II. Indications

III. Precautions

  1. Intubation attempts should not last >30 seconds
    1. Limit intubation attempt to 20 seconds in newborns
    2. Apneic Oxygenation may allow longer safe intubation times
  2. Optimize first attempt at intubation
    1. Encourage strategies that increase likelihood of first intubation attempt success (e.g. Video Laryngoscopy, bougie)
    2. First pass attempt has the lowest complication rate and marked complication rate after 2 intubation attempts
    3. Mort (2004) Anesth Analg 99(2): 607-13 [PubMed]
  3. Preoxygenate with 100% Oxygen
    1. See Endotracheal Intubation Preoxygenation
    2. Infants and children desaturate very quickly
      1. Intubation attempts should be brief and stopped as Oxygen Saturation drops below 90%
      2. Stop and re-oxygenate prior to another attempt
  4. Consider using an Oral Airway in infants and young children
    1. Infants have a large Tongue for their small Mandible
    2. Oral Airway may help keep the Tongue out of the way for the intubation
  5. Critical to avoid Vomiting during intubation
    1. Ensure adequate induction and paralytic dosing
    2. Wait at least 60 seconds following paralytic to minimize Vomiting risk
    3. Decompress Bowel Obstruction prior to intubation
    4. Elevate head of bed
    5. Exercise extreme caution with awake techniques (careful to avoid gag stimulation)
      1. Consider pretreatment with Antiemetic
    6. Two forms of suction on and immediately available
      1. Yanker suction
      2. Open suction tubing

IV. Protocol: Preparation

  1. See Endotracheal Intubation Preparation
    1. Includes SOAP-ME Mnemonic
  2. See Endotracheal Tube (includes Endotracheal Tube Stylet)
    1. Size and length selection of Endotracheal Tubes
    2. Lubricate stylet for easy removal (especially with hyperangulated devices such as Glidescope)
  3. See Extraglottic Device
    1. Includes Laryngeal Mask Airway or LMA
    2. Consider as emergency device in case of Endotracheal Intubation failure
  4. See Endotracheal Intubation Preoxygenation
    1. Includes Apneic Oxygenation
    2. Significantly extends duration of safe apnea during intubation
  5. See Direct Laryngoscope
    1. Includes sizes of Miller Blade and Macintosh Blade
  6. See Video Laryngoscope
    1. Includes Video Laryngoscopy devices such as Glidescope, C-MAC, MacGrath

V. Protocol: Positioning

  1. Optimal head and neck position
    1. Ear to sternal notch positioning (Levitan)
      1. Functional Residual Capacity (FRC) is decreased 20% in supine position (as compared with head forward position)
      2. Head should be forward with ear and Sternum should be at the same horizontal level
      3. Mandible should also be forward to maximize Thyroid to mental distance (and maximize mouth opening)
      4. Approximates the tripod position of a child in respiratory distress (head forward and jaw forward)
    2. Head on pillow(s) flexes the neck forward on the chest and head extended at the neck (Walls)
      1. Same position as ear to sternal notch position described above
    3. Sniffing position
      1. Sniffing position is similar to Ear to sternal notch positioning and the Head on pillow position
      2. Sniffing position is preferred over ramp position, for its better first-pass success, glottic view and less Hypoxia
        1. Semler (2017) Chest +PMID:28487139 [PubMed]
  2. Children
    1. Simple maneuvers (e.g. Jaw Thrust) are most effective in children
    2. Keep head position in midline to prevent soft tissue from obscuring view when head turned to side
    3. Children age > 2 years (Without C-Spine Injury)
      1. Head extension with pillow under occiput
      2. Chin lifted into sniffing position
    4. Infants age < 2 years
      1. Occiput naturally extends the large head
      2. Chin lifted to sniffing position
      3. Infants may need a small towel roll under the Shoulders to align the head
  3. Trauma
    1. See Emergency Airway Management
    2. In-line stabilization technique
      1. Assistant holds head down on bed, with little fingers applied to each ear to prevent side to side motion
      2. Remove Cervical Collar completely for intubation
      3. Load Elastic Bougie in side of mouth
      4. Orman and Weingart in Majoewsky (2013) EM:Rap 13(4):
    3. Precautions
      1. In-line stabilization may be ineffective and potentially harmful
        1. Manoach (2007) 50(3): 236-45 PMID:17337093 [PubMed]
        2. Santoni (2009) Anesthesiology 110(1): 24-31 [PubMed]
        3. Turner (2009) J Trauma 67(1): 61-6 [PubMed]
      2. In-line stabilization significantly prolongs intubation time and decreases first-pass success
        1. Thiboutot (2009) Can J Anaesth 56(6): 412-8 PMID: 19396507 [PubMed]
  4. Adjuncts
    1. See below for techniques to best visualize the cords
    2. Avoid Cricoid pressure (Sellick Maneuver)
      1. No longer recommended in 2013
        1. Worsens airway visualization
          1. Oh (2013) Ann Emerg Med 61(4): 407-13 [PubMed]
        2. Does not prevent aspiration
          1. Fenton (2009) Int J Obstet Anesth 18(2): 106-10 [PubMed]
      2. May facilitate glottis viewing if performed correctly (but typically worsens visualization in practical use)
      3. Optional in 2010 ACC Guidelines
        1. Does not prevent aspiration
        2. May impede intubation if performed incorrectly

