Steps to intubate a patient
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endotracheal intubation steps procedure RSI 2024
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Endotracheal Intubation: Step-by-Step Guide
The standard approach in emergency settings is Rapid Sequence Intubation (RSI), used in ~85% of all ED intubations. It is organized around the "7 Ps" framework.
Step 1 - Preparation
Assess the airway for difficulty (LEMON mnemonic: Look, Evaluate, Mallampati, Obstruction, Neck mobility). Check for:
- Limited mouth opening
- Short thyromental distance
- Cervical spine immobility
- Obesity, pregnancy, facial trauma, or airway swelling
Assemble equipment:
- Laryngoscope (handle + blade) - direct (Macintosh/Miller) or video laryngoscope
- Endotracheal tube (ETT) with stylet - typically 7.0-8.0 mm for adults
- 10-12 mL syringe (for cuff inflation)
- Bag-valve-mask (BVM) + oxygen source
- Yankauer suction - turned on and at bedside
- End-tidal CO2 (EtCO2) detector or capnography
- Bougie (intubating stylet)
- Tape or commercial tube holder
- Cricothyrotomy kit - located and accessible
Establish access & monitoring:
- IV access (minimum one, preferably two)
- Continuous pulse oximetry and cardiac monitoring
- Draw up and label all medications
- Communicate the plan to the entire team, including a backup plan for failed airway
- Roberts and Hedges' Clinical Procedures in Emergency Medicine, Pre-Intubation Checklist
Step 2 - Preoxygenation
Goal: Replace nitrogen in the lungs (denitrogenation) to create an oxygen reservoir in the functional residual capacity (FRC), extending safe apnea time to 6-8 minutes in a healthy adult.
- Apply high-flow oxygen at flush rate (40-70 L/min) via non-rebreather mask for 3-5 minutes - not just 15 L/min, which gives only ~65% FiO2
- Simultaneously place a nasal cannula at 10-15 L/min for apneic oxygenation (passive O2 delivery during laryngoscopy)
- Position the patient upright at 20-30° (reverse Trendelenburg) if possible - especially beneficial in obese patients, who desaturate fastest
- At-risk for rapid desaturation: obese, pregnant, critically ill, pediatric patients
- Rosen's Emergency Medicine, p. 31 | Roberts and Hedges', Preoxygenation section
Step 3 - Preintubation Optimization
Address abnormal physiology before inducing:
- Hypotension/shock: give IV fluids, blood products, or start vasopressors (norepinephrine) - induction agents cause vasoplegia and can precipitate circulatory collapse
- Bronchospasm: nebulized albuterol
- Severe acidosis: optimize ventilation if spontaneously breathing
- Identify and treat any correctable physiology to improve the chance of surviving the peri-intubation period
- Rosen's Emergency Medicine, Preintubation Optimization
Step 4 - Paralysis with Induction (Drug Administration)
Administer sedative/induction agent by rapid IV push, immediately followed by the neuromuscular blocking agent (NMBA):
| Drug | Dose | Notes |
|---|---|---|
| Ketamine (induction) | 1.5-2 mg/kg IV | Preferred in hemodynamically unstable or bronchospasm |
| Etomidate (induction) | 0.3 mg/kg IV | Hemodynamically neutral |
| Propofol (induction) | 1.5-2 mg/kg IV | Use with caution in hypotension |
| Succinylcholine (NMBA) | 1.5 mg/kg IV | Depolarizing; onset 45-60 sec; avoid in hyperkalemia, burns >24h, crush injury, lower motor neuron disease |
| Rocuronium (NMBA) | 1.2 mg/kg IV | Non-depolarizing; reversible with sugammadex 16 mg/kg; equivalent to succinylcholine at this dose |
- Do not bag the patient after induction unless SpO2 drops to <92%
- Assess relaxation ~45-60 seconds post-NMBA by testing mandibular mobility
- Rosen's Emergency Medicine, Paralysis with Induction | VUMC RSI Guideline 2024
Step 5 - Positioning
- Sniffing position: neck flexed on the body + head extended at the atlanto-occipital joint - aligns oral, pharyngeal, and laryngeal axes for direct laryngoscopy
