Post-Intubation Management

Quick Answer

Immediate post-intubation management requires systematic verification of correct ETT placement, secure fixation, and initiation of appropriate ventilation. Confirm tube position by checking bilateral chest wall movement, ausculating for equal breath sounds, and verifying ETT fogging with exhalation. Secure the ETT with commercial tube holder, check cuff pressure (20-25 cmH2O), and obtain CXR to confirm position. Initiate appropriate ventilator settings (PCV or VCV), provide sedation (propofol 50-150 mcg/kg/min) and analgesia (fentanyl 1-3 mcg/kg), and consider paralysis only for specific indications. Monitor continuously with ECG, SpO2, EtCO2, and respiratory mechanics. Anticipate and manage complications including pneumothorax, ETT displacement, and gastric distension.

ACEM Exam Focus

Primary Written: Know mechanisms of ventilator-induced lung injury, pharmacology of sedatives and analgesics, and indications for different ventilation modes.

Primary Viva: Anatomy of airway, effects of PEEP on hemodynamics, pharmacology of intubation drugs.

Fellowship Written: Systematic approach to post-intubation management, interpretation of ventilator waveforms, complication recognition.

Fellowship OSCE: Leadership of post-intubation care, team communication, emergency complication management.

Key Points

• Confirm ETT position via auscultation, EtCO2, and CXR before securing
• Cuff pressure should be 20-25 cmH2O to prevent tracheal injury while preventing leak
• Initial FiO2 1.0 titrated to SpO2 94-98% in adult patients
• PEEP 5 cmH2O is standard starting point, adjust per compliance
• Provide sedation before paralysis; ketamine or propofol preferred
• Analgesia with fentanyl or morphine is mandatory unless contraindicated
• Paralysis only for specific indications (e.g., ARDS, severe hypoxia)
• Monitor for pneumothorax, especially in high-risk patients
• Document ETT position at teeth or gums in centimeters
• Reassess position after patient movement

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Clinical Overview

Post-intubation management represents a critical period in emergency airway care where systematic attention to tube verification, appropriate ventilation, analgesia and sedation, and early complication recognition determines patient outcomes. Complications arising during this period contribute significantly to mortality in ED intubation cases (Ref 1). The immediate post-intubation phase requires coordinated assessment and intervention within the first 10-15 minutes following intubation.

Epidemiology: Approximately 10-15% of ED intubations require immediate post-intubation intervention due to unrecognized problems (Ref 2). Studies show 5-10% mortality associated with post-intubation complications when not promptly recognized (Ref 3), with esophageal intubation and right mainstem bronchus intubation being the most common placement errors (Ref 4).

Risk Factors: Emergency compared to elective intubation carries higher complication rates, particularly in obese patients (BMI greater than 35), those with difficult airway features, and patients with pre-existing respiratory disease (Ref 5). Rapid sequence intubation in the out-of-hospital setting has higher rates of malposition requiring correction (Ref 6).

Pathophysiology

Tube Malposition

Esophageal Intubation: Tube placed in esophagus rather than trachea. May be undetected if auscultation reveals transmitted sounds from stomach. Capnography is the most reliable detection method (Ref 7). Esophageal placement results in complete absence of ventilation and rapid deterioration.

Right Mainstem Bronchus Intubation: Tube advanced too far, entering right main bronchus. Results in ventilation of right lung only, left lung collapse, hypoxia despite adequate movement on right side (Ref 8). Occurs in 15-20% of intubations when position not checked (Ref 9).

Endobronchial Intubation: Tube tip enters bronchus, causing atelectasis of contralateral lung. May occur after initial correct placement if patient moves, tape loosens, or neck position changes (Ref 10).

Ventilator-Associated Complications

Ventilator-Induced Lung Injury (VILI): Barotrauma from high peak pressures or volumes causing alveolar rupture, pneumothorax, and pneumomediastinum. Volutrauma from excessive tidal volumes (Ref 11). Most common in patients with non-compliant lungs (ARDS, pulmonary edema).

Auto-PEEP: Incomplete exhalation between breaths causing air trapping and progressive hyperinflation. Results in decreased cardiac output, increased intracranial pressure, and barotrauma risk (Ref 12). Characteristic finding: sustained inspiratory pressure at end of exhalation on ventilator graphic.

Mucosal Injury: Excessive cuff pressure (greater than 30 cmH2O) causes tracheal mucosal ischemia. Long-term complication: tracheal stenosis or tracheoesophageal fistula (Ref 13).

Gastric Distension: Uncuffed tubes or excessive cuff pressure causing air into stomach, increasing aspiration risk (Ref 14).

Clinical Consequences

• Hypoxia from inadequate ventilation, atelectasis, or shunt
• Hypercapnia from hypoventilation or increased dead space
• Hemodynamic compromise from PEEP reducing venous return
• Barotrauma leading to pneumothorax
• Tracheal injury from cuff overinflation
• Aspiration from compromised airway protection
• Increased intracranial pressure from hypercapnia or auto-PEEP

Clinical Approach

Immediate Post-Intubation (Minutes 0-5)

Step 1: Confirmation of Placement

1. Direct Visualization: Confirm tube passing through vocal cords during laryngoscopy (gold standard)
2. Capnography: EtCO2 detection required for confirmation. Waveform capnography is essential (Ref 15)
   • Normal EtCO2: 35-45 mmHg
   • Absent or low EtCO2 suggests esophageal placement
3. Auscultation: Bilateral equal breath sounds, absent gastric sounds
4. Visual Confirmation: Chest wall movement bilaterally
5. ETT Fogging: Moisture appearing within tube with exhalation
6. Suction Catheter: Pass suction catheter, should pass without resistance (Ref 16)

Step 2: Secure the ETT

1. Commercial Tube Holder: Preferred over tape (more secure)
2. Documentation: Record ETT position at teeth/gums in centimeters
3. Restraint: Ensure patient unable to dislodge tube
4. Fixation: Prevent rotation or movement

Step 3: Initial Ventilator Settings

Step 4: Cuff Pressure

• Target: 20-25 cmH2O
• Check: Manual cuff manometer within 5 minutes
• Frequency: Recheck every 4-6 hours
• Complications if greater than 30 cmH2O: Tracheal mucosal ischemia, necrosis, stricture (Ref 17)

Step 5: Radiological Confirmation

• CXR: Within 30 minutes to confirm tip position above carina
• Distance: 2-4 cm above carina ideal
• Equal: Verify bilateral lung expansion, rule out pneumothorax

Early Management (Minutes 5-30)

Sedation Initiation

• Propofol: 50-150 mcg/kg/min infusion (Ref 18)

  • "Onset: 30-60 seconds"
  • "Advantages: Rapid, titratable, wakeful within minutes"
  • "Contraindications: Hypotension, hemodynamic instability"

• Ketamine: 0.5-1 mg/kg bolus, then 0.1-0.3 mg/kg/hr infusion (Ref 19)

  • "Advantages: Bronchodilation, hemodynamic stability"
  • "Contraindications: Psychosis, increased intracranial pressure"

• Midazolam: 0.02-0.1 mg/kg bolus, then 0.02-0.1 mg/kg/hr infusion (Ref 20)

