PROCEDURE

2 Endotracheal Intubation
(Perform)
Cindy Goodrich
PURPO SE: 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 • Videolaryngoscopy is gaining increased popularity as a

KNOWLEDGE method for oral intubation. This involves using fiberoptics
or a micro video camera encased in the laryngoscope that
• Anatomy and physiology of the pulmonary system should provides a wide-angle view of the glottic opening while
be understood. attempting oral intubation. Emerging literature supports
• Indications for endotracheal intubation include the this highly effective tool as a method to increase first-
following15,20: pass success by providing a superior view of the glottis
❖ Inadequate oxygenation and ventilation compared with traditional direct laryngoscopy.5,7,16 This
❖ Altered mental status (e.g., head injury, drug overdose) method also requires minimal lifting force, resulting in
for airway protection less movement of the cervical spine during intubation.13
❖ Anticipated airway obstruction (e.g., facial burns, epi- • Endotracheal tube size reflects the size of the internal
glottitis, major facial or oral trauma) diameter of the tube. Tubes range in size from 2 mm for
❖ Upper airway obstruction (e.g., from swelling, trauma, neonates to 9 mm for large adults. Endotracheal tubes that
tumor, bleeding) range in size from 7 to 7.5 mm are used for average-sized
❖ Apnea adult women, whereas endotracheal tubes that range in
❖ Ineffective clearance of secretions (i.e., inability to size from 8 to 9 mm are used for average-sized adult men
maintain or protect airway adequately) (Fig. 2-1).9,10,20 The tube with the largest clinically accept-
❖ High risk of aspiration able internal diameter should be used to minimize airway
❖ Respiratory distress, respiratory failure resistance and assist in suctioning.
• Pulse oximetry should be used during intubation so that • Double-lumen endotracheal tubes are used for indepen-
oxygen desaturation can be quickly detected and treated dent lung ventilation in situations with bleeding of one
(see Procedure 18).3,14 lung or a large air leak that would impair ventilation of
• Proper positioning of the patient is critical for successful the good lung.
intubation. • The patient’s airway should be assessed before intubation.
• Two types of laryngoscope blades exist: straight and The LEMON© mnemonic can be used to determine
curved. The straight (Miller) blade is designed so that the whether a difficult intubation is anticipated.3
tip extends below the epiglottis, to lift and expose the ❖ L = Look Externally: look for features associated with
glottic opening. The straight blade is recommended for a difficult intubation such as a short neck, prominent
use in obese patients, pediatric patients, and patients with incisors, broken teeth, a large protruding tongue, a
short necks because their tracheas may be located more narrow or abnormally shaped face, a receding jaw, or
anteriorly. When a curved (Macintosh) blade is used, the a prominent overbite.3
tip is advanced into the vallecula (the space between the ❖ E = Evaluate using the 3-3-2 rule: These three rules
epiglottis and the base of the tongue), to expose the glottic help to determine whether there will be alignment of
opening. the pharyngeal, laryngeal, and oral axes.3
• Laryngoscope blades are available with bulbs or with a Three fingers: distance between upper and lower
fiberoptic light delivery system. Fiberoptic light delivery incisors in the mouth opening
systems provide a brighter light. Bulbs are prone to Three fingers: distance between tip of chin and chin-
becoming scratched or covered with secretions. neck junction (hyoid bone)
Two fingers: distance between thyroid cartilage and
mandible
❖ M = Mallampati Grade: This scoring system provides
This procedure should be performed only by physicians, advanced
practice nurses, and other healthcare professionals (including critical care an estimate of the space available for oral intubation
nurses) with additional knowledge, skills, and demonstrated competence per using direct laryngoscopy. It relates the amount of
professional licensure or institutional standard. mouth opening to the size of the tongue. Classes1 and

8
 2 Endotracheal Intubation (Perform) 9

Figure 2-1 Parts of the endotracheal tube (Soft-Cuffed Tube by Smiths Industries Medical
Systems, Co, Valencia, CA). (From Kersten LD: Comprehensive respiratory nursing, Philadelphia,
1989, Saunders, 637.)

