Airway & Breathing Management

Indications for intubation, NIPPV vs intubation, and crashing patient management.

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◆Immediate indications for endotracheal intubation

•Airway protection: AMS unable to protect airway (severe TCA overdose, ETOH intoxication with respiratory distress, trauma)
•Mechanical obstruction/threat: expanding neck hematoma or massive facial trauma (cricothyrotomy if standard intubation precluded)
•Smoke inhalation: prioritize transoral ETT for hoarseness, carbonaceous sputum, pharyngeal edema, or facial burns
•Pediatric epiglottitis (fever, drooling, tripod): secure airway in the OR
•Congenital diaphragmatic hernia: intubate at birth; avoid bag-mask (worsens lung compression)

•Cardiogenic pulmonary edema → diuresis + CPAP/BiPAP
•COPD exacerbation with hypercarbia + acidosis → NIPPV; intubate if NIPPV fails or AMS
•Obesity hypoventilation syndrome → BiPAP for chronic hypercapnia

•COPD: target SpO₂ 88–92% to avoid V/Q mismatch worsening and O₂-induced hypercapnia
•Severe asthma: nebulized albuterol + systemic steroids; discharge once PEF ≥80% predicted
•Flash pulmonary edema (HTN): rapid BP control + ventilatory support
•Near-drowning: hypoxia → ARDS and cerebral edema; best prognosis = return of purposeful movements

•Tension PTX: clinical dx (hypotension, tracheal deviation, absent breath sounds) → needle decompression 2nd ICS midclavicular BEFORE CXR
•Massive hemothorax: hypoxia + hypotension → tube thoracostomy
•Prolonged ventilation (>10–14 days): transition to tracheostomy

•Aspiration pneumonia prevention: intubate if airway protection lost (stroke, advanced AD, PD)
•Preoperative FEV1 < 800 mL → contraindication to lung resection
•A-a gradient: normal in hypoxic patient = hypoventilation (opioids, OHS)

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