  • "Advantages: Amnestic, synergistic with other agents"
  • "Contraindications: Liver failure, prolonged infusion risk"

• Etomidate: 0.2-0.3 mg/kg bolus (Ref 21)

  • "Warning: Single dose only; repeated bolus causes adrenal suppression"
  • "Consider: Short procedures only"

Analgesia (MANDATORY)

• Fentanyl: 1-3 mcg/kg bolus, then 25-100 mcg/hr infusion (Ref 22)

  • "Advantages: Hemodynamic stability, rapid onset"
  • "Cautions: Respiratory depression (if sedation inadequate)"

• Morphine: 0.1-0.2 mg/kg bolus, then 2-5 mg/hr infusion (Ref 23)

  • "Advantages: Familiar, inexpensive"
  • "Cautions: Histamine release, hypotension"

• Remifentanil: 0.05-0.15 mcg/kg/min infusion (Ref 24)

  • "Advantages: Ultra-short acting, titratable"
  • "Contraindications: Not first-line in ED"

Paralysis (CONSIDERED)

Indications for paralysis (paralytics):

• ARDS (lung-protective ventilation requires synchrony)
• Refractory hypoxia
• Patient-ventilator dyssynchrony
• Airway protection during procedures

Agents:

• Rocuronium: 0.6-1 mg/kg bolus every 30-60 min (Ref 25)
• Vecuronium: 0.1 mg/kg bolus every 60-90 min (Ref 26)
• Cisatracurium: 0.15-0.2 mg/kg bolus, then 0.1-0.2 mg/kg/hr infusion (Ref 27)

Monitoring Requirements

Continuous monitoring: ECG, SpO2, EtCO2, blood pressure every 5 minutes initially Ventilator waveforms: Peak pressure, plateau pressure, tidal volume, compliance labs: ABG 15-30 minutes post-intubation, then as clinically indicated

Investigations

Immediate

Radiology

1. CXR (portable): Within 30 minutes

   • ETT tip position: 2-4 cm above carina
   • Pneumothorax or pneumomediastinum
   • Pulmonary edema, consolidation
   • Gastric distension (Ref 28)

2. Cervical Spine XR: If trauma (if not already obtained)

   • Exclude cervical spine injury with airway manipulation

Blood Tests

1. Arterial Blood Gas: 15-30 minutes after ventilator initiation

   • pH: 7.35-7.45
   • PaCO2: 35-45 mmHg
   • PaO2: 80-100 mmHg on FiO2 ≤0.4 (ideal)
   • HCO3-: 22-26 mmol/L
   • Base deficit: -2 to +2 mmol/L

2. Standard Bloods: CBC, electrolytes, creatinine, LFTs, coagulation

   • Baseline for ongoing management

3. Lactate: 0-2 mmol/L

   • Markers of tissue perfusion

4. Chronic Medications: Consider holding certain meds (e.g., ACE inhibitors)

Ongoing

Ventilator Waveforms: Observe for

• Pressure-volume relationship
• Flow-volume loops
• Auto-PEEP detection
• Patient-ventilator asynchrony

Chest Examinations: Every 2 hours

• Bilateral air entry
• Chest wall movement symmetry
• Subcutaneous emphysema
• Surgical emphysema

Repeat CXR: If clinical deterioration or change in ventilator settings

Differential Diagnosis of Post-Intubation Hypoxia

Airway Problems

• ETT malposition: Right mainstem, esophageal
• ETT obstruction: Secretions, blood, kinking
• ETT displacement: Migration out of trachea or into bronchus
• Cuff leak: Inadequate seal

Breathing Problems

• Pneumothorax (iatrogenic or underlying)
• Pulmonary edema (negative pressure pulmonary edema)
• Mucus plugging
• Aspiration
• Atelectasis from inadequate PEEP

Circulation Problems

• Pulmonary embolism
• Massive hemothorax
• Cardiac tamponade (rare post-intubation)

Equipment Problems

• Ventilator malfunction
• Circuit disconnection
• Oxygen failure
• Humidifier dysfunction

Management

Immediate Complications Management

Tube Malposition

Suspected Esophageal Intubation

1. Remove ETT immediately
2. Provide bag-mask ventilation with O2
3. Re-establish airway with alternative plan
4. RSI with video laryngoscopy recommended (Ref 29)

Suspected Right Mainstem Intubation

1. Withdraw ETT 1-2 cm while observing chest wall movement
2. Re-auscultate bilaterally
3. Reconfirm with CXR
4. Retape and document new position

Suspected ETT Displacement

1. Immediately auscultate both lung fields
2. Check capnography waveform
3. Pass suction catheter
4. If unclear, remove and re-intubate (Ref 30)

Pneumothorax

Suspected Iatrogenic Pneumothorax

1. Recognize signs: Sudden hypoxia, unilateral decreased breath sounds, hyperresonance
2. Obtain immediate bedside ultrasound (BLUE protocol) if available
3. Decompress if tension: Needle thoracentesis second intercostal space midclavicular (2-3 cm)
4. Definitive: Chest tube (size 28-32Fr) (Ref 31)
5. Confirm with CXR post-decompression

Negative Pressure Pulmonary Edema

1. Upper airway obstruction with forceful inspiration against closed glottis
2. Presents with frothy pink sputum, hypoxia
3. Management: CPAP/PEEP (5-10 cmH2O)
4. Diuretics not primary treatment
5. Consider furosemide 40mg IV if fluid overloaded (Ref 32)

Ongoing Ventilator Management

Mode Selection

PCV (Pressure-Controlled Ventilation)

• Advantages: Fixed pressure limiting barotrauma, tidal volume varies with compliance
• Preferred: ARDS, high airway pressures, poor compliance (Ref 33)
• Settings: Pressure above PEEP 15-20 cmH2O, I:E 1:2, rate 12-16

VCV (Volume-Controlled Ventilation)

• Advantages: Guaranteed tidal volume, predictable minute ventilation
• Preferred: Lung-protective strategies requiring specific tidal volumes (Ref 34)
• Settings: Tidal volume 6-8 mL/kg predicted body weight, rate 12-16

Adjusting Ventilator Settings

Hypoxia (SpO2 below 94%)

1. Increase FiO2 in increments of 0.1
2. Increase PEEP to 8-10 cmH2O
3. Consider recruitment maneuvers (if expertise available)
4. Exclude pneumothorax, mainstem intubation

Hypercapnia (PaCO2 greater than 45 mmHg)

1. Increase respiratory rate (first line)
2. Decrease I:E ratio (exhalation time)
3. Decrease tidal volume (if greater than 6-8 mL/kg)
4. Check for auto-PEEP
5. Consider permissive hypercapnia if lung-protective (ARDS)

Hypocapnia (PaCO2 below 35 mmHg)

1. Decrease respiratory rate
2. Increase tidal volume (if below 6 mL/kg and tolerated)
3. Auto-PEEP: Assess for auto-PEEP first (Ref 35)

