P R OC E D UR E 2

Endotracheal Intubation (Perform)

Cynthia A. Goodric h

PURPOSE:
Endotracheal intubation is performed to establish and maintain a patent airway, facilitate oxygenation and
ventilation, reduce the risk of aspiration, and assist with the clearance of secretions.

PREREQUISITE NURSING KNOWLEDGE

• Anatomy and physiology of the pulmonary system should be understood.
• Indications for endotracheal intubation include the following5,12 :
Altered mental status (head injury, drug overdose)
Anticipated airway obstruction (facial burns, epiglottitis, major facial or oral trauma)
Upper airway obstruction (e.g., from swelling, trauma, tumor, bleeding)
Apnea
Ineffective clearance of secretions (i.e., inability to maintain or protect airway adequately)
High risk of aspiration
Respiratory distress
• Pulse oximetry should be used during intubation so that oxygen desaturation can be detected quickly.
• Preoxygenation with 100% oxygen and a self-inflating manual resuscitation bag-valve-mask device with a tight-fitting
face mask should be performed for 3 to 5 minutes before intubation.
• Intubation attempts should take no longer than 15 to 20 seconds. If more than one intubation is necessary, ventilation
with 100% oxygen and a self-inflating manual resuscitation bag-valve-mask device with a tight-fitting face mask
should be performed for 3 to 5 minutes before each attempt. If intubation is not successful after three attempts,
consider use of other airway options, such as the Combitube or King Airway.
• Application of cricoid pressure (Sellick maneuver) may increase the success of the intubation. This procedure is
accomplished with applying firm downward pressure on the cricoid ring, pushing the vocal cords downward so that
they are visualized more easily. Once begun, cricoid pressure must be maintained until intubation is completed (Fig. 2-1).
 FIGURE 2-1 Cricoid pressure. Firm dow nw ard pressure on the cricoid ring pushes the vocal cords dow nw ard tow ard the field of vision w hile sealing the
esophagus against the vertebral column.

• Two types of laryngoscope blades exist: straight and curved. The straight (Miller) blade is designed so that the tip
extends below the epiglottis, to lift and expose the glottic opening. The straight blade is recommended for use in
obese patients, pediatric patients, and patients with short necks because their tracheas may be located more
anteriorly. When a curved (Macintosh) blade is used, the tip is advanced into the vallecula (the space between the
epiglottis and the base of the tongue), to expose the glottic opening.
• Laryngoscope blades are available with fiberoptic light delivery systems. These systems provide a brighter light than
bulbs, which can become scratched or covered with secretions.
• Endotracheal tube size reflects the size of the internal diameter of the tube. Tubes range in size from 2.5 mm for
neonates to 9 mm for large adults. Endotracheal tubes that range in size from 7 to 7.5 mm are used for average-sized
adult women, whereas endotracheal tubes that range in size from 8 to 9 mm are used for average-sized adult men
(Fig. 2-2).8,9,12 The tube with the largest clinically acceptable internal diameter should be used to minimize airway
resistance and assist in suctioning.4

FIGURE 2-2 Parts of the endotracheal tube (soft-cuffed tube by Smiths Industries Medical Systems, Co, Valencia, Calif). (From Kersten LD: Comprehensive
respiratory nursing, Philadelphia, 1989, Saunders, 637.)