2 predict a routine laryngoscopy, class 3 predicts dif-

ficulty, and class 4 predicts extreme difficulty. The
patient is asked to open his or her mouth as wide as
possible, sticking the tongue out. Look into the mouth
using a light to assess the amount of hypopharynx that
is visible.3
❖ O = Obstruction: Look for causes that might interfere
with intubation, such as tonsillar abscess, epiglottitis,
trauma, tumors, swollen tongue, and obesity.3
❖ N = Neck Mobility: Look for conditions that might
limit neck range of motion such as a hard cervical
collar (trauma), ankylosing spondylitis, previous neck
surgery, and rheumatoid arthritis. If trauma is not sus-
pected, ask the patient to touch his or her chin to his
or her chest and extend the neck to the ceiling.3
• Visualization of the vocal cords can be aided by using
laryngeal manipulation. This is accomplished by applying Figure 2-2 Cricoid pressure. Firm downward pressure on the
cricoid ring pushes the vocal cords downward toward the field of
backward, upward, and rightward pressure (BURP) on the vision while sealing the esophagus against the vertebral column.
thyroid cartilage to move the larynx to the right while the
tongue is displaced to the left by the laryngoscope blade.3
• Application of cricoid pressure (Sellick maneuver) may patients with facial fractures or suspected fractures at the
increase the success of the intubation as long as it does base of the skull, and after cranial surgeries, such as trans-
not interfere with ventilation or placement of the endotra- nasal hypophysectomy.3
cheal tube. This procedure is accomplished by applying • Improper intubation technique may result in trauma to the
firm downward pressure on the cricoid ring, pushing the teeth, soft tissues of the mouth or nose, vocal cords, and
vocal cords downward so that they are visualized more posterior pharynx.
easily (Fig. 2-2).When applied correctly it may protect • In trauma patients with suspected spinal cord injuries and
against insufflation of the stomach and aspiration of the those not completely evaluated, manual in-line cervical
lungs. If applied incorrectly it may interfere with ventila- immobilization of the head must be maintained during
tion and make laryngoscopy intubation more difficult. endotracheal intubation to keep the head in a neutral posi-
Once begun, cricoid pressure must be maintained until tion. An assistant should be directed to manually immo-
intubation is completed unless there is difficulty intubat- bilize the head and neck by placing his or her hands on
ing or ventilating the patient. The routine use of cricoid either side of the patient’s head, with thumbs along the
pressure is not recommended during cardiac arrest.14 mandible and fingers behind the head on the occipital
• Endotracheal intubation can be done via nasal or oral ridge. Gentle but firm stabilization should be maintained
routes. The route selected will depend on the skill of the throughout the procedure.3,10
practitioner performing the intubation and the patient’s • Confirmation of endotracheal tube placement should be
clinical condition. done immediately after intubation to protect against unrec-
• Nasal intubation requires a patient who is breathing spon- ognized esophageal intubation. This includes using both
taneously and is relatively contraindicated in trauma clinical findings and end-tidal carbon dioxide(CO2).3,4,14
10 Unit I Pulmonary System

❖Clinical findings consistent with tracheal placement • This procedure should be performed only by physicians,
include visualization of the tube passing through the advanced practice nurses, and other healthcare profession-
vocal cords, absence of gurgling over the epigastric area, als (including critical care nurses) with additional knowl-
auscultation of bilateral breath sounds, bilateral chest edge, skills, and demonstrated competence per professional
rise and fall during ventilation, and mist in the tube.14,15 licensure and institutional standard.
❖ End-tidal CO2 detectors assist in confirming proper
placement of the endotracheal tube into the trachea (see EQUIPMENT
Procedure 14). The presence of CO2 in the expired air
indicates that the airway has been successfully intu- • Personal protective equipment, including eye protection
bated, but does not ensure the correct position of the • Endotracheal tube with intact cuff and 15-mm connector
endotracheal tube. (women, 7-mm to 7.5-mm tube; men, 8-mm to 9-mm tube)
❖ Disposable end-tidal CO2 detectors are chemically • Laryngoscope handle with fresh batteries
treated with a nontoxic indicator that changes color in • Laryngoscope blades (straight and curved)
the presence of CO2. • Spare bulb for laryngoscope blades
❖ Continuous end-tidal CO2 (capnography) assists in • Flexible stylet
confirming proper placement of the endotracheal tube • Magill forceps (to remove foreign bodies obstructing the
into the trachea as well as allowing for detection of airway if present)
future tube dislodgment. • Self-inflating manual resuscitation bag-valve-mask device
❖ During cardiac arrest (nonperfusing rhythms), low with tight fitting face mask connected to supplemental
pulmonary blood flow may cause insufficient expired oxygen (15 L/min)
CO2.22 If CO2 is not detected, use of an esophageal • Oxygen source
detector device is recommended for confirmation of • Luer-tip 10-mL syringe for cuff inflation
proper placement into the trachea.2,3,14,18,23 • Water-soluble lubricant
❖ At least five to six exhalations with a consistent CO2 • Rigid pharyngeal suction-tip (Yankauer) catheter
level must be assessed to confirm endotracheal tube • Suction apparatus (portable or wall)
placement in the trachea because the esophagus may • Suction catheters
yield a small but detectable amount of CO2 during the • Bite-block or oropharyngeal airway
first few breaths.15 • Endotracheal tube–securing apparatus or appropriate tape
❖ Esophageal detector devices work by creating suction ❖ Commercially available endotracheal tube holder
at the end of the endotracheal tube by compressing a ❖ Adhesive tape (6 to 8 inches long)
flexible bulb or pulling back on a syringe plunger. • Stethoscope
When the tube is placed correctly in the trachea, air • Monitoring equipment: cardiac monitor, pulse oximetry,
allows for reexpansion of the bulb or movement of the and sphygmomanometer
syringe plunger. If the tube is located in the esophagus, • Disposable end-tidal CO2 detector, continuous end-tidal
no movement of the syringe plunger or reexpansion of CO2 monitoring device, and esophageal detection device
the bulb is seen. These devices may be misleading in • Drugs for intubation as indicated (induction agent, seda-
patients who are morbidly obese, in status asthmaticus, tion, paralyzing agents, lidocaine, atropine)
late in pregnancy, or in patients with large amounts of • Assortment of oropharyngeal airways and nasopharyngeal
tracheal secretions.14 airways
• Endotracheal tube cuff pressure should be checked after • Rescue airways such as LMA, King LT, or Combitube
verifying correct endotracheal tube position. The cuff • Failed airway equipment: gum elastic bougie, videolaryn-
pressure recommended for assistance in preventing both goscope, optical stylet fiberoptic scope, and cricothyroid-
microaspiration and tracheal damage is 20 to 30 cm otomy kit
H2O.11,17,19 Additional equipment, to have available as needed, includes
• Intubation attempts should take no longer than 15 to 20 the following:
seconds. If more than one intubation attempt is necessary, • Anesthetic spray (nasal approach)
ventilation with 100% oxygen using a self-inflating • Local anesthetic jelly (nasal approach)
manual resuscitation bag device with a tight-fitting face • Ventilator
mask should be performed for 3 to 5 minutes before each
attempt. If intubation is not successful after three attempts, PATIENT AND FAMILY EDUCATION
consider using another airway adjunct, such as a laryngeal
mask airway (LMA), Combitube, or King LT Airway (see • If time permits, assess the patient’s and the family’s level
Procedures 1, 7, and 8). of understanding about the condition and rationale for
• It is important to have a clearly defined difficult/failed endotracheal intubation. Rationale: This assessment iden-
airway plan and alternative airway equipment available at tifies the patient’s and the family’s knowledge deficits
the bedside in case of unsuccessful intubation. This may concerning the patient’s condition, the procedure, the
consist of a gum elastic bougie, LMA, and videolaryngo- expected benefits, and the potential risks. It also allows
scope. Surgical airway equipment such as that needed for time for questions to clarify information and voice con-
a cricothyroidotomy should be available at the bedside in cerns. Explanations decrease patient anxiety and enhance
case of a failed airway.15 cooperation.
 2 Endotracheal Intubation (Perform) 11