- In obese patients, elevate the head/upper torso significantly (ear-to-sternal-notch alignment)
- Cervical spine precautions: if C-spine injury suspected, use in-line stabilization - do not extend the neck
- Cricoid pressure (Sellick maneuver) is no longer recommended - it is frequently applied incorrectly and can worsen laryngoscopy
- Rosen's Emergency Medicine, Positioning
Step 6 - Placement of the Tube (Laryngoscopy)
Direct Laryngoscopy technique:
- Hold laryngoscope in the left hand
- Open the mouth with right hand (scissor technique)
- Insert blade into the right side of the mouth, sweeping the tongue to the left
- Curved (Macintosh) blade: tip seats in the vallecula (just anterior to epiglottis); lift upward and forward along the axis of the handle
- Straight (Miller) blade: tip goes under the epiglottis and lifts it directly
- Apply force in the direction of the laryngoscope handle (up and forward at ~45°) - do not lever back against the upper teeth
- Visualize the vocal cords / glottic opening
Grading the view (Cormack-Lehane):
- Grade I: full glottis visible - easy
- Grade II: posterior glottis visible - usually manageable
- Grade III: only epiglottis seen - difficult; use bougie
- Grade IV: epiglottis not visible - very difficult
Passing the tube:
6. With right hand, advance the ETT through the vocal cords under direct vision until the cuff is 2-3 cm past the cords (~23 cm at lip in males, ~21 cm in females)
7. Remove the stylet
8. Inflate the cuff with 5-10 mL air
If first pass is difficult: use a bougie - pass it through the cords, then railroad the ETT over it. The bougie is invaluable for Grade III views.
- Roberts and Hedges' Clinical Procedures in Emergency Medicine, Direct Laryngoscopy
Step 7 - Proof of Placement (Confirmation)
Never rely on a single method. Use all of the following:
- Waveform capnography / EtCO2 - gold standard; confirms CO2 from the lungs with 3 consistent waveforms
- Direct visualization of tube passing between the cords
- Bilateral chest rise with BVM ventilation
- Bilateral breath sounds (auscultate axillae first, then epigastrium - absent gurgling confirms non-esophageal placement)
- SpO2 maintained or improving
- Chest X-ray - after initial confirmation; ensures no mainstem (right) intubation; optimal ETT tip position is 2-4 cm above the carina
If esophageal intubation is suspected - remove the tube immediately, ventilate with BVM, and reattempt.
- Roberts and Hedges' Clinical Procedures in Emergency Medicine | Rosen's Emergency Medicine
Step 8 - Post-Intubation Management
- Secure the tube: tape or commercial holder at confirmed depth
- Initiate mechanical ventilation: typical starting settings - assist-control, tidal volume 6-8 mL/kg ideal body weight, RR 12-16, PEEP 5 cmH2O, FiO2 100% (then titrate down)
- Continuous capnography: target EtCO2 35-45 mmHg (lower ~30 mmHg if ICP concern)
- Sedation and analgesia: start long-acting sedation (e.g., propofol or midazolam infusion) + analgesia (fentanyl) - the NMBA will wear off
- Orogastric tube: decompress the stomach
- Check CXR: confirm tip position and check for pneumothorax
Quick Reference: Failed Airway Plan
Always have a backup plan before intubating:
- BVM ventilation if SpO2 falls
- Supraglottic airway (LMA / iGel) as rescue device
- Video laryngoscopy if direct view is poor
- Bougie for Grade III views
- Cricothyrotomy (surgical or needle) if "cannot intubate, cannot oxygenate"
Sources:
- Roberts and Hedges' Clinical Procedures in Emergency Medicine - Tracheal Intubation, Pre-Intubation, Preoxygenation, Direct Laryngoscopy
- Rosen's Emergency Medicine: Concepts and Clinical Practice - Rapid Sequence Intubation (7 Ps)
- Pfenninger and Fowler's Procedures for Primary Care - Tracheal Intubation
- VUMC RSI and Intubation Guideline, August 2024
- StatPearls - Tracheal Rapid Sequence Intubation
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