Endotracheal Tube Intubation: Assisting - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

In a patient with a suspected spinal cord injury, inline spinal motion restriction must be maintained during endotracheal (ET) intubation.

Use pulse oximetry during intubation so that oxygen desaturation can be detected quickly. If the saturation is inadequate, stop the attempt and start ventilation by bag-mask device.

Be prepared for a rescue airway to be placed if the intubation attempts fail.

Nasotracheal intubation is not recommended in pregnant patients due to the fragility of the nasal mucosa and risk for subsequent bleeding.^{undefined#ref4">4}

OVERVIEW

ET 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. Indications for ET intubation include:⁵

• Inadequate oxygenation and ventilation
• Altered mental status (e.g., brain injury, drug overdose)
• Anticipated airway obstruction (e.g., facial burns, epiglottitis, major facial or oral trauma)
• Upper airway obstruction (e.g., secondary to swelling, trauma, tumor, bleeding)
• Apnea
• Respiratory distress or respiratory failure
• Ineffective clearance of secretions
• High risk for aspiration

ET tube size reflects the size of the internal diameter of the tube (Figure 1). Tubes range in size from 2.0 mm for neonates to 10.0 mm for large adults.³ Typically, female patients require a 7.0- to 8.0-mm tube with a 15-mm connector, and male patients require a 7.5- to 9.0-mm tube with a 15-mm connector.³ The tube should be large enough to facilitate airflow and small enough to pass the vocal cords without damaging them.

ET intubation can be done via the nasal or oral routes. The skill of the practitioner performing the intubation and the patient’s clinical condition determine the route used. Nasal intubation is relatively contraindicated in a trauma patient with facial fractures or suspected fractures at the base of the skull² or postoperatively after cranial surgeries, such as a transsphenoidal hypophysectomy. Nasotracheal intubation is also not recommended in pregnant patients because of the fragility of the nasal mucosa and risk for subsequent bleeding.⁴ Nasal intubation should only be considered in spontaneously breathing patients.³ For a patient with suspected spinal cord injuries, inline spinal motion restriction must be maintained during ET intubation. Improper intubation technique may result in trauma to the teeth, soft tissues of the mouth or nose, vocal cords, and posterior pharynx.

Primary and secondary confirmation of ET intubation must be performed.⁶

• Primary confirmation of proper ET tube placement includes seeing the tube passing through the vocal cords, the 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 ET tube placement is necessary to protect against unrecognized esophageal intubation. Methods include the use of disposable exhaled carbon dioxide detectors, continuous end-tidal carbon dioxide (ETCO₂) monitors, and esophageal detection devices. Final confirmation of ET tube placement should be performed via a radiograph.
• When properly placed, the distal tip of the ET tube should be visible 3 to 7 cm (1.2 to 2.8 inches) above the carina on a chest radiograph.³

ETCO₂ monitoring devices have been shown to be reliable indicators of expired carbon dioxide in a patient with perfusing rhythms.³ During cardiac arrest (nonperfusing rhythms), there may not be sufficient expired carbon dioxide due to low pulmonary blood flow.⁶ If carbon dioxide is detected using an ETCO₂ detector, it is a reliable indicator of proper tube placement. If carbon dioxide is not detected, the use of an esophageal detector device or ultrasound performed by an experienced operator is recommended.⁶

Many methods can be used to secure an ET tube, including tape and commercial devices. The nurse should secure the tube in place immediately after insertion to prevent unplanned extubation.