• Explain the procedure and the reason for intubation, if the

clinical situation permits. If not, explain the procedure and Patient Preparation
reason for the intubation after it is completed. Rationale: • Perform a preprocedure verification and time out. Ratio-
This explanation enhances patient and family understand- nal: Ensures patient safety.
ing and decreases anxiety. • Ensure that the patient understands preprocedural teach-
• If indicated and the clinical situation permits, explain the ing, if appropriate. Answer questions as they arise, and
patient’s role in assisting with insertion of the endotra- reinforce information as needed. Rationale: Understand-
cheal tube. Rationale: This explanation elicits the patient’s ing of previously taught information is evaluated and
cooperation, which assists with insertion. reinforced.
• Explain that the patient will be unable to speak while the • Before intubation, initiate intravenous or intraosseous
endotracheal tube is in place but that other means of com- access. Rationale: Readily available intravenous or
munication will be provided. Rationale: This information intraosseous access may be necessary if the patient
enhances patient and family understanding and decreases needs to be sedated or paralyzed or needs other medica-
anxiety. tions because of a negative response to the intubation
• Explain that the patient’s hands are often immobilized to procedure.
prevent accidental dislodgment of the tube. Rationale: • Position the patient appropriately.
This information enhances patient and family understand- ❖ Positioning of the nontrauma patient is as follows:
ing and decreases anxiety. 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
PATIENT ASSESSMENT AND elevates it several inches, allowing for proper flexion
PREPARATION of the neck (Fig. 2-3). Rationale: Placement of the
head in the sniffing position allows for better visualiza-
Patient Assessment tion of the larynx and vocal cords by aligning the axes
• Verify correct patient with two identifiers. Rationale: of the mouth, pharynx, and trachea.
Prior to performing a procedure, the nurse should ensure ❖ Positioning of the trauma patient is as follows: manual
the correct identification of the patient for the intended in-line cervical spinal immobilization must be main-
intervention. tained during the entire process of intubation. Ratio-
• Assess for recent history of trauma with suspected spinal nale: Because cervical spinal cord injury must be
cord injury or cranial surgery. Rationale: Knowledge of suspected in all trauma patients until proved otherwise,
pertinent patient history allows for selection of the most this position helps prevent secondary injury should a
appropriate method for intubation, which helps reduce the cervical spine injury be present.
risk of secondary injury. • Premedicate as indicated. Rationale: Appropriate pre-
• Assess nothing-by-mouth status, the use of a self-inflating medication allows for more controlled intubation, reduc-
manual resuscitation bag-valve device with mask before ing the incidence of insertion trauma, aspiration,
intubation, and for signs of gastric distention. Rationale: laryngospasm, and improper tube placement.
Increased risk of aspiration and vomiting occurs with • As appropriate, notify the respiratory therapy department
accumulation of air (from the use of a self-inflating of impending intubation so that a ventilator can be set up.
manual resuscitation bag-valve-mask device), food, or Rationale: The ventilator is set up before intubation.
secretions.
• Assess level of consciousness, level of anxiety, and respi-
ratory 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.
Rationale: Ensures that the airway is free from any
obstructions.
• Assess vital signs and assess for the following: tachypnea,
dyspnea, shallow respirations, cyanosis, apnea, altered
level of consciousness, tachycardia, cardiac dysrhythmias,
hypertension, and headache. Rationale: Any of these con-
ditions may indicate a problem with oxygenation or ven-
tilation or both.
• Assess patency of nares (for nasal intubation). Rationale:
Selection of the most appropriate naris facilitates insertion
and may improve patient tolerance of the tube. Figure 2-3 Neck hyperextension in the sniffing position aligns
• Assess need for premedication. Rationale: Various medi- the axis of the mouth, pharynx, and trachea before endotracheal
cations provide sedation or paralysis of the patient as intubation. (From Kersten LD: Comprehensive respiratory nursing,
needed. Philadelphia, 1989, Saunders, 642.)
12 Unit I Pulmonary System

