Intubation

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Endotracheal Intubation

Purpose

Endotracheal (tracheal) intubation places a flexible tube through the mouth (orotracheal) or nose (nasotracheal) into the trachea to:

Secure and protect the airway
Allow mechanical ventilation and oxygenation
Permit suctioning of secretions
Prevent aspiration of gastric contents

Indications

Refractory hypoxemic or hypercapnic respiratory failure
Airway protection (altered mental status, intoxication, head trauma, severe upper GI bleeding with hematemesis)
Upper airway obstruction (angioedema, tumor, trauma)
Severe metabolic acidosis or shock, and need for controlled hyperventilation (e.g., raised intracranial pressure)
Combative or apneic patients, cardiac arrest

(Washington Manual of Medical Therapeutics, p. 280)

Relative contraindications/considerations prompting an alternate approach include an intact tracheostomy stoma, trismus (consider rapid-sequence or nasotracheal intubation), and severe facial/neck trauma (consider cricothyroidotomy). - Pfenninger and Fowler's Procedures for Primary Care, p. 2201

Equipment

Laryngoscope with fresh batteries, and at least two blade types (curved/Macintosh, straight/Miller) or a video laryngoscope
Endotracheal tubes of appropriate size with stylet (adult men 7-9 mm, adult women 6-8 mm; pediatric sized via Broselow tape or little-finger width; uncuffed tubes typically used under age 8)
10 mL syringe to test/inflate the cuff, water-soluble lubricant
Bag-valve-mask device connected to 100% oxygen (15 L/min), oral/nasopharyngeal airway
Suction with rigid (Yankauer) tip, or DeLee suction for neonates
End-tidal CO2 detector/capnograph to confirm placement
Pulse oximeter, cardiac monitor, blood pressure monitor
Tape or a commercial tube-holder to secure the tube once placed
Backup difficult-airway equipment: bougie/tube introducer, supraglottic airway, cricothyroidotomy kit
Sedative/induction and paralytic drugs for rapid-sequence intubation (RSI)

(Pfenninger and Fowler's Procedures for Primary Care, p. 2207; Washington Manual, p. 280)

Drugs commonly used for RSI

Drug	Action	Typical IV Dose	Onset	Duration	Notes
Propofol	Sedation/amnesia	0.5 mg/kg (unstable) - 1.5 mg/kg (stable)	30-60 sec	5-10 min	Causes hypotension/bradycardia; helpful in seizures
Etomidate	Sedation	0.15-0.3 mg/kg	15-45 sec	3-12 min	Hemodynamically neutral; can suppress cortisol
Ketamine	Sedation/analgesia	1-3 mg/kg	~30 sec	5-10 min	Raises HR/BP, bronchodilator
Midazolam	Sedation/amnesia	0.02-0.08 mg/kg	30-60 sec	15-30 min	Causes hypotension
Succinylcholine	Paralytic	1-1.5 mg/kg	30-60 sec	5-15 min	Avoid in hyperkalemia, malignant hyperthermia history, myopathy
Rocuronium	Paralytic	1 mg/kg	45-60 sec	30-45 min	Use caution if difficult airway/bag-mask ventilation anticipated

(Washington Manual of Medical Therapeutics, Table 8-2, p. 281)

Procedure (Direct Laryngoscopy, Orotracheal)

Position - "Sniffing" position: neck flexed, head extended, aligning oral-pharyngeal-tracheal axes. Obese patients may need a shoulder roll or ramp.
Preoxygenate with 100% oxygen via bag-valve-mask for 3-5 minutes until SpO2 stays above 95%; suction oral secretions as needed.
Check equipment during preoxygenation - test the ET tube cuff (inflate/deflate) and confirm the laryngoscope light works.
Sedate and paralyze (RSI) as indicated, then open the mouth and insert the laryngoscope blade along the right side of the mouth, sweeping the tongue leftward with the blade.
Visualize the cords - advance the blade to the base of the tongue and lift vertically (do not lever/tilt on the teeth) to expose the vocal cords.
Pass the tube - once cords are visualized, advance the ET tube with stylet through the cords with the right hand; remove the stylet once the cuff has passed the cords.
Inflate the cuff with the syringe.
Confirm placement - look for bilateral chest rise, auscultate breath sounds bilaterally and absence over the epigastrium, and confirm with end-tidal CO2 (colorimetric or capnograph) - this is the gold-standard confirmation.
Secure the tube with tape or a commercial holder, then connect to a ventilator and obtain a confirmatory chest x-ray to check tube depth.

Cricoid pressure (Sellick maneuver) is sometimes applied during RSI to reduce aspiration risk and bring the trachea into view, though its efficacy has been questioned in more recent literature. - Pfenninger and Fowler's Procedures for Primary Care, p. 2244

If the airway is anticipated to be difficult, a bougie/tube introducer or video laryngoscope should be available; a recent meta-analysis found the bougie approach improves first-attempt success compared to a stylet approach in difficult airways (PMID: 39101305).

Complications

Esophageal intubation (absent breath sounds, breath sounds over stomach - requires immediate recognition and reintubation), dental/oral trauma, hypoxia during attempts, hypotension from sedatives, aspiration, right mainstem bronchial intubation if advanced too far, and laryngeal/tracheal injury.

Recent evidence check

A 2024 systematic review/meta-analysis (PMID: 38730289) found comparable efficacy of endotracheal intubation performed in a helicopter cabin versus on the ground, relevant to prehospital/aeromedical settings, and does not contradict standard technique described above.

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