• Endotracheal intubation can be done via nasal or oral routes. The skill of the practitioner who performs the intubation
and the patient’s clinical condition determine the route used.
• Nasal intubation is relatively contraindicated in trauma patients with facial fractures or suspected fractures at the base
of the skull and after cranial surgeries, such as transnasal hypophysectomy.
• Improper intubation technique may result in trauma to the teeth, soft tissues of the mouth or nose, vocal cords, and
posterior pharynx.
• In patients with suspected spinal cord injuries, in-line cervical immobilization of the head must be maintained during
endotracheal intubation.
• Primary and secondary confirmation of endotracheal intubation should be performed.1,4
Primary confirmation of proper endotracheal tube placement includes visualization of the tube passing through the
vocal cords, absence of gurgling over the epigastric area, auscultation of bilateral breath sounds, bilateral chest rise
and fall during ventilation, and mist in the tube.
Secondary confirmation of proper endotracheal tube placement is necessary to protect against unrecognized
esophageal intubation. Methods include use of disposable end-tidal carbon dioxide (CO2 ) detectors, continuous
end-tidal CO2 monitors, and esophageal detection devices.
• End-tidal CO2 (PetCO2 ) monitoring devices have been shown to be reliable indicators of expired CO2 in patients with
perfusing rhythms.1,5,11,13,15 During cardiac arrest (nonperfusing rhythms), low pulmonary blood flow may cause
 insufficient expired CO2 .14 CO2 detected with an end-tidal CO2 detector is a reliable indicator of proper tube
placement.6 If CO2 is not detected, use of an esophageal detector device is recommended.1,3,11,15
• Disposable end-tidal CO2 detectors are chemically treated with a nontoxic indicator that changes color in the presence
of CO2 and indicates that the endotracheal tube has been placed successfully into the trachea.
• Continuous end-tidal CO2 monitors may be used to confirm proper endotracheal tube placement after intubation
attempts and allow for the detection of future tube dislodgment.
• Esophageal detector devices work by creating suction at the end of the endotracheal tube with compressing a flexible
bulb or pulling back on a syringe plunger. When the tube is placed correctly in the trachea, air allows for reexpansion
of the bulb or movement of the syringe plunger. If the tube is located in the esophagus, no movement of the syringe
plunger or reexpansion of the bulb is seen. These devices may be misleading in patients who are morbidly obese,
patients in status asthmaticus, patients late in pregnancy, or patients with large amounts of tracheal secretions.1
• Double-lumen endotracheal tubes are used for independent lung ventilation in situations with bleeding of one lung or
a large air leak that would impair ventilation of the good lung.
• The endotracheal tube also provides a route for the administration of emergency medications (e.g., lidocaine,
epinephrine, atropine, and naloxone) when no other routes of administration are available.4

EQUIPMENT
• Personal protective equipment, including eye protection
• Endotracheal tube with intact cuff and 15-mm connector (women, 7-mm to 7.5-mm tube; men, 8-mm to 9-mm tube)
• Laryngoscope handle with fresh batteries
• Laryngoscope blades (straight and curved)
• Spare bulb for laryngoscope blades
• Flexible stylet
• Self-inflating manual resuscitation bag-valve-mask device with face mask connected to supplemental oxygen (≥15
L/min)
• Oxygen source and connecting tubes
• Swivel adapter (for attachment to resuscitation bag or ventilator)
• Luer-tip 10-mL syringe for cuff inflation
• Water-soluble lubricant
• Rigid pharyngeal suction-tip (Yankauer) catheter
• Suction apparatus (portable or wall)
• Suction catheters
• Bite-block or oropharyngeal airway
• Endotracheal tube–securing apparatus or appropriate tape
Commercially available endotracheal tube holder
Adhesive tape (6 to 8 inches long)
Twill tape (cut into 30-inch lengths)
• Stethoscope
• Monitoring equipment: Continuous oxygen saturation and cardiac rhythm
• Secondary confirmation device: Disposable end-tidal CO2 detector, continuous end-tidal CO2 monitoring device, or
esophageal detection device
• Drugs for intubation as indicated (sedation, paralyzing agents, lidocaine, atropine)
Additional equipment (to have available depending on patient need or practitioner preference) includes the following:
• Anesthetic spray (nasal approach)
• Local anesthetic jelly (nasal approach)
• Magill forceps (to remove foreign bodies obstructing the airway)
• Ventilator

PATIENT AND FAMILY EDUCATION

• Assess patient’s and family’s level of understanding about the condition and rationale for endotracheal intubation.
Rationale: This assessment identifies the patient’s and family’s knowledge deficits concerning the patient’s condition,
the procedure, the expected benefits, and the potential risks. It also allows time for questions to clarify information
and voice concerns. Explanations decrease patient anxiety and enhance cooperation.
• Explain the procedure and the reason for intubation, if the clinical situation permits. If not, explain the procedure and
reason for the intubation after it is completed. Rationale: This explanation enhances patient and family
 understanding and decreases anxiety.
• If indicated and the clinical situation permits, explain the patient’s role in assisting with insertion of the endotracheal
tube. Rationale: This explanation elicits the patient’s cooperation, which assists with insertion.
• Explain that the patient will be unable to speak while the endotracheal tube is in place but that other means of
communication will be provided. Rationale: This information enhances patient and family understanding and
decreases anxiety.
• Explain that the patient’s hands often are immobilized to prevent accidental dislodgment of the tube. Rationale:
This information enhances patient and family understanding and decreases anxiety.

