Tracheal intubation and mechanical ventilation

Impending cardiorespiratory arrest is indicated by profound hypoxaemia on disconnection from oxygen or NIV, significant hypotension, or an altered mental state. Immediate intubation may then be required. As cardiovascular collapse is common after intubation, transfer of the spontaneously breathing patient to the ICU may, however, be safer. Collapse arises from a combination of reduced venous return secondary to positive intrathoracic pressure, and direct vasodilation and reduced sympathetic tone induced by sedative agents. Before intubation pre-oxygenation is essential. Intubation with the rapid sequence induction and cricoid pressure to reduce the risk of aspiration should ideally be performed by an experienced clinician. Suxamethonium is classically used for muscle relaxation as its short effect makes it safer in the event of a failure to intubate. Concerns about hyperkalaemic cardiac arrest31 have led to the increased use of short acting non-depolarising agents such as rocuronium. Doubts about the effectiveness of cricoid pressure in preventing aspiration32 have also resulted in a move to "head up" non-paralytic intubation. This is a high risk period in which profound hypotension may result in cardiac arrhythmia or arrest. Unless hypotension resolves rapidly with fluid replacement, cardiac tamponade induced by hyperinflation (bagging) should be suspected. In these circumstances, temporary disconnection of the endotracheal tube from positive pressure will lead to a return in cardiac output.

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