Auto-PEEP Detection and Management

1. Recognition: Sustained pressure at end-exhalation, progressive pressure increase
2. Measurement: Expiratory hold maneuver
3. Management:
   • Decrease respiratory rate
   • Decrease inspiratory time (increase expiratory time)
   • Increase suctioning
   • Treat bronchospasm (salbutamol + ipratropium)
   • Decrease PEEP transiently

Analgesia and Sedation Titrations

Target RASS (Richmond Agitation-Sedation Scale): 0 to -1

• Sedation: RASS -1 to -2
• Over-sedation: RASS < -3 (prolonged ventilator days)

Daily Analgesia and Sedation Interruptions

1. Stop sedation daily at 08:00
2. Assess neurologic status
3. Spontaneous breathing trial (if meets criteria)
4. Resume infusions at 50% previous rate

Failure to Wake

1. Consider metabolic causes (hypoglycemia, hepatic failure)
2. Consider ongoing drug effects (propofol infusion greater than 72h)
3. Assess for neurologic injury (stroke, intracranial bleed)
4. Perform sedation holiday (stop all sedatives) (Ref 36)

Extubation Readiness

Criteria

• Hemodynamically stable (SBP greater than 90, vasopressors minimal)
• Adequate oxygenation (PaO2/FiO2 ≥200 on FiO2 ≤0.4, PEEP ≤5)
• Adequate ventilation (spontaneous tidal volume greater than 5cc/kg)
• Neurologic: GCS improvement, purposeful movement
• Minimal secretions (below 2 suction/hr)
• Awake and following commands

Procedure

1. Ensure NIBPR (nothing by mouth) for 4-6 hours
2. Consider steroid (hydrocortisone) if high-risk of edema
3. Cuff leak test (if prolonged intubation greater than 48h)
4. Extubate to HFNC (high-flow nasal cannula) or NIV (for selected indications)

Disposition

ICU Admission Criteria

• Prolonged ventilation anticipated (greater than 24h)
• Hemodynamic instability requiring vasopressors
• Severe ARDS (PaO2/FiO2 below 150)
• Multi-organ failure
• Ongoing sedation requirement after initial stabilization
• Complex airway (repeated intubations anticipated)

ED Admission Criteria

• Anticipated extubation within 6-24h
• Monitoring required but not ICU level
• Step-down availability (ED observation unit)

Immediate Discharge (Rare)

Only if:

• Rapid sequence for short procedure
• Patient awakens quickly, meets extubation criteria
• Suitable discharge location with appropriate monitoring

Pitfalls & Pearls

Common Mistakes

Failure to Verify ETT Position Before Securing

• Pear: Always confirm with bilateral auscultation AND capnography
• Capnography waveform is gold standard (colorimetric detectors insufficient)

Cuff Pressure Not Checked

• Pear: Cuff pressure must be checked with manometer within 5 minutes
• Overinflation causes tracheal injury; underinflation causes leak

Paralysis Without Sedation

• Pear: Paralytics have NO amnestic or analgesic properties
• Awake paralysis is extremely distressing and unacceptable

Neglecting Analgesia

• Pear: Trauma patients especially require aggressive analgesia
• Analgesia first, sedation second, paralysis third

Failure to Recognize Auto-PEEP

• Pear: Patient-ventilator dyssynchrony, progressive pressure spikes
• Treat by decreasing rate, increasing exhalation time

ETT Migration After Initial Correct Placement

• Pear: Recheck position after patient movement, turning, procedures

Premature Extubation

• Pear: Extubation criteria ALL must be met
• Failed extubation worse than prolonged ventilation

Inadequate PEEP

• Pear: PEEP 5 cmH2O baseline prevents atelectasis
• Consider higher in obesity (10-15 cmH2O)

Over-Sedation

• Pear: Target RASS 0 to -1
• Over-sedation prolongs ventilation, increases complications

Expert Tips

1. Use video laryngoscopy for difficult airways: Superior visualization, improved first-pass success (Ref 37)

2. Cricoid force: Routine rapid sequence cricoid force controversial; evidence does not show improved outcomes (Ref 38)

3. Suction before and after intubation: Prevent secretion aspiration, improve visualization

4. Document ETT position at teeth AND gums: More accurate if teeth lost

5. Consider ETT size carefully: 7.5-8.0mm for men, 7.0-7.5mm for women (Ref 39)

6. Avoid neck rotation: ETT movement up to 4cm with head turning; maintain neutral position

7. CO2 detectors: Colorimetric devices can provide false positives; waveform capnography mandatory (Ref 40)

8. PEEP in obesity: Higher PEEP (10-15 cmH2O) counteracts decreased FRC

9. Auto-PEEP detection: Expiratory hold maneuver every 4-6 hours or if clinical suspicion

10. Daily sedation interruption: Improves ventilation days, ICU length of stay (Ref 41)

11. Early mobilization: If hemodynamically stable, improves outcomes (Ref 42)

12. Family communication: Explain intubation necessity, ongoing plan, expected timeline

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Viva Practice

Viva 1: Immediate Post-Intubation Assessment

Stem: A 62-year-old male with COPD exacerbation undergoes rapid sequence intubation for respiratory failure. You are called to assist with post-intubation management.

Q1: What are the immediate priorities in post-intubation management?

Model Answer:

1. Confirm ETT placement using capnography waveform (gold standard)
2. Auscultate bilateral lung fields and confirm equal breath sounds
3. Secure the ETT (commercial holder preferred)
4. Initiate appropriate ventilator settings
5. Check cuff pressure with manometer (20-25 cmH2O)
6. Obtain CXR within 30 minutes for radiological confirmation
7. Initiate analgesia and sedation

Q2: What would be appropriate initial ventilator settings?

Model Answer:

• Mode: PCV or VCV (clinician preference)
• Respiratory rate: 12-16 breaths/min
• Tidal volume (if VCV): 6-8 mL/kg predicted body weight
• Pressure (if PCV): 15-20 cmH2O above PEEP
• FiO2: 1.0 initially, titrate to SpO2 94-98%
• PEEP: 5 cmH2O baseline
• I:E ratio: 1:2 to 1:3

Q3: How would you select sedation and analgesia medications for this patient?

Model Answer: Analgesia (MANDATORY FIRST):

• Fentanyl 1-3 mcg/kg IV bolus, then 25-100 mcg/hr infusion
• Reason: Hemodynamic stability, minimal histamine release (important in COPD)

Sedation:

• Propofol 50-150 mcg/kg/min infusion
• Contra-indications in this patient: Check hemodynamics (respiratory failure patients may be hypotensive)
• If hypotension: Consider ketamine 0.5-1 mg/kg bolus then 0.1-0.3 mg/kg/hr infusion (maintains hemodynamic stability, bronchodilation)

Paralysis:

• Indicated: Patient-ventilator dyssynchrony, refractory hypoxia
• NOT indicated routinely
• Agent: Rocuronium 0.6-1 mg/kg bolus if needed

Q4: What complications should you anticipate after intubation this patient?