VI. Technique

  1. See Rapid Sequence Intubation
  2. Head and Neck Position are described above
  3. Hand Position: Infant (reverse for left hand dominant)
    1. Left Thumb and Index finger hold Laryngoscope
    2. Left middle and ring finger hold chin
    3. Left pinky finger pushes down on Larynx
    4. Right hand inserts ET Tube
  4. Adjuncts: Elastic Bougie
    1. Consider holding Elastic Bougie, placed by right molars while positioning Laryngoscope
    2. Allows for quick placement of Elastic Bougie in difficult airways without losing sight of the cords
    3. Not helpful in young children due to an incomplete calcification of tracheal rings
    4. Reference
      1. http://emcrit.org/wee/bougie-prepass-and-criccon/
  5. Endotracheal Tube insertion
    1. Approach: Levitan technique for Direct Laryngoscopy (two landmark)
      1. Start with "epiglottoscopy"
        1. Insert Laryngoscope in midline with finger hold at the blade-Laryngoscope junction
        2. Advance until epiglottis is visualized
        3. Tongue can be swept at this point
      2. Visualize arytenoid cartilages (corneiform tubercle, corniculate tubercle) at posterior end of aryepiglottic folds
        1. Cartilages attach to the vocal ligaments (Vocal Cords) and articulate in and out to open and close the glottis
        2. Cartilages form a distinct, easily recognizable boundary between Larynx (anterior) and esophagus (posterior)
        3. Distinct cartilage appearance alone is an adequate landmark
          1. Even without direct visualization of the Vocal Cords (upside-down V)
        4. Visualize the Endotracheal Tube passing anterior to the arytenoid cartilages
          1. Nearly ensures entry through the Larynx and trachea
      3. References
        1. Levitan (2013) Practical Emergency Airway Management Course
    2. Insert Laryngoscope
      1. Direct Laryngoscopy
        1. Levitan recommends inserting in Laryngoscope in midline to visualize epiglottis
          1. Then sweep the Tongue to side
        2. Standard technique recommends inserting Laryngoscope into right mouth (at the Tonsillar Pillars)
          1. Then sweep Tongue to midline
      2. Glidescope (Video Laryngoscopy)
        1. Insert Glidescope in midline and without Tongue sweep
        2. Do not insert glidescope too far
          1. Excessive depth is a very common reason for an inability to pass the ET Tube
          2. Indications to withdraw Laryngoscope a few centimeters
            1. ET Tube passage is difficult (also confirm use of hyperangulated stylet)
            2. Cords are seen at close range
    3. Extend blade over base of Tongue
      1. Insertion location depends on blade type
        1. Curved blade (Macintosh Blade): Tip into vallecula
        2. Straight Blade (Miller Blade): Tip over the epiglottis
        3. Caveat: Curved blades may be used as straight blades (over the epiglottis) and vice versa
      2. Avoid entering esophagus first
        1. Risk of laryngeal Trauma
        2. Visualize the epiglottis first and then advance
      3. Pointers in young children (typically straight blade)
        1. Insert the blade midline (does not require sweeping Tongue except possibly in syndromic children)
        2. Avoid inserting the Laryngoscope Blade too far and then pulling back
          1. Landmarks are difficult to interpret (esopagus may appear similar to trachea in children)
        3. Insert the blade only to the Tongue base and then lift at a 45 degree angle
        4. May insert the blade slightly further (millimeter) if the epiglottis still in way
    4. Exert traction upward along axis of handle (after epiglottis visualized)
      1. Straightens the airway for a direct line of intubation
      2. Do not use teeth or gums as a fulcrum
        1. Results in significant oral/dental Trauma
      3. Exception: Glidescope intubation requires no upward traction
