In this episode, I’ll discuss the pharmacist’s role in predicting the need for intubation.
Because of how drug delivery systems are set up in most US hospitals with medications stored in automated dispensing cabinets, there can be a considerable delay between the time a physician makes a decision to intubate a patient until the time the team is ready with medications to facilitate that intubation.
One of the most valuable things a pharmacist on a critical care team can do is to be able to predict the pharmacotherapy needs of a patient in advance, including when medications are likely to be needed in order to facilitate intubation. This will shorten the lag time between the decision to intubate and the time intubation can realistically occur.
By predicting this need in advance, calculating doses, preparing and labeling syringes, the pharmacist can also enhance medication safety and free up the rest of the care team to remain hands-on with the patient ensuring adequate pre-oxygenation, IV access, and supportive care.
Traditional training does little to prepare a pharmacist to identify a patient who needs intubation. Having some idea of a physician’s decision-making process can help let a pharmacist know what to look for to identify a patient needing intubation.
The decision to intubate is often based on clinical experience as much as it is based on objective data. Three questions are often considered to make the decision:
1. Can the patient protect their airway?
2. Can the patient adequately oxygenate?
3. What is the anticipated clinical course?
The patient’s level of consciousness, ability to swallow, and the ability to clear secretions affect whether or not they can protect their airway. Seizure, stroke, airway obstruction, and bleeding into the airway are possible examples of a patient unable to protect their airway.
Whether or not a patient can adequately oxygenate can be evaluated by looking at oxygen saturation, blood gas results, response to non-invasive respiratory support, respiratory rate, and accessory muscle use. COPD exacerbation, asthma exacerbation, and acute pulmonary edema are examples of conditions where a patient might not be able to oxygenate.
If the natural course of a patient’s disease makes it likely they will experience respiratory failure, the physician will elect to intubate the patient before they experience respiratory failure. Sepsis from pneumonia, burn victims with evidence of smoke inhalation, overdose, trauma, extreme agitation requiring high doses of sedatives, or having respiratory compromise and requiring endoscopy, bronchoscopy, operating room procedure are examples of when a patient may need to be intubated based on their expected clinical course.
By considering this information, a pharmacist can obtain needed medications in advance, calculate appropriate doses, and when the decision to intubate is made, be ready to immediately prepare the medications in a timely, efficient, and safe manner.
There is much more to the pharmacology of airway management than predicting when the patient will be intubated. Members of my Hospital Pharmacy Academy have access to my Airway Pharmacology Masterclass, where I cover paralytic and sedative choices for the 6 different types of airway scenarios, as well as how to anticipate and deal with complications related to intubation. To get immediate access to this and other practical resources for hospital pharmacists, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.