Consider the following as the key reasons to intervene on your patient's airway:

1. Failure to oxygenate

2. Failure to ventilate

3. Inability to protect airway

4. Anticipated clinical course

Failure to maintain adequate oxygenation, despite supplemental oxygen, in a condition that is not reversible is a cause for intubation. Possible reversible causes include pulmonary edema or other conditions where the use of noninvasive positive pressure ventilation (NIPPV) can help overcome the pathophysiology at hand. Opioid overdose or something similar is another reversible cause.

Same as the above. Worsening hypercapnia that does not respond to other measures will eventually require intubation. Altered mental status from a post-ictal state and severe COPD exacerbations are two common causes for ventilatory failure and subsequent hypercapnia requiring intubation.

Answer this question by standing next to the patient, observing their ability to control their secretions. Pooling of secretions in the oral cavity is a sign that the patient may have lost the ability to safely swallow, with these secretions likely leaking into the trachea and making its way to the lungs – greatly increasing morbidity and mortality.

This rule pertains to the patient that at this moment in time does not break any of the above 3 rules. However, such is the nature of their presenting problem, you know they will progress to the point where this will happen, and intubation early is a smart move. Good examples of this are angioedema patients who are not responding to standard treatments, yet in front of you are protecting their airway and are adequately oxygenating and ventilating – but you know that if the observed swelling or respiratory distress is allowed to continue this will be a much harder patient to intubate.

Now let’s think back to your patient, and apply the rules 1 by 1:

1. Oxygenation: Her oxygen sat is 97% on 2L by NC

2. Ventilation: You place a nasopharyngeal airway, and raise the head of her bed, and her sonorous breathing improves. You feel that at this time she is ventilating adequately, but make the decision to place End-Tidal CO2 to help with this thought going forward

3. Airway Protection: She is controlling her secretions, swallowing adequately, with no pooled secretions in her oropharynx

4. Clinical Course: This remains uncertain at this point. You are unsure if she has ingested anything else with the large amount of ethanol that is likely on board.

You make the decision to not intubate on initial presentation. You feel that you can continue your workup and provide frequent reassessments, keeping the golden rules at the front of your thoughts as you progress.

You relay your plan to your (somewhat nervous) attending. They subsequently appear less nervous knowing you have a plan and it was thoughtfully crafter.

Well played young Doctor, well played.

The above patient doesn’t improve with time. You know you have to intervene. You are unsure whether to give meds or not, and at that moment your attending gets pulled into a room to deliver a pre-term infant…should you or should you not RSI your patient? And if so, how?