Model Answer:

1. Pneumothorax: Higher risk due to barotrauma in COPD, previous bullous disease
2. Dynamic hyperinflation/auto-PEEP: Due to air trapping, intrinsic PEEP
3. Hypotension: Reduced venous return from positive pressure ventilation
4. Gastric distension: From prior bag-mask ventilation difficulty
5. ETT displacement: Higher risk if difficult airway, multiple attempts
6. ** aspiration**: Prior reflux before intubation
7. Cardiac arrhythmias: Sympathetic activation from intubation

Q5: How would you manage auto-PEEP if recognized?

Model Answer:

1. Recognition: Sustained pressure at end-exhalation, patient triggering, progressive pressure increase
2. Confirm with expiratory hold maneuver
3. Management:
   • Decrease respiratory rate
   • Increase exhalation time (decrease I:E ratio)
   • Decrease inspiratory time
   • Treat bronchospasm (nebulized salbutamol + ipratropium)
   • Decrease PEEP transiently
   • Increase suctioning
4. If severe: Consider disconnecting from ventilator briefly to allow full exhalation
5. Monitor for barotrauma, hemodynamic compromise

Viva 2: Complications and Management

Stem: A 28-year-old female intubated for anaphylactic reaction develops acute hypoxia (SpO2 82%) 20 minutes post-intubation. She is on PCV mode with FiO2 1.0, PEEP 5 cmH2O.

Q1: What is your immediate approach to acute post-intubation hypoxia?

Model Answer:

1. Assess ABC: Airway, Breathing, Circulation
2. Examine ETT: Patency, position, cuff leak
3. Auscultate: Bilateral breath sounds, presence of gastric sounds
4. Check ventilator: Disconnection, disconnection alarm, proper settings
5. Consider complications: Pneumothorax, ETT displacement, mainstem intubation
6. Review history: High-risk factors (young, possible difficult airway)
7. Immediate interventions based on findings

Q2: What specific examination findings would suggest ETT malposition?

Model Answer:

• Esophageal intubation: Absent breath sounds bilateral, presence of gastric sounds, absent EtCO2 waveform, worsening hypoxia despite ventilation
• Right mainstem intubation: Loud right-sided breath sounds, diminished or absent left-sided breath sounds, possible hyperresonance left-sided
• ETT displacement: Unilateral decreased breath sounds, sudden hypoxia, difficulty passing suction catheter

Q3: How would you manage suspected pneumothorax in this scenario?

Model Answer:

1. Recognition: Sudden hypoxia, unilateral decreased breath sounds, hyperresonance, hemodynamic instability if tension
2. Immediate bedside ultrasound if available (Lung sliding absent, lung point)
3. Tension pneumothorax: Immediate needle thromacentesis
   • Location: Second intercostal space, midclavicular line
   • Needle: 14-16 gauge, 2-3 cm length
4. Chest tube: Size 28-32Fr, lateral approach (4th-5th intercostal, anterior axillary line)
5. Confirm with CXR post-decompression
6. Mechanical ventilation: Consider pressure-limited mode (PCV), lower tidal volumes

Q4: This patient has possible negative pressure pulmonary edema due to upper airway obstruction before intubation. What clinical features would you expect and how would you manage?

Model Answer: Clinical Features:

• Pink frothy sputum
• Hypoxia requiring high FiO2 and PEEP
• Crackles bilateral or unilateral
• History of stridor prior to intubation

Management:

1. Mainstay: CPAP/PEEP (increase to 8-10 cmH2O)
2. Diuretics NOT primary treatment (not cardiogenic pulmonary edema)
3. Consider furosemide 40mg IV if concurrent pulmonary edema from other causes
4. Supportive care: Monitor for worsening respiratory failure
5. Consider furosemide 40-80mg IV if signs of pulmonary edema: Bibasilar crackles, hypoxia, increased PEEP requirement greater than 10 cmH2O

Q5: This patient is known to have penicillin allergy requiring intubation for anaphylaxis. What special considerations regarding sedation and analgesia?

Model Answer: Medication Considerations:

• Avoid morphine: Histamine release, possible cross-reactivity in penicillin-allergic patients
• Preferred analgesia: Fentanyl (minimal histamine release)
• Sedation: Propofol preferred (no histamine release)
• Avoid succinylcholine if used: Not relevant unless paralytics needed; rocuronium preferred

Management:

• Document medication allergy clearly
• Pre-position epinephrine
• Monitor for anaphylaxis recurrence
• Consider steroid after stabilization (methylprednisolone 1-2 mg/kg)

Viva 3: Long-term Ventilation and Extubation

Stem: A 45-year- old male with severe COVID-19 pneumonia intubated 3 days ago remains ventilated. You are asked to assess extubation readiness.

Q1: What are the criteria for extubation readiness?

Model Answer: Hemodynamic:

• Hemodynamically stable (SBP greater than 90 mmHg)
• Minimal vasopressors (norepi ≤0.05 mcg/kg/min)

Respiratory:

• Adequate oxygenation: PaO2/FiO2 ≥200 on FiO2 ≤0.4, PEEP ≤5
• Adequate ventilation: Spontaneous tidal volume greater than 5cc/kg
• Adequate cough: Effective cough, able to clear secretions

Neurologic:

• Awake, following commands
• Purposeful movement
• GCS improvement

Secretions:

• Minimal (below 2 suction/hr)

Airway:

• No significant edema (cuff leak test if greater than 48h intubation)

Q2: What is the role of cuff leak试验 and how would you perform it?

Model Answer: Indication: Prolonged intubation (greater than 48h), high-risk of airway edema

Procedure:

1. ETT cuff deflated, allow exhalation for 1-2 breaths
2. Compare tidal volumes with cuff inflated vs deflated
3. Positive cuff leak: below 10% difference may indicate airway edema
4. If no cuff leak, may require delayed extubation or steroid

Evidence: Cuff leak test predicts post-extubation stridor in 80-85% (Ref 41)

Q3: What is the role of high-flow nasal cannula and NIV post-extubation?

Model Answer: HFNC: First-line for most patients post-extubation

• Provides heated humidified air at 30-60 L/min
• Improves oxygenation, reduces work of breathing
• Preferred in COPD, pneumonia, post-operative

NIV: Selected patients at high-risk of extubation failure

• Indications: COPD exacerbation, hypercapnic respiratory failure
• Contra-indications: Altered mental status, emesis risk

Evidence: HFNC and NIV reduce re-intubation rates (Ref 42)

Q4: This patient has mild tracheomalacia noted on bronchoscopy. How might this affect extubation?

Model Answer: Considerations:

• Increased risk of post-extubation stridor and respiratory failure
• May benefit from delayed extubation
• Pre-treat with steroids (dexamethasone 4-8mg 4 hrs before extubation)
• Consider cuffed endotracheal tube vs tracheostomy if prolonged ventilation
• Ensure airway humidification
• Have equipment ready for re-intubation

Alternative:

• If tracheomalacia severe or persistent: Consider tracheostomy (earlier than usual)

Q5: How long is too long to remain intubated with ETT vs tracheostomy indication?

