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The Pump

cardiac assessment and optimization in the peri-intubation period


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Your need to intubate may have a negative impact on a cardiovascular system that is already in shock. Learn how to assess and support heart function BEFORE intubation to avoid cardiovascular collapse in the peri-intubation period and beyond.

Enhanced Digital Content

Use this learning space in two ways. As an online course, scroll down and enter the online learning space. Explore each section below, or use the navigation tool to go directly to the content you’re interested in. Then, use this enhanced digital content in one of our pop-up physical spaces for hands-on procedure training, skills challenges, and expert coaching.


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The Pathophysiology of Intubation

The impact of positive pressure

How will your decision to intubate impact the heart of a critically ill patient? In order to be prepared for the consequences of the procedure of intubation you need to first know what effect that procedure will have. We explain it here.

How to Assess the Pump

the Apical 4 Chamber View

The best way to evaluate RV contractility is to get a good apical four-chamber view. Is the RV bigger than the LV? That’s a sign of RV dysfunction.

Assessing Volume Status

A plethoric IVC suggests a volume overload state or obstructive pathology (tamponade, PE). >50% collapse with inspiration or compression suggests euvolemia or hypovolemia. The RV is preload dependent to an extent, but excess fluid can quickly overload the RV and worsen RV dysfunction–so consider vasopressors early.

Venous Congestion
The Vexus Score

Not convinced by your IVC ultrasound? The Venous Excess Ultrasound grading system can help provide additional information to evaluate fluid status.

how bad & acute or chronic

POCUS can be used to quickly evaluate for RV dysfunction and potential cardiovascular collapse in the peri-intubation period. The apical 4-chamber view and TAPSE are key components of assessing the RV.

measuring tapse

Tricuspid annular plane systolic excursion or (TAPSE) has a strange name but is simple to measure. It’s done in the apical 4 chamber view using m-mode. We show you how to do it here. Is the measurement less than 1.6cm? That means poor contractility.

Optimize Cardiac Function


Decreased RV contractility and poor systemic perfusion despite optimizing preload and using vasopressors? Consider adding an inotrope.


pH, PaO2, and PCO2

Pulmonary vasodilation, or decreased PVR, will reduce afterload for the right ventricle. Oxygen is a potent pulmonary vasodilator, meaning pre-oxygenation should be optimized for patients with RV failure in the peri-intubation period. Hypercapnia will increase PVR and RV afterload. NIPPV can be used to improve both oxygenation and ventilation peri-intubation, but beware of using excess PEEP.

Pulmonary Vasodilators

Oxygen is the ultimate pulmonary vasodilator, but O2 isn’t enough there are pharmacologic options that can be considered to decrease pulmonary vascular resistance (PVR).

Guided Practice

HANDS-ON training

Remember, if you’re in one of our pop-up learning spaces or a PAC Live event, find this icon and use the multimedia tools for hands-on guided practice.

  1. Look for this icon.
  2. Snap the QR code.
  3. Begin your hands-on practice.
  4. Get feedback on your skills.

Don’t forget to ask our faculty coaches for real-time expert feedback and earn points!

Earn Points

Keep yourself on track and get credit for completion using this guide.

  1. Open the guide to a tab on your browser.
  2. Visit each poster & review the content.
  3. Complete any challenges to earn points.


Join the Simulation
Earn Points

Turn this learning space into an immersive flipped classroom and test your knowledge in our high-fidelity simulation. Earn points towards completion of this space.

You’ve Reached the End

before you leave REMEMBER TO
  1. Collect all available points within this space in the user guide.
  2. Submit your user guide to earn credit for your work.
  3. Choose the next learning space to explore!

Well done! You’ve reached the end. Feel free to go back into the physical space to review any hands-on skills or visit all the digital content anytime, anywhere in its online home here.

What’s Next

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