TABLE OF CONTENTS
“Should I intubate now?”
This used to be the question that sent me into a spiral during my early ER days. I would overthink, hesitate, or doubt myself — until I started following one simple algorithm.
In reality, there are only three reasons to intubate.
Everything else is noise.
If you learn to answer these three questions, airway decisions become calm, structured, and safe.
Let’s break them down.
1. Failure to Maintain or Protect the Airway
Start here: Is the airway patent?
The quickest test is simply talk to your patient.
A strong, clear voice = patent airway.
Two signs that suggest the airway is not maintained:
- Inability to phonate clearly
- Stridor
If you see these, attempt basic manoeuvres:
- Head tilt–chin lift
- Jaw thrust
- OPA / NPA
But remember:
These can open the airway — not protect it.
Next: Is the airway protected?
If the airway is not maintained, it is by definition not protected.
Additional signs of poor airway protection:
- Reduced volitional or spontaneous swallowing
- Pooling of secretions in the oropharynx
Do not use gag reflex to judge airway protection. It is unreliable and misleading.
2. Failure of Oxygenation or Ventilation
Ventilation = moving air in and out.
Oxygenation = exchanging gases effectively.
A patient needs both to be adequate.
Ask:
- Is the patient oxygenating
- Did I attempt using supplemental oxygen?
- Is the patient ventilating?
(rising CO₂, tiring, silent chest, accessory muscle fatigue)
If failure persists despite appropriate oxygen or simple interventions
→ Intubate.
3. Anticipated Clinical Course
(This is the trickiest and the most feared indication.)
Sometimes the airway is fine now, but you know it won’t stay that way.
Ask yourself:
“Will the answer to Question 1 or 2 change soon?”
Examples:
- Corrosive ingestion: airway is patent now, but edema is coming
- Expanding neck hematoma
- Severe head injury with declining mental status
- Toxins with progressive CNS depression
If the answer is yes
→ Intubate.
“Will it change during the patient’s stay in the ER or during transfer?”
If deterioration is likely while you’re responsible
you need to plan ahead.
If yes, then ask:
“Can I monitor and reassess in time?”
This becomes critical when:
- Sending the patient to CT
- Shifting to another floor
- Short staffing
- Combining multiple unstable patients
If the answer is no
→ A controlled intubation is safer than a crash intubation.
⚠️ Important Clarification
Metabolic acidosis or hemodynamic instability
Alone are NOT indications to intubate.
In fact, these patients represent a subset of physiologically difficult airways, where intubation can worsen instability if not planned well.
This algorithm simplified my decision-making, reduced my anxiety, and improved my confidence as an emergency physician.
Want to Read More?
- Walls RM, Murphy MF, eds. Manual of Emergency Airway Management. 5th ed. Philadelphia: Wolters Kluwer; 2018.
- Walls RM, Hockberger RS, Gausche-Hill M, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 10th ed. Philadelphia: Elsevier; 2022.
(Airway Management chapter)
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