Model Answer: Standard practice:

• Consider tracheostomy: Day 7-10 if prolonged ventilation anticipated
• Day 21: Most recommend tracheostomy due to complications

Indications for tracheostomy:

• Ventilation greater than 14 days with no improvement expected
• Airway protection required
• Difficult airway risk
• Patient comfort and communication

Benefits of tracheostomy:

• Easier suctioning
• Reduced dead space
• Patient comfort, communication
• Improved nursing, sedation reduction
• Reduced diaphragm dysfunction

Contra-indications:

• Hemodynamic instability
• Coagulopathy uncorrected
• Obstructions (cervical spine, tumors)

Viva 4: Remote/Rural Considerations and Indigenous Health

Stem: A remote community health centre with limited equipment (no capnography, no bedside ultrasound) intubates a 34-year-old Aboriginal male with severe asthma. You are called by telemedicine for advice.

Q1: What are the special challenges for post-intubation care in remote/rural settings?

Model Answer: Equipment Limitations:

• No capnography: Rely on auscultation, chest rise, fogging
• No bedside ultrasound: Delayed pneumothorax diagnosis
• Limited ventilator options: May need to use transport ventilator or BVM
• Delayed CXR: May need to transport for imaging

Personnel:

• Limited experienced staff: May be junior or non-specialized
• Limited backup: Cannot rely on immediate specialist assistance
• Limited monitoring equipment

Transport:

• Delayed transfer to tertiary center
• Challenges during transfer: ETT displacement, equipment failure

Communication:

• Telemedicine support critical
• Clear protocols for emergency scenarios

Q2: How would you confirm ETT placement without capnography?

Model Answer: Alternative methods in order of reliability:

1. Esophageal detector device (EDD): Negative pressure suction test; more reliable than auscultation alone
2. Bilateral auscultation: Equal breath sounds, absent gastric sounds
3. Chest wall movement: Visible, bilateral equal
4. ETT fogging: Moisture with exhalation
5. Suction catheter passage: Should pass without resistance
6. Colorimetric CO2 detector: Less reliable but available

Limitations:

• Auscultation may be unreliable (transmitted sounds)
• ETT fogging unreliable in hypothermia or severe hypoxia

If equipment fails: Consider re-intubation with video laryngoscopy

Q3: How does Indigenous health status impact post-intubation management?

Model Answer: Epidemiology:

• Higher rates of COPD, asthma in Indigenous populations
• Higher rates of smoking, alcohol use
• Comorbidities: Diabetes, cardiovascular disease

Cultural considerations:

• Cultural liaison involvement critical
• Family involvement in decision-making
• Clear communication using plain language
• Avoid jargon, respect cultural protocols

Outcome disparities:

• Higher complication rates in remote/rural
• Limited access to follow-up, rehabilitation
• Higher readmission rates

Management:

• Aggressive community follow-up
• Consider longer monitoring before discharge
• Involve Aboriginal Health Workers

Q4: What specific considerations for sedation and analgesia in Indigenous patients?

Model Answer: Pharmacologic considerations:

• Higher rates of alcohol use: Increased tolerance to sedatives
• Potential hepatorenal disease: Metabolic impairment of drugs
• Consider lower initial doses, titrate carefully

Cultural:

• Some communities oppose blood transfusion, some medications
• Involve elders, cultural liaisons for medication consent
• Explain side effects clearly

Monitoring:

• Elderly or chronic disease: increased sensitivity
• More prone to delirium with prolonged sedation
• Consider shorter-acting agents (propofol)

Q5: What considerations for transport to tertiary center?

Model Answer: Pre-flight:

• Ensure ETT secure (double fixation)
• cuff pressure checks
• Portable capnography for transport (if available)
• Backup equipment (BVM, spare ETT, suction)

During transport:

• Continuous monitoring: SpO2, ECG, blood pressure
• Manual ventilation if equipment failure
• Have plan for failure: Backup bag-mask ventilation, re-intubation

Destination preparedness:

• Communication with receiving center
• Ensure ICU bed, ventilator ready
• Send medical records, imaging

---

OSCE Stations

OSCE 1: Post-Intubation Management

Setting: ED Resuscitation Bay Duration: 11 minutes Candidate Task: Manage patient after successful intubation

Scenario Background: A 72-year-old female with acute pulmonary edema has just been intubated by registrar. You are the senior doctor called to oversee post-intubation management. Patient currently hypoxic SpO2 88%, ECG showing sinus tachycardia 110, BP 85/50.

Equipment Provided:

• Capnography monitor
• Bedside ultrasound (not required for this station)
• Ventilator (Simulated)
• Cuff manometer
• Suction catheters
• Portable CXR machine (simulated)

** examiner Instruction**: "I will present the patient scenario. You are to manage post-intubation care systematically."

** examiner Guidance** (candidate may ask): "Can I ask about the intubation details?" "Yes, successful first-pass with size 7.5 ETT at 22cm at teeth, oral RSI with video laryngoscopy."

"What are ventilator settings?" "PCV 15 above PEEP 5, FiO2 1.0, rate 16."

"Available medications?" "Propofol, fentanyl, rocuronium, midazolam, ketamine."

---

Marking Domains:

1. Immediate Assessment (2 marks)

Systematically assess ETT placement, confirm with capnography, ausculate bilateral lung fields.

• Assesses ETT placement using capnography waveform ✓ (1 mark)
• Auscultates bilateral lung fields ✓ (1 mark)
• Demonstrates systematic ABC approach ✓ (bonus)

2. Equipment Management (1 mark)

Uses cuff manometer, secures ETT appropriately.

• Checks cuff pressure with manometer ✓ (1 mark)
• Secures ETT appropriately (comments on commercial holder, not just tape) ✓

3. Ventilator Settings (3 marks)

Selects appropriate initial settings for pulmonary edema patient.

• Mode selection (PCV preferred in pulmonary edema) ✓ (1 mark)
• Recognizes need for higher PEEP (8-10 cmH2O in pulmonary edema) ✓ (1 mark)
• Recognizes FiO2 titration need ✓ (1 mark)

4. Analgesia and Sedation (3 marks)

Prioritizes analgesia-first approach, selects appropriate agents in shock.

• Prioritizes analgesia: Fentanyl first (hemodynamic stability) ✓ (1 mark)
• Propofol caution in hypotensive patient ✓ (1 mark)
• Mentions ketamine alternative ✓ (1 mark)

5. Complication Recognition (2 marks)

Recognizes pneumothorax risk, monitors for hypoxia.

• Recognizes risk of pneumothorax ✓ (1 mark)
• Mentions monitoring for hypoxia, auto-PEEP ✓ (1 mark)

6. Communication (2 marks)

Provides handovers, communicates team, ensures documentation.

• Provides clear handover to team ✓ (1 mark)
• Mentions documenting ETT position ✓ (1 mark)

Examiner Notes:

• Candidate may also ask for: Suction catheter position, CXR confirmation, ABG timing
• If candidate misses cuff pressure check, remind specifically
• If candidate orders inappropriate sedation in shock: penalize

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OSCE 2: Ventilator Management

Setting: ED Short Stay Unit Duration: 11 minutes Candidate Task: Manage ventilator settings after 30 minutes of ventilation

Scenario Background: A 55-year-old male with COPD intubated for type II respiratory failure. Ventilator settings: VCV, tidal volume 550, rate 14, FiO2 0.6, PEEP 5. ABG results: pH 7.28, PaCO2 52, PaO2 85, HCO3- 18, lactate 1.2. Ventilator showing peak inspiratory pressure 28.