Procedure for Performing Endotracheal Intubation

Steps Rationale Special Considerations
General Setup
1. HH
2. PE
3. Establish intravenous or Provides access to deliver indicated
intraosseous access if not present. medications.
4. Attach patient to monitoring Provides continuous patient
equipment including cardiac and monitoring during intubation.
blood pressure monitor and pulse
oximeter.
5. Set up suction apparatus, and Prepares for oropharyngeal
connect rigid suction-tip catheter suctioning as needed.
to tubing.
6. Check equipment.
A. Choose appropriate-sized Appropriate-sized endotracheal Generally a 7–7.5-mm internal
endotracheal tube. tubes facilitate both intubation diameter tube is used for adult
and ventilation. females and an 8–9-mm internal
diameter for adult males.9,10,14,20
B. Use 10-mL syringe to inflate Verifies that equipment is functional Once the endotracheal tube cuff has
cuff on tube, assessing for and that tube cuff is patent been checked for leaks and it is
leaks. Completely deflate cuff. without leaks; prepares tube for completely deflated, place back into
insertion. its packaging to avoid
contamination.
C. Insert the stylet into the Provides structural support for the Stylet must be recessed by at least 0.5
endotracheal tube, ensuring flexible endotracheal tube during inch from the distal end of the tube
that the tip of the stylet does insertion. Maintaining the tip of so that it does not protrude beyond
not extend past the end of the the stylet within the lumen of the the end of the tube.
endotracheal tube. endotracheal tube prevents
damage to the vocal cords and
trachea.
D. Connect the laryngoscope Verifies that the equipment is Check the bulb for brightness.
blade to the handle, and functional. Replace bulb if dull or burnt out.
ensure the blade’s bulb is
securely seated.
7. Assess patient’s airway to Use of LEMON© mnemonic can
determine whether a difficult assist in determination of difficult
intubation is anticipated. intubation.3
(Level D*)
8. Position the patient’s head by Allows for visualization of the The ear (external auditory meatus) and
flexing the neck forward and vocal cords with alignment of the sternal notch should be aligned when
extending the head, in sniffing mouth, pharynx, and trachea. patient is examined from the side.
position (only if neck trauma is This allows for flexion of the
not suspected; see Fig. 2-3). If cervical spine.15 Placement of a
spinal trauma is suspected, small towel under the occiput
request that an assistant maintain elevates it, allowing for proper neck
the head in a neutral position flexion. Do not flex or extend neck
with in-line spinal of patient with suspected spinal cord
immobilization. injury; the head must be maintained
in a neutral position with manual
in-line cervical spine
immobilization.3
9. Check the mouth for dentures and Dentures should be removed before
remove if present. oral intubation is attempted but
may remain in place for nasal
intubation.