        1. However airway is not straightened, so must use the glidescope stylet with the deep hockey-stick distal bend
        2. Due to unstraightened airway with glidescope, unbent ET Tube will be difficult to target the trachea
    5. Employ techniques to best visualize the cords
      1. Avoid cricoid pressure (see above)
      2. Bimanual Intubation Technique (Levitan)
        1. While left hand holds Laryngoscope, right hand manipulates Thyroid catilage (as in BURP technique)
        2. Intubating clinician initially manipulates the Thyroid cartilage (instead of assistant)
        3. Once positioned, assistant may be used to hold position while intubator passes ET Tube
      3. BURP Alternative in children
        1. Intubator places their hand over an assistants hand which is in turn held over the anterior neck
        2. Intubator moves the assistants hand (especially backwards) to align airway
        3. When cords are well visualized, assistant holds position and inubator removes their hand
        4. Especially useful in in young children who typically have an anterior positioned Larynx
      4. BURP Maneuver
        1. Assistant moves Thyroid cartilage backward, upward and rightward
        2. Less effective in young children
        3. Bimanual technique is preferred (see above)
    6. Tube insertion
      1. Slow down the Endotracheal Tube insertion (avoid ramming the tube into the airway)
      2. Avoid obstructing view on tube insertion
        1. Endotracheal Tube shape in Direct Laryngoscopy should be straight-to-cuff
          1. ET Tube is straight until distal end near cuff, where the stylet is bent 30 degrees up
          2. When inserted, the tube is hidden below the horizon until rises at level of Larynx
      3. Other strategies to avoid obstructing view
        1. Insert ET Tube from the right corner of mouth
      4. Hyperangulated devices (e.g. Glidescope)
        1. See Endotracheal Tube Stylet
        2. Once tube passes through cords, it will catch on anterior tracheal rings due to hyperangulation
        3. Stylet must be at least partially withdrawn or tube rotated 90 degrees right (clockwise) to further insert ET
        4. Hold ET Tube tightly as stylet is pulled out following tube placement
          1. Stylet may be wedged in tube and can result in dislodging the tube
          2. Stylet should be pulled out by withdrawing toward the patient's feet (instead of straight up)
    7. Position ET Tube
      1. Black marker on ET Tube at level of cords
      2. Cuffs should be placed just below cords
      3. See Endotracheal Tube for insertion depths for children
      4. Typically 23 cm for men, 21 cm for women

VII. Evaluation: Assess Tube Position

  1. Confirming tracheal placement is among the most critically important steps in Endotracheal Intubation
    1. When in doubt, pull the tube
  2. Positive Pressure Ventilations to assess tube position
    1. Avoid over-ventilating (too fast or with too much volume)
      1. Hold the bag-valve-mask under-handed like a football hold
      2. Squeeze with only one hand
    2. Observe for symmetrical chest movement
    3. Auscultate for equal breath sounds
      1. Chest auscultation at mid-axillary line (least likely to hear transmitted sounds from epigastrium)
  3. Document absent breath sounds over Stomach
  4. Vapor condenses on inside of tube with exhalation
  5. End-tidal carbon dioxide (End-Tidal CO2 Detector, required by new guidelines 2010)
    1. May be low if Cardiac Output low (esp. infants)
    2. Loss of EtCO2 wave form may be loss of pulse (instead of esophageal intubation)
      1. Check a pulse first, prior to removing an Endotracheal Tube
  6. Confirmation with Ultrasound
    1. Ultrasound can be used to distinguish endotracheal from esophageal intubation
    2. Ultrasound can confirm Endotracheal Tube above carina
      1. Fill ET Tube balloon with saline and can see the top of balloon at sternal notch
      2. https://vimeo.com/155465873

