In recent years, there has been an increase in the number of patients considered candidates for ED intubations.^1-4 In one series, 41.3% of ED intubations were for airway protection, while 57.4% were for mechanical ventilation.⁴

There are several major reasons for endotracheal intubation (ETI):

• Failure to maintain adequate oxygenation and ventilation.
  
• Absent or inadequate respirations.
  
• Impending airway obstruction or failure
  
• Inability to protect the airway.
  
• Inability to swallow or handle secretions.
  
• Coma (Glasgow Coma Scale ≤ 8).
  

Pharmacologic paralysis and intubation are not generally preferred over sedation for an emotionally distressed or intoxicated individual. In certain circumstances, however, it may be necessary to sedate and paralyze a combative patient in order to perform essential diagnostic procedures and to protect the patient from harm. This scenario is seen most often in the trauma bay, where a combative patient with a potential cervical spine injury may require "aggressive" control.

There are numerous recommendations regarding the need for intubation that hinge upon numerical data such as blood gas indices. While these objective criteria provide an aura of science, most ED intubations are correctly based upon the clinical judgment of the physician.

Physical examination often provides more guidance in airway decisions than the patient's history. A long dissertation from a patient regarding how short of breath they are is reassuring. The more "long-winded" the exposition, the better!