Avoiding Circulatory Complications during Endotracheal Intubation and Initiation of Positive Pressure Ventilation

Constantine A. Manthous, MD, FACP, FCCP


J Emerg Med. 2010;38(5):622-631. 

In This Article

Abstract and Introduction


Background: In many hospitals, emergency physicians commonly initiate invasive positive-pressure ventilation. Objectives: To review common patient- and ventilator-related factors that can promote hemodynamic instability during and after endotracheal intubation. Discussion: Venous return is proportional to mean systemic pressure (Pms) minus right atrial pressure (Pra). Endotracheal intubation with positive-pressure ventilation often reduces Pms while always increasing Pra, so venous return inevitably decreases, resulting in hypotension in almost one-third of patients. This article reviews the pathophysiology of respiratory failure, the basic circulatory physiology associated with endotracheal intubation, and methods that may be helpful to reduce the frequency of intubation-related hypotension. Conclusion: Although unproven, preventive measures taken before, during, and after endotracheal intubation are likely to minimize the frequency, magnitude, and duration of intubation-related hypotension.


Emergency physicians (EPs) face the broadest range of illnesses, including those with very high acuity, in all ages of patients. In many hospitals, EPs are the physicians who most often recognize respiratory failure and initiate endotracheal intubation and positive-pressure ventilation (ETI/PPV). Patients frequently decompensate rapidly and unexpectedly, and EPs provide critical care at a highly vulnerable point in the trajectory of illness. Although it may be ideal for the EP and intensivist to initiate ETI/PPV together as a team, more often, EPs face this crisis before an intensivist can be summoned to assist. Accordingly, it is reasonable for EPs to consider the intensivist's approach to minimize morbidity and mortality. This article reviews the pathophysiology of respiratory failure, explores cardiopulmonary interactions associated with ETI, and highlights high-risk scenarios (distilled from real cases) in which predictable adverse cardiopulmonary events may be circumvented or attenuated.


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