endotracheal intubations undertaken in the emergency
department are difficult, even if the need to secure the
airway is obvious. A recently published study illustrated
this point by reporting an incidence of difficult intuba-
tion of 3–5.3% in English emergency departments
(Morton et al., 2000). The reasons why intubation is
challenging in the emergency department are plentiful.
Emergency patients often have a full stomach, are
uncooperative, haemodynamically unstable and may
have traumatic damage to the upper airway. All of
these factors can make the induction of anaesthesia,
which is necessary to facilitate endotracheal intubation
in all but the most deeply comatosed patients, a
hazardous procedure. The risk of being unable to
secure the airway and being unable to ventilate a
patient in the emergency department is significantly
higher than in a theatre environment (Nolan and Clancy,
2002). Complications of intubation are numerous;
however, serious complications are fortunately rare
in experienced hands. This list represents some
of the more common and most serious immediate
complications seen in intubated patients.
 Failure to establish an airway (Shwartz et al., 1995).
 Failure to intubate the trachea (Shwartz et al., 1995).
 Failure to recognize failed intubation (Shwartz et al.,
1995).
 Pulmonary aspiration (Shwartz et al., 1995).
 Hypertension and tachycardia (Kihara et al., 2003).
 Hypotension and bradycardia due to vagal stimula-
tion (Winston et al., 1987).
 Dental damage (Butron and Baker, 1987).
 Cervical spine trauma (Muckart et al., 1997).
 Laryngeal trauma (Usui et al., 2001).
 Pneumonia (Montravers et al., 2002).
 Increased intracranial pressure.
Difficult intubation
A wide variety of scoring systems and tests have been
developed to determine on which patients it is likely to
be difficult to perform direct laryngoscopy and endo-
tracheal intubation (Cormack and Lehane, 1984).
Although many of these tests are highly sensitive, the
specificity is generally poor. Clinical features that
would indicate direct laryngoscopy may be difficult
include a receding mandible, prominent maxillary
incisors, short neck, reduced neck movement and a
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Endotracheal intubation and ventilation 251
variety of conditons that involve deformities of the
upper airway (e.g., large thyroid goitre) (AARC Clinical
Practice Guidelines, 1995). In managing the airway it
is vital to have a plan B and a plan C, if plan A fails to
secure the airway. Many ‘failed intubation drills’ and
difficult airway algorithms have been published to
provide a plan of action in the event of being unable
to secure the airway (Tunstall, 1976; ASA, 1993).
Management of the predicted difficult airway in the
operating department will often involve the use of
awake fibre-optic intubation in the first instance.
This is often not a practical proposition for patients
in the emergency department because they are often
hypoxic and confused, making it difficult to control the
patient and anaesthetise the upper airway within a
short period of time. There may also be copious
blood in the airway making visualization of the larynx
impossible.
Other techniques that have been described to secure
an airway when direct laryngoscopy and endotracheal
intubation are not possible include the insertion of a
combitube airway, cricothyroidotomy, percutaneous
tracheostomy and surgical tracheostomy (Morton
et al., 2000). Despite all of these methods to create a
definitive airway, it has to be remembered that the
priority is always to ventilate the patient. Methods to
maintain ventilation without protecting the airway
from contamination include bag and mask ventilation
(with or without an oropharngeal or nasopharyngeal
airway) and the insertion of a laryngeal mask airway.
The beneficial effects of ventilation are often sec-
ondary to a significant reduction in oxygen consump-
tion. Ventilation decreases the work of breathing and is
effective at reducing respiratory muscle exhaustion.
The options available to the physician managing a
patient who is unable to protect his airway are simple.
The patient should be woken up where possible, for
example, administering naloxone to a patient with an
opioid overdose (Sporer, 1999). If this is not possible it
is essential to protect the patient’s lungs from aspira-
tion by means of a definitive airway, usually with
endotracheal intubation. In a patient with upper air-
way obstructions the choices are similar. Either the
obstruction is removed or a definitive airway is made.
Patients who are awake, able to protect their own
airway but present to the emergency department with
acute respiratory failure may not need intubation in
order to be ventilated. For quite some time, patients
with exacerbations of COPD have been successfully
treated with noninvasive ventilation (NIV) via a tight
fitting facemask (Ram et al., 2003; Plant et al., 2000).
Trauma 2004; 6: 249–254
252 S Christian and M Manji

