The seven Ps, from preparation to post-intubation management
Expansion
The seven Ps:
- P - Preparation: drugs, suction, tilting trolley, monitoring, and a failed intubation plan
- P - Pre-oxygenation, for 3 minutes or 8 vital capacity breaths
- P - Pretreatment, where indicated
- P - Paralysis with induction: an induction agent immediately followed by a muscle relaxant
- P - Protection and positioning, with cricoid pressure if used
- P - Placement with proof: waveform capnography
- P - Post-intubation management: sedation, ventilation, tube securing, chest radiograph
Drugs: induction with ketamine (haemodynamically stable, useful in shock), propofol (causes hypotension) or etomidate; paralysis with suxamethonium (fast on and off, but avoided in hyperkalaemia, burns over 24 hours old, spinal injury and neuromuscular disease) or rocuronium (reversible with sugammadex).
“Capnography confirms the tube; nothing else does.” A sustained waveform over six breaths is the standard, and its absence in a perfusing patient means oesophageal intubation until proven otherwise.
Predict difficulty before starting, using LEMON: Look externally, Evaluate 3-3-2, Mallampati, Obstruction, Neck mobility.
Cricoid pressure is increasingly questioned, since it can worsen the laryngoscopic view, and it should be released if it impedes intubation.