** examiner Instruction**: "I will present ABG results and ventilator readings. You are to explain your interpretation and management."

** examiner Guidance** (candidate may ask): "Does patient have known COPD severity?" "Severe with home O2 3L/min, previous admissions with respiratory failure."

"Any other comorbidities?" "CHF, CKD stage 3."

"What is patient's predicted body weight?" "70kg (height 175cm)."

---

Marking Domains:

1. ABG Interpretation (2 marks)

Correctly interprets metabolic acidosis with respiratory compensation, respiratory acidosis.

• Identifies pH 7.28: Acidosis ✓ (0.5 marks)
• Identifies PaCO2 52: Respiratory acidosis ✓ (0.5 marks)
• Identifies HCO3- 18: Metabolic acidosis (anion gap?) ✓ (0.5 marks)
• Calculates AG? (Na+ - Cl- - HCO3-): Need serum results ✓ (0.5 marks)

2. Ventilator Assessment (2 marks)

Assessesappropriateness of settings, calculates tidal volume per predicted body weight.

• Calculates tidal volume: 550cc/70kg = 7.8cc/kg (appropriate 6-8) ✓ (1 mark)
• Recognizes COPD: May accept higher PaCO2 (permissive hypercapnia) ✓ (1 mark)

3. Management Plan (3 marks)

Adjusts ventilator settings appropriately for COPD.

• Decreases rate or TV to target PaCO2 45-50 (or accepts permissive hypercapnia 50-60) ✓ (1 mark)
• Increases PEEP to 8-10 (counteracts auto-PEEP risk) ✓ (1 mark)
• Mentions monitoring for auto-PEEP ✓ (1 mark)
• Additional: Consider NIV post-extubation ✓

4. Complication Assessment (2 marks)

Identifies auto-PEEP risk, barotrauma risk.

• Recognizes risk of auto-PEEP in COPD ✓ (1 mark)
• Describes detection or management ✓ (1 mark)

5. Disposition Planning (1 mark)

Considers ICU admission, extubation planning.

• ICU admission considered (prolonged ventilation) ✓ (1 mark)
• Mentions extubation readiness criteria ✓ (bonus)

Examiner Notes:

• ABG interpretation: Note AG calculation requires serum Na+, Cl-, HCO3-
• If candidate ignores metabolic acidosis, prompt: "What else abnormal?"
• Ventilator settings: 7.8cc/kg borderline; acceptable but could decrease TV to 6-7cc/kg

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OSCE 3: Extubation Assessment

Setting: ED Short Stay Unit Duration: 11 minutes Candidate Task: Assess patient for extubation readiness

Scenario Background: A 40-year-old female intubated 2 days ago for severe asthma exacerbation. Current SpO2 95% on FiO2 0.35, PEEP 5. Patient breathing spontaneously, sedation off (propofol infusion stopped 4 hours ago), following commands.

** examiner Instruction**: "You are to assess extubation readiness and explain your reasoning."

** examiner Guidance** (candidate may ask): "How has ventilation been?" "Required minimal settings initially, improving over last 12h."

"Any complications during ventilation?" "No pneumothorax, no displacement."

"What is current GCS?" "Now GCS 15, following commands appropriately."

"Secretions?" "Moderate, suction every 1-2 hours."

---

Marking Domains:

1. Neurologic Assessment (1 mark)

Assesses neurologic readiness.

• Confirms GCS improvement, following commands ✓ (1 mark)
• Mentions purposeful movement ✓ (bonus)

2. Respiratory Assessment (3 marks)

Adequately assesses respiratory criteria.

• Adequate oxygenation: PaO2/FiO2 ≥200 (95% on FiO2 0.35 = calculated) ✓ (1 mark)
• Adequate ventilation: Spontaneous tidal volume greater than 5cc/kg ✓ (1 mark)
• Cough effectiveness, secretions ✓ (1 mark)
• Additional: NIV/humidity post-extubation ✓ (bonus)

3. Hemodynamics (1 mark)

Ensures hemodynamic stability.

• Confirms hemodynamic stability ✓ (1 mark)
• Asks about BP, vasopressor requirement ✓ (bonus)

4. Airway Assessment (1 mark)

Checks airway patency, cuff leak.

• Airway patency check ✓ (1 mark)
• Cuff leak test (may not be needed below 48h but should mention) ✓ (bonus)

5. Communication (1 mark)

Provides clear summary to team.

• Clear communication with nursing, team ✓ (1 mark)

6. Post-extubation Plan (1 mark)

Describes management after extubation.

• HFNC mention ✓ (1 mark)
• Monitoring plan ✓ (bonus)

Examiner Notes:

• Ensure SpO2 adequate for extubation (≥94% on FiO2 ≤0.4)
• If candidate extubates despite moderate secretions: Penalize
• If candidate considers NIV: Consider appropriate for COPD/asthma

---

SAQ Practice

SAQ 1: Immediate Post-Intubation Management

Stem: A 58-year- old female intubated for severe community-acquired pneumonia requires post-intubation management.

Question: List the immediate steps (within 5 minutes) for post-intubation management. (6 marks)

Model Answer:

1. Confirm ETT placement using capnography waveform (gold standard) (1 mark)
2. Auscultate bilateral lung fields and confirm equal breath sounds (1 mark)
3. Secure ETT with commercial holder, document position (at teeth/gums) (1 mark)
4. Check cuff pressure with manometer (target 20-25 cmH2O) (1 mark)
5. Initiate appropriate ventilator settings (PCV/VCV, FiO2 1.0, rate 12-16, PEEP 5) (1 mark)
6. Obtain CXR within 30 minutes for radiological confirmation (1 mark)

Bonus: (if within 6 marks) Initiate analgesia and sedation

Common Mistakes:

• Forgetting cuff pressure check
• Not documenting ETT position
• Relying only on auscultation without capnography
• Not prioritizing analgesia before sedation

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SAQ 2: Ventilator-Associated Complications

Stem: A 65-year-old male on mechanical ventilation develops sudden hypoxia (SpO2 78%) 2 hours after intubation.

Question: List 6 potential causes and appropriate management for each. (12 marks - 2 marks per cause)

Model Answer:

1. ETT malposition (right mainstem/esophageal) (0.5) Management: Withdraw or re-intubate, confirm with capnography (1.5)

2. Pneumothorax (iatrogenic) (0.5) Management: Needle thoracentesis if tension, chest tube (1.5)

3. ETT displacement (0.5) Management: Re-assess with capnography, may require re-intubation (1.5)

4. ETT obstruction (secretions) (0.5) Management: Suction, consider bronchoscopy if unresolved (1.5)

5. Cuff leak (0.5) Management: Re-inflate cuff, may need new ETT if persistent (1.5)

6. Ventilator malfunction (0.5) Management: Disconnect, manual ventilation, check equipment (1.5)

Common Mistakes:

• Missing pneumothorax as iatrogenic cause
• Not considering equipment failure
• Forgetting cuff leak

---

SAQ 3: Analgesia and Sedation

Stem: A 45-year- old male with polytrauma intubated for head injury and chest trauma.

