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Team Intubation. Safe and successful intubation often requires a team effort. Here the laryngoscopist is assisted by personnel providing lip retraction, thyroid manipulation, endotracheal tube balloon insufflation, and cervical spine stabilization. (Photo contributor: Lawrence B. Stack, MD.)

MAXIM: Endotracheal intubation is not always the best initial intervention for respiratory failure.


Some patients in respiratory distress may benefit from other interventions, short of intubation. Patients with flash pulmonary edema may have dramatic improvement with intravenous nitroglycerin, intravenous furosemide, and bilevel positive airway pressure (BiPAP) ventilation (see Fig. 22.1). Patients with airway narrowing (edema, neoplasm, stricture, foreign body) can have significant decreased work of breathing by decreasing airway resistance to inspired gas using administration of helium-oxygen (HELIOX) mixture. HELIOX, usually as a 78%:22% helium-to-oxygen mixture, is much less dense than either air or 100% oxygen by virtue of helium replacing nitrogen or oxygen, respectively. This lowers resistance to laminar flow by as much as 25% to 20%, and the effects are immediate.


Bi-Level Positive Airway Pressure. This patient with chronic obstructive pulmonary disease rapidly improved with the application of BiPAP. (Photo contributor: Steven J. White, MD.)


  1. Alternative ventilatory adjuncts include HELIOX (see Fig. 22.3), continuous positive airway pressure (CPAP), BiPAP (see Fig. 22.1), and Vapotherm (see Fig. 22.2). These adjuncts may prevent the need for intubation in selected patients.


Vapotherm. Application of Vapotherm (high-flow warmed oxygen) rapidly improved this toddler with pneumonia and reactive airway disease. (Photo contributor: Lawrence B. Stack, MD.)


HELIOX Delivery System. An 80% helium 20% oxygen HELIOX delivery system. Use a non-rebreather mask at 8 L/min in patients with suspected upper airway obstruction. (Photo contributor: Lawrence B. Stack, MD.)

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