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.
 2 Endotracheal Intubation (Perform) 13

Procedure for Performing Endotracheal Intubation—Continued

Steps Rationale Special Considerations
10. Suction the mouth and pharynx Provides for a clear view of the
as needed if copious secretions posterior pharynx and larynx.
are visualized.
11. Insert oropharyngeal airway if Assists in maintenance of upper Use only in unconscious patients with
indicated (see Procedure 9). airway patency. Helps to improve an absent gag reflex.
ability to ventilate during
bag-valve-mask ventilation.
12. Preoxygenate for 3–5 minutes, Helps prevent hypoxemia. Gentle Bag-valve-mask ventilation may not be
with 100% oxygen via a breaths reduce incidence of air needed in the spontaneous breathing
nonrebreather mask if ventilations entering stomach (leading to patient. Avoid aggressive positive-
are adequate or via a self-inflating gastric distention, aspiration), pressure ventilation with a self-
manual resuscitation bag-valve- decrease airway turbulence, and inflating manual resuscitation bag
mask device (see Procedure 31) if distribute ventilation more evenly because this may increase the risk
ventilations are inadequate. within the lungs. for gastric vomiting.
(Level D*) Preoxygenation ensures that
nitrogen is washed out of the
lungs and will extend the
allowable apneic time until the
oxygen in the lungs is used up.4,15
13. Premedicate patient as indicated. Sedates and relaxes the patient,
allowing easier intubation.
14. Remove oropharyngeal airway if Clears the airway for advancement
present. of the laryngoscope blade and
For nasotracheal intubation, proceed endotracheal tube.
to Step 35
Orotracheal Intubation
15. Grasp laryngoscope (with blade Prepares for efficient blade Grasp handle as low as possible and
in place and illuminated light on) placement. keep wrist rigid to prevent using
in left hand. upper teeth as a fulcrum.
16. Use fingers of right hand to open Provides access to oral cavity. Use a scissor-like motion with thumb
the mouth. and second finger of right hand to
gently open the mouth. Hold the tips
of the thumb and middle finger of
the right hand together. Insert them
between the upper and lower
incisors. Using a scissor-like motion
move fingers past one another by
flexing each finger.15
17. Using a controlled motion, slowly Displaces the tongue to the left, Avoid pressure on the teeth and lips.
insert the blade into the right side increasing visualization of the Inserting the blade smoothly and
of the patient’s mouth, using it to glottic opening (Fig. 2-5). quickly obtaining an optimal view of
push the tongue to the left (Fig. the glottis opening will help to
2-4). Advance the blade inward increase first-pass success.15 If the
and toward midline past the base patient’s chest is obstructing
of the tongue. placement of the laryngoscope
handle, consider placing blankets or
towels under the head and upper
back to elevate the head relative to
the chest. Do not do this if cervical
spine injury is suspected.15 In trauma
victims, consider turning the handle
90 degrees to insert the blade into
the mouth and rotate to midline as
the blade is advanced.

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.

Procedure continues on following page

14 Unit I Pulmonary System

Procedure for Performing Endotracheal Intubation—Continued

Steps Rationale Special Considerations

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 the oropharynx, and the laryn-
goscope is lifted to expose the epiglottis.

18. Visually identify the epiglottis Identification of anatomical External laryngeal manipulation
and vocal cords. landmarks provides landmarks for (BURP) may assist with
successful intubation visualization of the vocal cords.3
Apply BURP on the thyroid cartilage
to move the larynx to the right while
the tongue is displaced to the left by
the laryngoscope blade.3 This may
be done by the intubator or by an
assistant.
Cricoid pressure (Sellick maneuver)
may provide increased visualization
of the vocal cords by moving the
trachea posteriorly. This is
accomplished by applying firm
downward pressure on the cricoid
ring, pushing the vocal cords
downward so that they are visualized
more easily (see Fig. 2-1). Once
cricoid pressure is applied, it must
be maintained until the intubation is
completed. The routine use of
cricoid pressure is not recommended
during cardiac arrest.14
 2 Endotracheal Intubation (Perform) 15

Procedure for Performing Endotracheal Intubation—Continued

Steps Rationale Special Considerations
19. Carefully advance the blade Identification of the epiglottis is key
toward the epiglottis in a well- for successful direct laryngoscopy
controlled manner. intubation.
A. With a curved blade, advance Exposes the glottic opening. Keep left arm and back straight when
tip into vallecula (area This lifting motion elevates the pulling upward, allowing for use of
between the base of the epiglottis, keeping the tongue out shoulders when lifting patient’s head
tongue and the epiglottis) and of the way, allowing for maximal to the bed (Fig. 2-6). Levering back
exert outward and upward exposure of the glottis. on the laryngoscope handle will
gentle traction at a 45-degree impair the view and may damage the
angle (decreases the risk of teeth. Touching the teeth indicates
teeth inadvertently being used excessive levering or ineffective
as a fulcrum). Lift the lift.15
laryngoscope in the direction
of the handle to lift the tongue
and posterior pharyngeal
structures out of the way,
allowing for exposure of the
glottis opening. Do not allow
the handle to lever back,
causing the blade to hit the
teeth.

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.