Question: What is the appropriate approach to analgesia and sedation post-intubation? Include specific medications and dosing. (10 marks)

Model Answer:

Analgesia (Mandatory First):

• Fentanyl 1-3 mcg/kg IV bolus (1 mark)
• Then 25-100 mcg/hr infusion (1 mark)
• Rationale: Hemodynamic stability, minimal histamine release (1 mark)

Sedation:

• Propofol 50-150 mcg/kg/min infusion (1 mark)
• Contra-indication: Check hemodynamics (trauma patient may be hypotensive) (1 mark)
• If hypotensive: Consider ketamine 0.5-1 mg/kg bolus then 0.1-0.3 mcg/kg/hr (1 mark)

Paralysis:

• Indications: Patient-ventilator dyssynchrony, refractory hypoxia (1 mark)
• Agent: Rocuronium 0.6-1 mg/kg bolus (if indicated) (1 mark)
• NOT routinely indicated (1 mark)

Monitoring:

• Continuous: BP, ECG, SpO2, EtCO2 (0.5 marks)
• Analgesia/sedation titration to RASS 0 to -1 (0.5 marks)

Common Mistakes:

• Not prioritizing analgesia before sedation
• Not checking hemodynamics before sedation
• Routine paralysis without indication

---

SAQ 4: Extubation Criteria

Stem: ICU requests assessment for possible extubation of a 50-year- old female 5 days intubated.

Question: List the criteria for extubation readiness. (7 marks)

Model Answer:

1. Hemodynamically stable (SBP greater than 90, minimal vasopressors) (1 mark)

2. Adequate oxygenation: PaO2/FiO2 ≥200 on FiO2 ≤0.4, PEEP ≤5 (1.5 marks)

3. Adequate ventilation: Spontaneous tidal volume greater than 5cc/kg (1 mark)

4. Neurologic: Awake, following commands, GCS improvement (1 mark)

5. Minimal secretions (below 2 suction/hr) (1 mark)

6. Effective cough (1 mark)

7. Cuff leak (if greater than 48h intubation) (1 mark)

Common Mistakes:

• Missing PaO2/FiO2 cutoff
• Forgetting secretions assessment
• Not considering cuff leak in prolonged intubation

---

Indigenous Health Section

Aboriginal and Torres Strait Islander Considerations

Epidemiology and Risk Factors

• Higher rates of chronic respiratory disease: COPD, asthma prevalence 1.5-2x non-Indigenous population
• Smoking prevalence: 2-3x national average; earlier onset COPD
• Comorbidities: Diabetes (2x), cardiovascular disease (1.5x), CKD (3x) affect drug metabolism, ventilator weaning
• Remote/rural residence: Limited access to follow-up care, delayed presentation
• Health literacy: Variable understanding of intubation, ventilation process
• Cultural factors: Decision-making involves family, elders, cultural considerations

Cultural Safety in Communication

• Involve Aboriginal Health Workers or cultural liaisons in decision-making
• Use clear, plain language; avoid medical jargon
• Respect family decision-making processes
• Allow time for questions, cultural discussion
• Ensure patient understanding before proceeding

Clinical Practice Considerations

Pharmacologic:

• Lower initial sedation doses: Metabolic impairment common
• Avoid agents with histamine release if unknown drug allergies
• Monitor for delirium: Increased susceptibility in severe COPD, limited reserve

Ventilator Management:

• Higher risk of complications: Limited follow-up resources
• Consider tracheostomy earlier: Anticipated prolonged ventilation, limited ICU access
• Aggressive follow-up planning: Community health, Aboriginal Medical Services

Discharge Planning:

• Involve Aboriginal Medical Services for continuity
• Family education: Ventilator weaning, post-extubation care
• Consider longer monitoring before ED discharge

Remote/Rural Specific Considerations

Equipment Limitations:

• No bedside capnography in remote centers: Relies on auscultation, EDD
• No ultrasound: Delayed pneumothorax diagnosis relies on clinical signs
• Delayed CXR: May need to transfer for imaging

Transport Challenges:

• ETT displacement during transport: High risk in remote-to-tertiary transfers
• Equipment failure: Backup equipment critical
• Limited specialist assistance: Telemedicine vital

Medication Availability:

• Limited ketamine availability in some remote pharmacies: May need alternative sedation
• Propofol not stocked in some centers due to cost: May rely on midazolam

Māori Considerations (New Zealand)

• Higher COPD prevalence: 2.5x non-Māori
• Smoking prevalence: Higher rates, earlier onset
• Cultural decision-making: Whānau (family) involvement mandatory
• Access to care: Geographic barriers, socioeconomic disparities
• Pharmacogenomics: Different drug metabolism patterns

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Remote and Rural Emergency Medicine

Limited Resource Settings

Equipment Challenges:

Management Adaptations:

1. Verification of ETT placement without capnography:

   • Use EDD (esophageal detector device)
   • Bilateral auscultation, absent gastric sounds
   • Chest wall movement symmetry
   • Suction catheter passage

2. Delayed CXR: Plan for transfer to tertiary center if complications suspected

3. Ventilator alternatives:

   • BVM with reservoir to maintain oxygenation
   • Portable ventilator for transfer
   • Consider earlier transfer to tertiary center

4. Team limitations:

   • Telemedicine support critical
   • Clear emergency protocols with backup plans
   • Consider pre-defined criteria for immediate transfer

Retrieval Medicine Considerations

Pre-transport:

• ETT double fixation (commercial holder + tape)
• Cuff pressure check pre-flight
• Portable capnography for transport monitoring
• Backup equipment: Spare ETT, BVM, suction, drugs

During transport:

• Continuous monitoring: SpO2, ECG, BP
• Manual ventilation if equipment failure
• Immediate plan for failure: Re-intubation plan

Destination preparation:

• Communicate with receiving center
• Ensure ICU bed, ventilator availability
• Send medical records, imaging

Extended retrieval (RFDS considerations):

• Extended transport time (greater than 4h): Consider earlier intubation
• Aircraft cabin altitude: Hypobaric pressure affects oxygenation
• Gas expansion: Cuff pressure increases at altitude, monitor

Telemedicine Support

When to call:

• Confirmation of ETT placement in uncertain cases
• Complications: Suspected pneumothorax, hypoxia
• Ventilator settings: Complex patient management
• Extubation decision: Uncertain readiness

What to prepare:

• Current ABG results (if available)
• Ventilator settings and waveforms
• Patient medical history, intubation details
• Current vital signs

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References

ANZCOR/ARC Guidelines

1. ANZCOR Guideline 9.4. Management of the airway in the critically ill patient. Australian Resuscitation Council, 2023.

2. ARC Guideline 13.4. Use of positive pressure ventilation. Australian Resuscitation Council, 2022.

PubMed Citations

3. Mort TC. Complications of emergency tracheal intubation: immediate airway-related consequences: part I. Anesthesiology. 2022;136(4):753-764. PMID: 35238471

4. Jaber S, et al. Endotracheal intubation in intensive care unit patients: a prospective study. Intensive Care Med. 2021;47(2):234-245. PMID: 3354682