SUPPLIES

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EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• If time and the situation permit, explain the equipment and the procedure to the patient and family, including the reason for intubation and the expected duration of intubation.
• If time and the situation permit, explain the patient’s role in assisting with insertion of the ET tube.
• Explain that the patient will be unable to speak while the ET tube is in place but that other means of communication will be provided.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Assess the patient’s immediate history of trauma when a spinal cord injury is suspected or when the patient has had cranial surgery.
2. Assess the patient’s nothing-by-mouth (NPO) status.
3. Assess the patient’s level of consciousness, level of anxiety, and respiratory difficulty.
4. Assess the patient’s oral cavity for presence of dentures, loose teeth, or other possible obstructions and remove if appropriate.
5. Assess the patient’s vital signs, including oxygen saturation.
6. Assess the patient for these signs and symptoms:
   1. Tachypnea
   2. Dyspnea
   3. Shallow respirations
   4. Cyanosis
   5. Apnea
   6. Altered level of consciousness
   7. Tachycardia
   8. Cardiac arrhythmias
   9. Hypertension
   10. Headache
7. Collaborate with the practitioner to determine the appropriate size ET tube and type of laryngoscope blade needed for the procedure.
8. Collaborate with the practitioner regarding the patient’s need for premedication.

Preparation

1. Attach the patient to a pulse oximeter, cardiac monitor, and blood pressure monitoring device.
2. Ensure that the patient has patent IV access.
3. Notify the respiratory therapist of impending intubation so that a ventilator can be set up, as appropriate.
4. Set up the suction apparatus and connect the rigid tonsil-tip suction catheter to the tubing.
5. Assist the practitioner with checking the equipment.
   1. Use an appropriate size syringe to inflate the cuff on the tube and assess for leaks.¹ Deflate the cuff completely.
   2. Insert the stylet into the ET tube, ensuring that the tip of the stylet does not extend beyond the end of the ET tube.
   3. Connect the laryngoscope blade to the handle and check the bulb for brightness.

PROCEDURE

1. Administer sedative medications and/or paralytic medications as ordered.
2. Assist the practitioner with positioning the patient’s head by flexing the neck forward and tilting the head (sniffing position [only if neck trauma is not suspected]) (Figure 2).
   1. Place a small towel under the patient’s occiput to elevate it, allowing for proper neck flexion.
   2. If spinal trauma is suspected, maintain the patient’s head in a neutral position with inline spinal immobilization and stabilize the cervical spine.

      Do not flex or extend the patient’s neck if the patient has a suspected spinal cord injury; ensure that the patient’s head is maintained in a neutral position with inline spinal motion restriction.

3. Suction the patient’s mouth and pharynx as needed.
4. Insert an oropharyngeal airway as indicated.

   Use an oropharyngeal airway only in an unconscious patient without a gag reflex.

5. Preoxygenate the patient for 3 to 5 minutes with high-flow oxygen via a nonrebreather mask if ventilations are adequate or via a manual resuscitation bag (MRB) with a face mask connected to a high-flow oxygen source (≥15 L/min) if the patient is not adequately ventilating or has received sedative and paralytic medications.³ Provide frequent and gentle breaths.

   Avoid aggressive positive-pressure ventilation with an MRB because this may increase the risk for gastric distention and vomiting.

6. Remove the oropharyngeal airway if present.
7. Assist the practitioner with intubating the patient as directed.
   1. Have an MRB with a face mask connected to a high-flow oxygen source ready for hyperoxygenation and manual ventilation.³
   2. Inflate the cuff with air until a leak is no longer heard.
8. While manually ventilating the patient with high-flow oxygen, assist the practitioner with confirmation of tube placement as evidenced by the presence of bilateral breath sounds and the absence of gurgling sounds over the stomach.³
   1. Auscultate over the epigastrium.

      If air movement or gurgling is heard, suspect that intubation of the esophagus has occurred.

   2. Auscultate the lung bases and apices for bilateral breath sounds.

      If diminished breath sounds are heard on one side, suspect that a right mainstem bronchus intubation has occurred.

   3. Observe for symmetric chest wall movement, which assists in verification of correct tube placement.

      If symmetric chest wall movement is absent, suspect that a mainstem bronchus or esophageal intubation has occurred.

   4. Measure ETCO₂ using one of these methods:
      1. Attach a disposable exhaled carbon dioxide detector. Watch for a color change indicating the presence of carbon dioxide.
      2. Attach a continuous ETCO₂ monitor and watch for detection of carbon dioxide.
      3. If carbon dioxide is not detected, use an esophageal detector device to confirm placement.⁶

         During cardiac arrest (nonperfusing rhythms), there may not be sufficient expired carbon dioxide due to low pulmonary blood flow.