B. With a straight blade, advance Exposes the glottic opening. Keep left arm and back straight when
tip just beneath the epiglottis Using the paraglossal technique pulling upward, allowing for use of
and exert gentle traction allows for a better view by shoulders when lifting patient’s head
outward and upward at a displacing the tongue with (decreases use of teeth as a fulcrum).
45-degree angle to the bed. minimal effort.15 Using a straight blade may provide a
Blade may be inserted to the better view when the larynx is more
right of the tongue into the anterior or in those with a receding
natural gutter between the chin.15 Midline insertion of the blade
lower molars (paraglossal often results in difficulty in
technique) or midline.15 Do controlling the tongue which may
not allow the handle to lever obscure the view, particularly in
back, causing the blade to hit unconscious adults.
the teeth.
20. Lift the laryngoscope handle up Allows for correct placement of Do not use the blade as a pry bar; this
and away from the operator (at a tube into trachea (Fig. 2-7). may result in damage to the teeth or
45- to 55-degree angle from the mouth.15
trachea) until the vocal cords are BURP may assist with visualization of
visualized. the vocal cords.3
Procedure continues on following page
16 Unit I Pulmonary System

Procedure for Performing Endotracheal Intubation—Continued

Steps Rationale Special Considerations

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.)

21. Hold end of tube in right hand Tube is placed with the right hand.
with curved portion downward.
22. With use of direct vision, gently Tube must be seen passing through The front teeth or gums should be
insert tube from right corner of the vocal cords to ensure proper aligned between the 19-cm and
mouth through the vocal cords placement. Advance tube 1.25– 23-cm depth markings on the tube to
(Fig. 2-8) until the cuff is no 2.5 cm farther into the trachea. ensure the tip of the tube is above
longer visible and has passed When correctly positioned, the tip the carina.4 Common tube placement
through the vocal cords (Fig. of the tube should be halfway at the teeth or gums is 20–21 cm for
2-9). Do not apply pressure on between the vocal cords and the women and 22–23 cm for men.10,15
the teeth or oral tissues. carina.4,14 If intubation is unsuccessful within 30
seconds, or the patient’s oxygen
saturations falls below 90% during
the attempt, remove the tube.15
Ventilate with 100% oxygen with a
bag-valve-mask device before
another intubation attempt is made
(repeat Steps 13 through 20).
Before reattempting intubation, correct
problems related to positioning,
procedure, or equipment.
 2 Endotracheal Intubation (Perform) 17

Procedure for Performing Endotracheal Intubation—Continued

Steps Rationale Special Considerations

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.

23. When the tube is correctly Firmly holding tube at the lips An assistant may remove the stylet
placed, continue to hold it provides stabilization and while the intubator firmly holds the
securely in place at the lips with prevents inadvertent extubation. endotracheal tube in place,
right hand while first withdrawing preventing dislodgement of the tube.
the laryngoscope blade and then
the stylet with left hand.
24. Inflate cuff with 5–10 mL of air Inflation volumes vary depending In adults, decreased mucosal capillary
depending on the manufacturer ’s on manufacturer and size of tube. blood flow (ischemia) results when
recommendation. Do not Keep cuff pressure between 20 pressure is greater than 40 mm
overinflate the cuff. (Level M*) and 30 mm Hg to decrease risk of Hg.4,14
aspiration and prevent ischemia Consider using manometer to measure
and decreased blood flow.11,14 cuff pressure and increase or
decrease pressure as indicated to
achieve cuff pressure of 20–30 mm
Hg.11,14
25. Confirm endotracheal tube Ensures correct placement of
placement while manually endotracheal tube.
bagging with 100% oxygen.
A. Auscultate over epigastrium. Allows for identification of If air movement or gurgling is heard,
(Level D*) esophageal intubation.4,14 esophageal intubation has occurred.
The tube must be removed and
intubation reattempted. Improper
insertion may result in hypoxemia,
gastric distention, vomiting, and
aspiration.

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.
*Level M: Manufacturer’s recommendations only.