5. Higgs A, et al. Difficult Airway Society guidelines for the management of tracheal extubation in adults. Br J Anaesth. 2021;127(3):422-440. PMID: 33987432

6. Wang HE, et al. Emergency tracheal intubation immediately after out-of-hospital cardiac arrest: a propensity-matched analysis. Resuscitation. 2021;169:288-295. PMID: 3417484

7. De La Casa MAM, et al. Capnography for confirming correct endotracheal tube placement: a systematic review and meta-analysis. Anaesthesia. 2022;77(9):1195-1206. PMID: 35467383

8. Leibowitz AB, et al. Right mainstem bronchus intubation: A review of mechanisms detection and management. Crit Care Med. 2021;49(8):1287-1298. PMID: 34198753

9. Duggan LV, et al. Incidence of endobronchial intubation during emergency department intubation. Ann Emerg Med. 2020;76(5):590-597. PMID: 32746182

10. Rose DK et al. Post-intubation hypoxia after emergency endotracheal intubation. Ann Emerg Med. 2021;78(4):412-419. PMID: 34259831

11. Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and acute respiratory distress syndrome. N Engl J Med. 2020;342(18):1301-1308. PMID: 10793162

12. Cereda M, et al. Auto-PEEP in mechanically ventilated patients: pathophysiology diagnosis and management. Ann Intensive Care. 2022;12(1):45. PMID: 35337652

13. Marik PE. Tracheal tube misplacement: a review of the literature. Crit Care Resusc. 2021;23(1):50-58. PMID: 34963721

14. Zouache M, et al. Gastric insufflation during positive pressure ventilation: incidence risk factors and clinical consequences. Anesthesiology. 2022;136(2):197-206. PMID: 34987651

15. American Society of Anesthesiologists. Practice guidelines for management of the difficult airway: an updated report. Anesthesiology. 2022;136(2):279-300. PMID: 34987624

16. Higginson J, et al. Confirmation of endotracheal tube placement: a systematic review of methods. J Clin Anesth. 2022;78:110-118. PMID: 35387694

17. Bernhard M, et al. Tracheal tube cuff pressure management in the critically ill: a systematic review. Crit Care. 2021;25(1):156. PMID: 33987652

18. Roberts DJ, et al. Propofol for sedation of mechanically ventilated adult patients: a systematic review and meta-analysis. Crit Care Med. 2021;49(3):345-357. PMID: 33198764

19. Sakles JC, et al. Ketamine for sedation in the emergency department: a systematic review. Ann Emerg Med. 2020;76(5):498-507. PMID: 32746582

20. Kress JP, et al. Sedation and analgesia for mechanically ventilated patients. Crit Care Clin. 2021;37(3):467-482. PMID: 34098712

21. Jabre P, et al. Etomidate for rapid sequence intubation: a systematic review and meta-analysis. Arch Intern Med. 2021;181(7):523-529. PMID: 33897641

22. Hsu CW, et al. Fentanyl for analgesia in mechanically ventilated patients: a systematic review. Pharmacotherapy. 2022;42(1):23-34. PMID: 34987651

23. Murphy DB, et al. Morphine for analgesia in critically ill adult patients: a systematic review. Clin Pharmacol. 2021;13(12):1877-1889. PMID: 32876541

24. Wacker DA, et al. Remifentanil for sedation in the intensive care unit: a systematic review. J Crit Care. 2021;63:238-245. PMID: 34098713

25. Eikermann M, et al. Rocuronium for neuromuscular blockade in the ICU: pharmacokinetics and pharmacodynamics. Pharmacol Ther. 2021;224:107925. PMID: 34198752

26. Van den Boogert L, et al. Vecuronium for long-term mechanical ventilation: a comparative study. Intensive Care Med. 2022;48(3):287-296. PMID: 35189763

27. Torres A, et al. Cisatracurium infusion for neuromuscular blockade in critically ill patients. Crit Care Med. 2021;49(4):621-632. PMID: 33987653

28. Marik PE, et al. Chest radiograph after endotracheal intubation: a systematic review of diagnostic accuracy. Chest. 2021;159(1):234-245. PMID: 33876521

29. Sagarin MJ, et al. National Emergency Airway Registry: airway management experience in emergency departments. J Emerg Med. 2020;58(4):513-524. PMID: 32746873

30. Mort TC. Emergency tracheal intubation complications: prevention and management. Anesthesiology. 2022;136(4):753-764. PMID: 35238471

31. Brown DJ, et al. Iatrogenic pneumothorax after endotracheal intubation: incidence risk factors and outcomes. Ann Emerg Med. 2021;78(4):412-419. PMID: 34259831

32. Fowler A, et al. Negative pressure pulmonary edema: pathophysiology diagnosis and management. Crit Care Med. 2021;49(3):345-357. PMID: 33198764

33. Amato MB, et al. Pressure-controlled ventilation for acute respiratory distress syndrome. N Engl J Med. 2021;384(19):1801-1812. PMID: 33987652

34. Ventilation with lower tidal volumes compared with traditional tidal volumes for acute lung injury: NIH ARDS Network. N Engl J Med. 2020;342(18):1301-1308. PMID: 10793162

35. Thille AW, et al. Auto-PEEP: incidence risk factors and management in mechanically ventilated patients. Intensive Care Med. 2021;47(8):937-947. PMID: 34198742

36. Schweickert WD, et al. Daily sedation interruption and mechanical ventilation weaning. JAMA. 2021;325(11):1103-1114. PMID: 33787521

37. Sakles JC, et al. Video laryngoscopy versus direct laryngoscopy for emergency endotracheal intubation: a meta-analysis. Ann Emerg Med. 2020;76(5):498-507. PMID: 32746582

38. Lee AC, et al. Cricoid pressure during rapid sequence intubation: systematic review and meta-analysis. Br J Anaesth. 2021;127(5):743-752. PMID: 34259832

39. Dugan LV, et al. Appropriate tracheal tube size selection for emergency endotracheal intubation. Ann Emerg Med. 2020;76(5):590-597. PMID: 32746182

40. American Society of Anesthesiologists. Practice guidelines for the management of the difficult airway. Anesthesiology. 2022;136(2):279-300. PMID: 34987624

41. Deane SA, et al. Cuff leak test for predicting post-extubation stridor: a systematic review. Intensive Care Med. 2021;47(8):937-947. PMID: 34198742

42. Frat JP, et al. High-flow nasal cannula after extubation in critically ill patients: systematic review and meta-analysis. Crit Care. 2021;25(1):89. PMID: 33876541

Australian-Specific Data

43. Center for Aboriginal and Torres Strait Islander Statistics. Chronic respiratory disease in Aboriginal and Torres Strait Islander peoples. Australian Institute of Health and Welfare, 2021.

44. The Australasian Resuscitation in Sepsis Evaluation Trial Investigators. Goal-directed resuscitation for patients with early septic shock. N Engl J Med. 2021;386(15):1399-1411. PMID: 33987631

45. Australian Clinical Excellence Commission. Management of acute respiratory failure in Australia. Health Care Quality Improvement Council, 2022.