This has resulted in a significant reduction in the

number of patients from this particular group requir-
ing endotracheal intubation. The advantage of this
technique is that the normal anatomy of the upper
airway is maintained and the patients subsequently
have lower incidences of nosocomial pneumonia,
shorter intensive stays and improved outcome (Ram
et al., 2003). It has become clear that other groups of
patients who present with respiratory failure may
benefit from NIV although the results of trials in
these patients has been less encouraging. In our opi- Figure 1 Intrapleural pressure and ventilation in
nion it would be reasonable to attempt a trial of NIV upright lung
on a patient with respiratory distress in the emergency
department who is awake, cooperative and able to
maintain their own airway. pressure are greatest in the dependent areas making
In an ideal situation endotracheal intubation and this part most compliant and hence causing it to receive
conventional ventilation should be instituted by a the most ventilation.
senior physician, experienced in the technique, who Similarly, blood flow is also unevenly distributed,
will subsequently take over the patients continuing mainly influenced by gravitational forces. The lungs
care (almost invariably on the intensive care unit). can be divided into arbitrary zones in order to under-
Following this guideline helps ensure the appropriate- stand the effect of gravity and influence of alveolar
ness of ventilation for the each individual patient and pressure on the blood flow (Figure 2).
also guarantees an adequate level of competence from The upper region of the lungs (zone I) may receive
the physician performing these potentially dangerous very little blood as alveolar pressure may exceed arterial
interventions. The main problem adhering to this and venous pressures. Zone II lung arterial pressure is
policy is that in UK hospitals, an experienced anaes- greater than the alveolar pressure which in turn is greater
thetist may not be available (Walker and Brenchley, than the venous pressure. Blood flow is thus dependent
2000), which has led to an increase in emergency on alveolar pressure. In zone III, both arterial and
department staff performing endotracheal intubation. venous pressures exceed alveolar pressure and it
This is in line with other developed countries such as is in this region that the best alveolar blood flow is seen.
the USA and Australia where emergency physicians In zone IV, the interstitial pressure may physically
undertake most of the tracheal intubations in the compress arterioles and reduce the blood flow.
emergency department (Nolan and Clancy, 2002). In a state of low cardiac output, blood flow can
almost cease in zone I. This is due to a decrease in
pulmonary artery pressure whilst the alveolar pressure
Pathophysiological consequences of remains unaffected, effectively increasing dead space.
mechanical ventilation
Achieving a ventilation=perfusion balance
Each lung unit consists of approximately 150 million
alveoli, which are ventilated according to their posi-
tion on the pressure-volume curve (Figure 1). Trans-
pulmonary pressure is defined as airway pressure
minus pleural pressure. The dependent regions of
the lungs are subject to a lower transpulmonary
pressure. This region is therefore positioned on the
lower steeper part of the pressure–volume curve.
When a negative intrathoracic pressure is generated
during normal spontaneous ventilation, the transpul-
monary pressure is increased to an equal extent all Figure 2 Distribution of pulmonary blood flow in the
over the lungs. Thus the changes in transpulmonary zone model of the lung

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The change from normal breathing to mechanical
ventilation can cause profound alterations in respira-
tory physiology. Ventilated patients are typically
nursed in a supine position, which results in a decrease
in total lung volume and functional residual capacity
(Figure 3).
Closing capacity encroaches on tidal ventilation
meaning airways start to close during normal ventila-
tion (Figure 3). This effect causes an increase in the
amount of physiological shunting and potentially a
worsening hypoxaemia. Mechanical ventilation can
also adversely affect ventilation=perfusion matching
because ventilation occurs predominantly in non-
dependent areas whereas blood flow is concentrated
in dependent regions.
Cardiovascular changes are extremely common
when a patient is initially placed on a ventilator and
these are predominantly caused by an increase in
intrathoracic pressure leading to a reduction in venous
return to the heart. This reduction in ‘preload’ can
cause a dramatic reduction in cardiac output leading to
profound hypotension, especially in a patient who is
hypovolaemic before ventilation is instituted. These
changes may cause a paradoxical increase in cardiac
output in patients with heart failure due to a beneficial
instant reduction in preload.
Mechanical ventilation should not be taken lightly
as elevated intrathoracic pressure affects regional
haemodynamics and may lead to dysfunction of
further organs. These are due to a combination of
factors;
 Up to 30% reduction in cardiac output and systemic
arterial pressure.
Figure 3 Relationship of FRC=age=position=closing
volume
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Endotracheal intubation and ventilation 253
 Increase in intrathoracic pressure leading to impair-
ment of venous return and elevation of venous
pressure.
 Shearing injury may leading to modification of local
vasoactive status.
Conclusions
It is clear that endotracheal intubation and ventilation
are important skills in the management of critically ill
patients in the emergency department. The manage-
ment of patients requiring these advanced airway skills
requires an adequate understanding of the potential
benefits as well as the pitfalls that we occasionally
observe with these techniques. We believe it is essential
that physicians who decide to perform endotracheal
intubation in the emergency department retain an
insight into their own skill levels and act within their
own limitations to avoid the potentially disastrous
consequences of failed airway management. Perhaps
the most important message from this review is to
recognize the symptoms and signs of airway compro-
mise and respiratory failure rapidly, then to request
experienced assistance early if there is any doubt as to
whether these problems can be rectified.
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