Procedure continues on following page

18 Unit I Pulmonary System

Procedure for Performing Endotracheal Intubation—Continued

Steps Rationale Special Considerations
B. Auscultate lung bases and Assists in verification of correct
apices for bilateral breath tube placement into the trachea. A
sounds. (Level D) right main-stem bronchus
intubation results in diminished
left-sided breath sounds.3,4
C. Observe for symmetrical chest Assists in verification of correct Absence may indicate right main stem
wall movement. (Level D) tube placement.3,4,14 or esophageal intubation.
D. Attach disposable end-tidal Disposable CO2 detectors may be CO2 detectors usually are placed
CO2 detector. Watch for color used to assist with identification between the self-inflating manual
change, which indicates the of proper tube placement.6,9,18,21 resuscitation bag-valve mask device
presence of CO2. (Level B*) Detection of CO2 confirms proper and the endotracheal tube. CO2
endotracheal tube placement into detectors should be used in
the trachea.3,4,14 conjunction with physical
assessment findings. At least five to
six exhalations with a consistent
CO2 level must be assessed to
confirm endotracheal tube placement
in the trachea because the esophagus
may yield a small but detectable
amounts of CO2 during the first few
breaths.15
or
Attach continuous end-tidal CO2 Continuous end-tidal CO2 is a At least five to six exhalations with a
monitor and watch for detection of reliable indicator of proper tube consistent CO2 level must be
CO2 (see Procedure 14). (Level B) placement and also allows for assessed to confirm endotracheal
detection of future tube tube placement in the trachea since
dislodgment.14 the esophagus may yield small but
detectable amounts of CO2 during
the first few breaths.15
or
Consider use of esophageal detection During cardiac arrest (nonperfusing
device in cardiac arrest. (Level B) rhythms), low pulmonary blood
flow may cause insufficient
expired CO2.22
If CO2 is not detected, use of an
esophageal detector device is
recommended.2,8,12,18,23
E. Evaluate oxygen saturation Spo2 decreases if the esophagus has Spo2 findings should be used in
(Spo2) with noninvasive pulse been inadvertently intubated. The conjunction with physical
oximetry. (see Procedure 18). value may or may not change in a assessment findings.
(Level D) right main-stem bronchus
intubation.4,14
26. If CO2 detection, assessment Esophageal intubation results in gas
findings, or Spo2 reveals that the flow diversion and hypoxemia.4,14
tube is not correctly positioned,
deflate cuff and remove tube
immediately. Ventilate and
hyperoxygenate with 100%
oxygen for 3–5 minutes, then
reattempt intubation, beginning
with Step 13.

*Level B: Well-designed, controlled studies with results that consistently support a specific action, intervention, or treatment.
*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.
 2 Endotracheal Intubation (Perform) 19

Procedure for Performing Endotracheal Intubation—Continued

Steps Rationale Special Considerations
27. If breath sounds are absent on the Absence of breath sounds on the When correctly positioned, the tube tip
left, deflate the cuff and withdraw left may indicate right main-stem should be halfway between the vocal
tube 1-2 cm. Reevaluate for intubation, which is common cords and the carina.
correct tube placement (Step 25). because of the anatomical
position of the right main-stem
bronchi.2
28. Connect endotracheal tube to Reduces motion on tube and mouth
oxygen source via self-inflating or nares.
manual resuscitation bag-valve
device, or mechanical ventilator,
using swivel adapter.
29. Insert a bite-block or Prevents the patient from biting The bite-block should be secured
oropharyngeal airway (to act as a down on the endotracheal tube. separately from the tube to prevent
bite-block) along the endotracheal dislodgment of the tube.
tube, with oral intubation if
indicated.
30. Secure the endotracheal tube in Prevents inadvertent dislodgment of Commercial tube holder or tape should
place (according to institutional tube.1,4,9,14 not cause compression on sides or
standard). (Level B*) front of the neck, which may result
in impaired venous return to the
brain.14
Consider manually holding the
endotracheal tube when moving the
patient to prevent inadvertent
dislodgement of the tube.
Use of Commercially Available Endotracheal Tube Holder
A. Apply according to Allows for secure stabilization of Commercially available tube holders
manufacturer ’s directions. the tube, decreasing the are often more comfortable for
(Level M*) likelihood of inadvertent patients and easier to manage if the
extubation. endotracheal tube is manipulated.15
Use of Adhesive Tape
A. Prepare tape as shown in Fig. Use of a hydrocolloid membrane on
2-10. the patient’s cheeks helps protect
the skin.
Second piece of adhesive
Adhesive tape stuck to first piece Figure 2-10 Methods of securing adhesive tape. Example
(sticky side) (nonsticky) protocol for securing the endotracheal tube with adhesive
Tear in end tape. 1. Clean the patient’s skin with mild soap and water. 2.
of tape Remove oil from the skin with alcohol and allow to dry. 3.
Apply a skin adhesive product to enhance tape adherence.
(When the tape is removed, an adhesive remover is neces-
sary.) 4. Place a hydrocolloid membrane over the cheeks to
protect friable skin. 5. Secure with adhesive tape as shown.
(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.)

*Level B: Well-designed, controlled studies with results that consistently support a specific action, intervention, or treatment.
*Level M: Manufacturer’s recommendations only.