PATIENT ASSESSMENT AND PREPARATION

Patient Assessment
• Verify correct patient with two identifiers. Rationale: Prior to performing a procedure, the nurse should ensure the
correct identification of the patient for the intended intervention.
• Assess immediate history of trauma with suspected spinal cord injury or cranial surgery. Rationale: Knowledge of
pertinent patient history allows for selection of the most appropriate method for intubation, which helps reduce the
risk for secondary injury.
• Assess nothing-by-mouth (NPO) status, the use of a self-inflating manual resuscitation bag-valve device with mask
before intubation, and signs of gastric distention. Rationale: Increased risk of aspiration and vomiting occurs with
accumulation of air (from the use of a self-inflating manual resuscitation bag-valve-mask device), food, or secretions.
If a patient who has gastric distention or who has eaten recently needs to be intubated, anticipate the need to use
cricoid pressure to decrease the risk of aspiration.
• Assess level of consciousness, level of anxiety, and respiratory difficulty. Rationale: This assessment determines the
need for sedation or the use of paralytic agents and the patient’s ability to lie flat and supine for intubation.
• Assess oral cavity for presence of dentures, loose teeth, or other possible obstructions and remove if appropriate.
• Assess vital signs and for the following:
Tachypnea
Dyspnea
Shallow respirations
Cyanosis
Apnea
Altered level of consciousness
Tachycardia
Cardiac dysrhythmias
Hypertension
Headache
• Rationale: Any of these conditions may indicate a problem with oxygenation or ventilation or both.
• Assess patency of nares (for nasal intubation). Rationale: Selection of the most appropriate naris facilitates insertion
and may improve patient tolerance of tube.
• Assess need for premedication. Rationale: Various medications provide sedation or paralysis of the patient as
needed.

Patient Preparation
• Perform a pre-procedure verification and time out, if non-emergent. Rational: Ensures patient safety.
• Ensure that the patient understands preprocedural teaching, if appropriate. Answer questions as they arise, and
reinforce information as needed. Rationale: Understanding of previously taught information is evaluated and
reinforced.
• Before intubation, initiate intravenous or intraosseous access. Rationale: Readily available intravenous or
intraosseous access may be necessary if the patient needs to be sedated or paralyzed or needs other medications
because of a negative response to the intubation procedure.
• Position the patient appropriately.
Positioning of the nontrauma patient is as follows: Place the patient supine with the head in the sniffing position, in
which the head is extended and the neck is flexed. Placement of a small towel under the occiput elevates it several
inches, allowing for proper flexion of the neck (Fig. 2-3). Rationale: Placement of the head in the sniffing position
allows for visualization of the larynx and vocal cords by aligning the axes of the mouth, pharynx, and trachea.
 FIGURE 2-3 Neck hyperextension in the sniffing position aligns the axis of the mouth, pharynx, and trachea before endotracheal intubation. (From Kersten LD:
Comprehensive respiratory nursing, Philadelphia, 1989, Saunders, 642.)

Positioning of the trauma patient is as follows: Manual in-line cervical spinal immobilization must be maintained
during the entire process of intubation. Rationale: Because cervical spinal cord injury must be suspected in all
trauma patients until proved otherwise, this position helps prevent secondary injury should a cervical spine injury
be present.
• Premedicate as indicated. Rationale: Appropriate premedication allows for more controlled intubation, reducing
the incidence of insertion trauma, aspiration, laryngospasm, and improper tube placement.
• As appropriate, notify the respiratory therapy department of impending intubation so that a ventilator can be set up.
Rationale: The ventilator is set up before intubation.
Procedure for Performing Endotracheal Intubation
FIGURE 2-4 Technique of orotracheal intubation. The laryngoscope blade is inserted into the oral cavity from the right, pushing the tongue to the left as it is
introduced.
FIGURE 2-5 The blade is advanced into oropharynx, and the laryngoscope is lifted to expose the epiglottis.

FIGURE 2-6 The tip of the blade is placed in the vallecula, and the laryngoscope is lifted further to expose the glottis. The tube is inserted through the right
side of the mouth.
FIGURE 2-7 The endotracheal tube is passed through the vocal cords. (From Flynn JM, Bruce NP: Introduction to critical care skills, St Louis, 1993, Mosby, 56.)

FIGURE 2-8 The tube is advanced through the vocal cords into the trachea.
 FIGURE 2-9 The tube is positioned so that the cuff is below the vocal cords, and the laryngoscope is removed.

