When to intubate in CCS and MCQ's?

[Smashingdude]

Hey everyone,

Okay, so there are various criteria I see around the books of when I should intubate in CCS. Some base it on a specific ABG criteria (PaCO2>50, PaO2<60), some on Altered Mental Status. The problem with AMS is that its severity is all clinically dependent i.e a stupourus patient may still be able to maintain an airway. So when do I know I have to intubate, and shouldn't waste any time.

Please, can someone list the situations in CCS where I should intubate? And is that ABG criteria correct?

Thanks

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[Mad Jack]

A pH of less than 7.3 is usually on that list if I remember correctly. And be careful with that CO2, if you've got a CO2 of 65 but a pH of 7.39 you shouldn't be tubing someone. Dat CO2 retainer, gets people errytime.

 

[menicke]

most of the times if a patient is alert yiou can try BiPAP or CPAP before you intubate.

 

[futuredoctor10]

most of the times if a patient is alert yiou can try BiPAP or CPAP before you intubate.

How do you decide when to try BiPAP vs CPAP? (not asking for CCS as much as for clinical practice)

 

[pianoman511]

Short answer, there are no clear guidelines as to when to intubate but some good rules of thumb are GCS<8, failure to oxygenate or get rid of CO2 where bipap isn't an option or failed, or there is impending airway compromise (angioedema, infection, tumor, etc).

 

[pianoman511]

BiPAP is preferred in the hospital setting as it is better tolerated by patients because there is less pressure during exhalation. CPAP generally used prehospital.

 

[Instatewaiter]

How do you decide when to try BiPAP vs CPAP? (not asking for CCS as much as for clinical practice)

If they have the mental status to handle CPAP/Bipap, their condition is somewhat reversible and their oxygenation or CO2 are salvagable.

So if they are obtunded- tube them
If they are in say heart failure or some other reversible process and you think with some positive pressure you can get them over the hump fine. Otherwise tube them. For instance, a pneumonia is not quickly reverisble so if their trajectory is bad, you tube them.
If their PaO2 is low despite oxygen (usually around 60) or pH at or below 7.2 -tube them

 

[Instatewaiter]

BiPAP is preferred in the hospital setting as it is better tolerated by patients because there is less pressure during exhalation. CPAP generally used prehospital.

No.

Both CPAP and bipap have pressure during exhalation (ie the EPAP on bipap)

CPAP is used for oxygenation and Bipap for CO2 retention. Both are commonly used in the hospital. Both are also used outside of the hospital.

 

[pianoman511]

1) hence my use of the word of "less"

2) hence my use of "generally" (which is true, since CPAP setups are cheaper for agencies and there are disposable setups, rare to see prehospital bipap except on interfacility transfers)

 

[CaribbeanKeith]

I took the CCS portion yesterday. I did not have any cases requiring intubation. UWorld does not have any either... coincidence?