Procedure continues on following page

20 Unit I Pulmonary System

Procedure for Performing Endotracheal Intubation—Continued

Steps Rationale Special Considerations
B. Secure tube by wrapping Secures the endotracheal tube in Tape should not cause compression on
double-sided tape around place. sides or front of the neck, which
patient’s head and torn tape may impair venous return to the
edges around endotracheal brain.14
tube.
31. Reevaluate for correct tube Verifies that the tube was not
placement (Step 25). inadvertently displaced during the
securing of the tube.
32. Note position of tube at teeth or Establishes a baseline for future Common tube placement at the teeth
gums (use centimeter markings assessment of possible or gums is 20–21 cm for women and
on tube). endotracheal tube migration, in or 22–23 cm for men.10,15
out.
33. Hyperoxygenate and suction Removes secretions that may
endotracheal tube and pharynx obstruct tube or accumulate on
(see Procedure 10) as needed. the top of the cuff.
34. Confirmation of correct tube Chest radiograph documents actual Because a chest radiograph is not
position should be verified with a tube location (distance from the immediately available, it should not
chest radiograph. (Level D*) carina). be used as the primary method of
tube assessment.3,10,14
Nasotracheal Intubation
35. Follow Steps 1 through 14. Steps necessary to initiate nasal Dentures may be left in place for
intubation. nasotracheal intubation.
36. Spray nasal passage with Anesthetizes and vasoconstricts
anesthetic and vasoconstrictor, as nasal mucosa to decrease
indicated or ordered. incidence of trauma and bleeding.
37. Lubricate tube with local Allows for smooth passage of tube.
anesthetic jelly.
38. Slowly insert tube into selected Tube is introduced into airway
naris, and guide tube up from the channel.
nostril, then backward and down
into the nasopharynx.
39. Gently advance the tube until Tube is located at opening of Breath sounds become maximal just
maximal sound of moving air is trachea. before entering the glottis.
heard through the tube.
40. While listening, continue to Facilitates movement of tube Magill forceps may assist with
advance tube during inspiration. through glottic opening. advancement of tube.
41. When endotracheal tube is A properly inflated cuff will
placed, inflate cuff. (See Step 24) minimize secretion aspiration and
facilitate stabilization in the
trachea.
42. Follow Steps 25-28 and 30-34 to For nasotracheal intubation note
evaluate tube placement and position of tube at nare.
secure tube in place.
43. Remove PE . Reduces transmission of
microorganisms and body
secretions; Standard Precautions.
44. HH

*Level D: Peer-reviewed professional and organizational standards with the support of clinical study recommendations.
 2 Endotracheal Intubation (Perform) 21

Expected Outcomes Unexpected Outcomes

• Placement of patent artificial airway • Intubation of esophagus or right main-stem bronchus
• Properly positioned and secured airway (improper tube placement)
• Improved oxygenation and ventilation • Accidental extubation
• Facilitation of secretion clearance • Cardiac dysrhythmias because of hypoxemia and
vagal stimulation
• Broken or dislodged teeth
• Leaking of air from endotracheal tube cuff
• Oral or nasal trauma with bleeding
• Tracheal injury at tip of tube or at cuff site
• Laryngeal edema
• Vocal cord trauma
• Suctioning of gastric contents or food from
endotracheal tube (aspiration)
• Obstruction of endotracheal tube

Patient Monitoring and Care

Steps Rationale Reportable Conditions
These conditions should be reported
if they persist despite nursing
interventions.
1. Auscultate breath sounds on Allows for detection of tube • Absent, decreased, or unequal
insertion, with every manipulation movement or dislodgment. breath sounds
of the endotracheal tube and every
2–4 hours and as needed.
2. Maintain tube stability, with use of Reduces risk of movement and • Unplanned extubation
specially manufactured holder, twill dislodgment of tube.
tape, or adhesive tape.
3. Monitor and record position of tube Provides for identification of • Tube movement from original
at teeth, gums, or nose (in reference tube migration. position
to centimeter markings on tube).
4. Maintain endotracheal tube cuff Provides adequate inflation to • Cuff pressure less than 20 or
pressure of 20–30 mm Hg.11,14 decrease aspiration risk and higher than 30 mm Hg that
prevents overinflation of cuff persists despite nursing
to avoid tracheal damage.11,14 interventions.
5. Hyperoxygenate and suction Prevents obstruction of tube • Inability to pass a suction catheter
endotracheal tube, as needed (see and resulting hypoxemia. • Copious, frothy, or bloody
Procedure 10). secretions
• Significant change in amount or
character of secretions
6. Assess for pain and inadequate Allows identification of pain • Pain not controlled by medications
sedation. and/or discomfort related to or nursing interventions
the intubation. • Observed ventilator dyssynchrony
7. Inspect nares or oral cavity once Allows for the detection of • Redness, necrosis, skin breakdown
per shift while patient is intubated. skin breakdown and necrosis.
Procedure continues on following page
22 Unit I Pulmonary System

Documentation
Documentation should include the following:
• Patient and family education • Clinical confirmation of tube placement including
• Vital signs before, during, and after intubation, assessment of breath sounds
including oxygen saturation and end-tidal CO2. • Measurement of cuff pressure
• Size of endotracheal tube • Number of intubation attempts
• Type of intubation: oral or nasal • Use of any medications
• Type and size of blade used • Patient response to procedure
• Depth of endotracheal tube insertion in centimeters at • Occurrence of unexpected outcomes
teeth, gums, or naris • Pain assessment, interventions, and effectiveness
• Confirmation of tube placement, including chest
radiograph, end-tidal CO2 detector, and capnography
(method of placement confirmation)

References and Additional Readings

For a complete list of references and additional readings for
this procedure, scan this QR code with any freely available
smartphone code reader app, or visit
http://booksite.elsevier.com/9780323376624.