VIII. Protocol: Post-intubation Management

  1. Secure ET Tube
    1. Confirm tube position again by auscultation
    2. Tape ET Tube in place and fix to cheek with benzoin
    3. Note the distance marker at lips in chart
    4. Commercial tube holder highly recommended
  2. Orogastric Tube or Nasogastric Tube (if no Basilar Skull Fracture risks)
    1. Helps prevent aspiration
    2. Reduces Stomach volume which can interfere with ability to ventilate (especially in children)
  3. Chest XRay
  4. Manage Low Blood Pressure
    1. IV Fluid bolus

IX. Protocol: Post-Intubation Sedation and Analgesia

X. Management: Post-Intubation mechanical Ventilator settings

  1. Children (under age 8 years)
    1. Precaution: Reduce rate and Tidal Volume for Asthma Exacerbation (allow for permissive hypercapnia)
    2. Respiratory Rate: 20-25 breaths per minute
    3. Tidal Volume: 5-7 cc/kg
    4. Set peak inspiratory pressure to 12-20 cm H2O in infants
  2. Precautions
    1. Avoid Hyperventilation (results in lung hyperexpansion and decreases venous return)
    2. Start with low Respiratory Rate and low Tidal Volume (and gradually advance as needed)
    3. Limit peak pressures
    4. Asthma and COPD are very high risk for Hyperventilation-related complications (including barotrauma)
    5. Do not attempt to fix acid-base abnormalities initially (Permissive hypercapnea is preferred)
    6. Observe minute ventilation prior to intubation and approximate this for Mechanical Ventilation settings
      1. Critical in Metabolic Acidosis

XI. Management: Trouble-Shooting Inadequate Ventilation or Oxygenation

  1. See Ventilator Troubleshooting
  2. DOPE Mnemonic
    1. Dislodged tube
    2. Obstructed tube
    3. Pneumothorax
    4. Equipment failure
  3. Detailed approach
    1. Confirm tube positioned correctly as above
    2. Is ET Tube too small, cuff under-inflated?
    3. Is the pop-off valve on Resuscitation bag depressed?
      1. Higher ventilation pressures are needed with Near-drowning, pulmonary edema, and Asthma
    4. Is the Bag-Valve Device Leaking?
      1. Compress the bag against an Occluded ET connection (air will be expelled from any leaks)
    5. Is the operator providing adequate tidal breaths?
    6. Is there a Pneumothorax present?

XIII. References

  1. Levitan (2013) Practical Airway Management Course, Baltimore
  2. Majoewsky (2012) EM: RAP-C3 2(5): 3-4
  3. Gausche-Hill and Claudius in Majoewsky (2012) EM-RAP 12(12): 6-7
  4. Walls (2012) Emergency Airway Management, 3rd Ed, Lippincott, Philadelphia, p. 63-80

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

Ontology: Intubation, Intratracheal (C0021932)