FIGURE 2-10 Methods of securing adhesive tape. Example protocol for securing the endotracheal tube w ith adhesive tape. 1, Clean the patient’s skin w ith
mild soap and w ater. 2, Remove oil from the skin w ith alcohol and allow to dry. 3, Apply a skin adhesive product to enhance tape adherence. (When tape is
removed, an adhesive remover is necessary.) 4, Place a hydrocolloid membrane over the cheeks to protect friable skin. 5, Secure w ith adhesive tape as
show n. (From Henneman E, Ellstrom K, St John RE: AACN protocols for practice: care of the mechanically ventilated patient series, Aliso Viejo, CA, 1999, American Association of
Critical-Care Nurses, 56.)

References
1. American Heart Association, Guidelines 2005 American Heart Association guidelines for cardiopulmonary
resuscitation and emergency cardiovascular care. adjuncts for airway control and ventilation. Circulation. 2005;
112((Suppl) IV):51–57.
2. Barnason, S, et al. Comparison of two endotracheal tube securement techniques on unplanned extubation,
oral mucosa, and facial skin integrity. Heart Lung. 1998; 27:409–417.
3. Bozeman, WP, et al. Esophageal detector device versus detection of end-tidal carbon dioxide level in
emergency intubation. Ann Emerg Med. 1996; 27:595–599.
4. Cummins RO, ed.. Airway, airway adjuncts, oxygenation, and ventilation. ACLS: principles and practice.
American Heart Association: Dallas, 2003:135–180.
5. Goldberg, JS, et al. Colorimetric end-tidal carbon dioxide monitoring for tracheal intubation. Anesth Analg.
1990; 70:191–194.
6. Hayden, SR, et al. Colorimetric end-tidal CO2 detector for verification of endotracheal tube placement in out-
of-hospital cardiac arrest. Acad Emerg Med. 1995; 2:499–502.
7. Hendey, GW, et al. The esophageal detector bulb in the aeromedical setting. J Emerg Med. 2002; 23:51–55.
8. Henneman, E, Ellstrom, E, St John RE, Airway management. AACN protocols for practice: care of the
mechanically ventilated patient series. American Association of Critical-Care Nurses, Aliso Viejo,CA, 1999.
9. Holleran, RS, Air and surface patient transport. principles and practice. ed 3. Mosby, St Louis, 2003.
10. Kasper, CL, et al. The self-inflating bulb to detect esophageal intubation during emergency airway
management. Anesthesiology. 1998; 88:898–902.
11. Schaller, RJ, et al, Comparison of a colorimetric end-tidal CO2 detector and an esophageal aspiration device for
verifying endotracheal tube placement in the prehospital setting. a six-month experience. Prehosp Disaster Med
1997; 12:57–63.
12. Stewart, C. Tracheal intubation. In: Stewart C, ed. Advanced airway management. New Jersey: Prentice Hall;
2002:76–113.
13. Takeda, T, et al. The assessment of three methods to verify tracheal tube placement in the emergency setting.
Resuscitation. 2003; 56:153–157.
14. Varon, AJ, et al. Clinical utility of a colorimetricend-tidal CO2 detector in cardiopulmonary resuscitation and
emergency intubation. J Clin Monit. 1991; 7:289–293.
15. Zaleski, L, et al. The esophageal detector device. Does it work. Anesthesiology. 1993; 79:244–247.

Additional Readings
Committee on Trauma, Americ an College of S urgeons. advanc ed trauma life support manual. Americ an College of S urgeons, Chic ago, 2004.
Ellis, DY, Harris, T, Zideman, D, Cric oid pressure in the -emergenc y department rapid sequenc e trac heal -intubation. a risk-benefit analysis. Ann Emerg Med 2007;
50:653–656.
Emergenc y Nurses Assoc iation, Trauma nursing c ore c ourse. provider manual. ed 6. Emergenc y Nurses Assoc iation, Des Plaines, IL, 2007.
National Assoc iation of Emergenc y Tec hnic ians, PHTLS . basic and advanc ed prehospital trauma life support. ed 5. Mosby, S t Louis, 2003.
Roberts JR, Hedges JR, eds. Clinic al proc edures in emergenc y medic ine, ed 4, Philadelphia: S aunders, 2004.

This proc edure should be performed only by physic ians, advanc ed prac tic e nurses, and other healthc are professionals (inc luding c ritic al c are nurses)

with additional knowledge, skills, and demonstrated c ompetenc e per professional lic ensure or institutional standard.