Endotracheal Intubation

1. See Also
   1. Rapid Sequence Intubation
2. Precautions: Consider alternative airway management if not skilled in intubation
   1. Esophageal Tracheal Combitube (ETC)
   2. Laryngeal Mask Airway (LMA)
3. Indications
   1. See Advanced Airway
4. Preparation
   1. Prepare for Rapid Sequence Intubation if not crash airway or awake intubation needed for difficult airway
   2. Monitoring Pulse Oximetry (Hypoxemia, Bradycardia)
      1. Pretreatment with Atropine 0.02 mg/kg is no longer recommended
   3. Check laryngoscope for light and blade size
      1. Estimated blade size selection
         1. With laryngoscope blade held next to patient's face
            1. Blade should reach between lips and Larynx
         2. Better to choose a blade too long than too short
      2. Adult: #3 to #4 Macintosh Blade (curved)
      3. Child <8 yo: #2 Macintosh Blade (curved)
      4. Term Infant: #1 Miller Blade (straight)
      5. Premature Infant: #0 Miller Blade (straight)
   4. Check suction
   5. Select ET size and length (See Endotracheal Tube)
   6. Stylet (if used) should NOT extend beyond distal ET
   7. Intubation attempts should not last >30 seconds
      1. Limit intubation attempt to 20 seconds in newborns
   8. Preoxygenate with 100% Oxygen
5. Technique
   1. Head and Neck Position
      1. Children age > 2 years (Without C-Spine Injury)
         1. Head extension with pillow under occiput
         2. Chin lifted into sniffing position
      2. Infants age < 2 years
         1. Occiput naturally extends head
         2. Chin lifted to sniffing position
   2. Hand Position: infant (reverse for left hand dominant)
      1. Left Thumb and 1st finger hold laryngoscope
      2. Left 2nd and 3rd finger hold chin
      3. Left 5th finger pushes down on Larynx
      4. Right hand inserts ET Tube
   3. Endotracheal Tube insertion
      1. Insert laryngoscope into the right mouth
      2. At the tonsillar pillars sweep Tongue to midline
      3. Extend blade over base of Tongue and
         1. Curved blade: tip into vallecula
         2. Straight Blade: tip over the epiglottis
         3. Avoid entering esophagus first
            1. Risk of laryngeal trauma
      4. Exert traction upward along axis of handle
         1. Do not use teeth or gums as a fulcrum
            1. Results in significant oral/dental trauma
      5. Insert ET Tube from the right corner of mouth
         1. Avoids obstructing view
         2. Cricoid pressure may facilitate glottis viewing
      6. Position ET Tube
         1. Black marker on ET Tube at level of cords
         2. Cuffs should be placed just below cords
6. Evaluation: Assess Tube Position
   1. Symmetrical Chest Movement
   2. Auscultate for equal breath sounds
   3. Document absent breath sounds over Stomach
   4. Vapor condenses on inside of tube with exhalation
   5. End-tidal carbon dioxide (required by new guidelines)
      1. May be low if Cardiac Output low (esp infants)
7. Management: Trouble-Shooting Inadequate Ventilation or Oxygenation
   1. Mnemonic: DOPE
      1. Dislodged tube
      2. Obstructed tube
      3. Pneumothorax
      4. Equipment failure
   2. Confirm tube positioned correctly as above
   3. Is ET Tube too small, cuff (>8yo) under-inflated?
   4. Is the pop-off valve on Resuscitation bag depressed?
      1. With Near-drowning, pulmonary edema, and Asthma
         1. higher ventilation pressures are needed
   5. Is the Bag-Valve Device Leaking?
      1. Compress the bag against an Occluded ET connection
         1. Air will be expelled from any leaks
   6. Is the operator providing adequate tidal breaths?
   7. Is there a Pneumothorax present?
8. Management: Secure the 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