Concepts Therapeutic or Preventive Procedure (T061)
MSH D007442
ICD9 96.04
SnomedCT 182681006, 182684003, 150945006, 150942009, 150941002, 112798008
English Endotracheal Intubations, Intratracheal Intubation, Intratracheal Intubations, Intubation, Endotracheal, Intubation, Intratracheal, Intubations, Endotracheal, Intubations, Intratracheal, Endotracheal Intubation, Endotracheal intubation NOS, Endotracheal tube insertion, endotracheal tube insertion (treatment), endotracheal tube insertion, insertion of endotracheal (ET) tube, Insert endotracheal tube, trachea intubation, endotracheal intubation, endotracheal intubations, intubation endotracheal, intubation tracheal, intratracheal intubation, tracheal intubation, Endotracheal tube insertion (procedure), Endotracheal intubation NOS (procedure), Tracheal intubation (procedure), Trachea--Intubation, Intubation of trachea, Insertion of endotracheal tube, Endotracheal intubation, Tracheal intubation, Insertion of endotracheal tube (procedure)
Swedish Intubering, intratrakeal
Spanish Intubación endotraqueal, intubación endotraqueal, SAI (procedimiento), intubación endotraqueal, SAI, Endotracheal intubation NOS, inserción de un tubo endotraqueal (procedimiento), inserción de un tubo endotraqueal, intubación de la tráquea, Intubación Endotraqueal, Intubación Intratraqueal
Dutch endotracheale intubatie, Intratracheale intubatie, Intubatie, endotracheale, Intubatie, intratracheale
Portuguese Intubação endotraqueal, Intubação Endotraqueal, Intubação Intratraqueal
German Endotrachealintubation, Intubation, endotracheale, Intubation, intratracheale
Japanese キカンナイソウカン, 気管内挿管, 気管内挿管法, 挿管法-気管内, 挿管-気管内
Finnish Trakeaali-intubaatio
Russian INTUBATSIIA ENDOTRAKHEAL'NAIA, INTUBATSIIA INTRATRAKHEAL'NAIA, ИНТУБАЦИЯ ИНТРАТРАХЕАЛЬНАЯ, ИНТУБАЦИЯ ЭНДОТРАХЕАЛЬНАЯ
Czech Endotracheální intubace, endotracheální intubace, intratracheální intubace, intubace intratracheální
French Intubation endo-trachéale, Intubation intratrachéale, Tubage endotrachéal, Tubages endotrachéaux, Tubage trachéal, Intubation intra-trachéale, Tubages trachéaux, Intubation endotrachéale, Intubation trachéale
Croatian INTUBACIJA, ENDOTRAHEALNA
Polish Intubacja dotchawicza
Hungarian Endotrachealis intubáció
Norwegian Intubering, endotrakeal, Endotrakeal intubering, Intratrakeal intubering, Intubering, intratrakeal
Italian Intubazione endotracheale

Ontology: Laryngoscopy (C0023072)

Definition (NCI_NCI-GLOSS) Examination of the larynx (voice box) with a mirror (indirect laryngoscopy) or with a laryngoscope (direct laryngoscopy).
Definition (NCI) Endoscopic examination of the larynx.
Definition (MSH) Examination, therapy or surgery of the interior of the larynx performed with a specially designed endoscope.
Definition (CSP) observation, therapy or surgery of the interior of the larynx using an endoscope for direct visual examination or by observation of the reflection in a laryngeal mirror.
Concepts Diagnostic Procedure (T060)
MSH D007828
ICD10 41849-00
SnomedCT 142484008, 28760000
CPT 1005837
English Laryngoscopies, Laryngoscopy, laryngoscopy, Endoscopy Procedures on the Larynx, Endoscopic exploration of larynx, Endoscopy of larynx, Laryngoscopy (procedure), Laryngoscopy, NOS, Endoscopic exploration of larynx, NOS, Endoscopy of larynx, NOS
Swedish Laryngoskopi
Japanese コウトウキョウケンサ, 内視鏡検査-喉頭, 喉頭鏡検査, 内視鏡下手術-喉頭, 喉頭鏡検査法, 喉頭鏡下手術, 喉頭鏡法
Czech laryngoskopie, Laryngoskopie
Finnish Laryngoskopia
Russian LARINGOSKOPIIA, ЛАРИНГОСКОПИЯ
Croatian LARINGOSKOPIJA
Polish Laryngoskopia, Wziernikowanie krtani
Hungarian Laryngoscopia
Norwegian Laryngoskopi
Spanish endoscopia de la laringe, exploración endoscópica de la laringe, laringoscopia (procedimiento), laringoscopia, Laringoscopia, Laringoscopía
Dutch laryngoscopie, Laryngoscopie
French Laryngoscopie
German Laryngoskopie
Italian Laringoscopia
Portuguese Laringoscopia

Ontology: Direct examination of larynx (C0392823)

Concepts Diagnostic Procedure (T060)
SnomedCT 173039003, 78121007
CPT 31515
English DL - Direct laryngoscopy, Direct examination of larynx, direct laryngoscopy (treatment), direct laryngoscopy, Laryngoscopy;direct, Direct laryngoscopy, Direct laryngoscopy (procedure), Direct laryngoscopy, NOS
Spanish laringoscopia directa (procedimiento), laringoscopia directa