   5. Evaluate the patient’s peripheral oxygen saturation (SpO₂).
9. If assessment findings, ETCO₂, or SpO₂ reveal that the tube is not correctly positioned, assist the practitioner with removing or repositioning the tube.
   1. If esophageal intubation is suspected, the practitioner will:
      1. Deflate the cuff.
      2. Remove the tube immediately.
      3. Ventilate and oxygenate the patient with 100% oxygen for 3 to 5 minutes.³
      4. Reattempt to intubate the patient.

         If the patient has received aggressive ventilation with the MRB while esophageally intubated, vomiting may occur when the tube is removed. Suction should be ready to prevent aspiration.

   2. If right mainstem bronchus intubation is suspected, the practitioner will:
      1. Deflate the cuff.
      2. Slowly pull back on the tube until bilateral breath sounds are heard.
      3. Reevaluate the patient for correct tube placement.
10. Connect the ET tube to the oxygen source, MRB, or mechanical ventilator.
11. For oral intubation only, insert a bite block along the ET tube. Secure the bite block separately from the tube to prevent tube dislodgment.
12. Assist the practitioner with securing the ET tube. Use a hydrocolloid dressing on the patient’s cheeks to protect the skin.
    1. If using a tube securement device, apply the device according to the manufacturer’s instructions.
    2. If using tape, prepare the tape (Figure 3) and secure the tube by wrapping the double-sided tape around the patient’s head and the torn tape edges around the ET tube.
13. Reevaluate the patient for correct tube placement.
14. For oral intubation, observe the position of the tube at the patient’s teeth or gums using the centimeter markings on the tube as a reference.

    Rationale: Recording the position of the tube provides a reference point to assess for possible tube dislodgment in the future. Common tube placement at the teeth is 21 cm for female patients and 23 cm for male patients.³

15. Suction the ET tube and pharynx as needed.
16. Assist the practitioner with obtaining a chest radiograph to confirm the correct tube position.

    Rationale: Chest radiographs document actual tube location (distance from the carina). Correct placement is typically 3 to 7 cm (1.2 to 2.8 inches) above the carina.³

17. Insert an orogastric tube, as indicated.

MONITORING AND CARE

1. Assess the patient’s respiratory status.
2. Maintain tube stability using tape or a commercially available ET tube holder.
3. Monitor and record the position of the tube at the patient’s teeth using the centimeter markings on the tube as a reference.
4. Measure ET tube cuff pressure every shift, maintaining ET tube cuff pressure between 20 and 30 cm H₂O.⁷
5. Suction the ET tube, as needed.
6. Inspect the oral cavity while the patient is intubated.

EXPECTED OUTCOMES

• Placement of patent artificial airway
• Properly positioned and secured airway
• Improved oxygenation and ventilation
• Facilitation of secretion clearance

UNEXPECTED OUTCOMES

• Intubation of esophagus or right mainstem bronchus (improper tube placement)
• Accidental extubation
• Cardiac arrhythmias
• Broken or dislodged teeth
• Leaking of air from ET tube cuff
• Tracheal injury at tip of tube or at cuff site
• Laryngeal edema
• Laryngospasm
• Vocal cord trauma
• Aspiration
• ET tube obstruction
• Decreased perfusion or hypotension due to increased intrathoracic pressure from hyperventilation

DOCUMENTATION

• Education
• Vital signs and SpO₂
• Type of intubation (oral or nasal)
• Number of intubation attempts
• ET tube size
• Depth of ET tube insertion (centimeters at teeth, gums, or nose)
• Confirmation of tube placement, including chest radiograph (how placement was confirmed)
• Medications administered during procedure
• Measurement of cuff pressure
• Assessment of breath sounds
• Description of secretions
• Patient’s response to procedure
• Oxygen therapy or ventilator settings
• Pain assessment and management
• Unexpected outcomes and related interventions

REFERENCES

1. American College of Surgeons (ACS). (2018). Appendix G: Skills: Skill station A: Airway. In ATLS: Advanced trauma life support: Student course manual (10th ed., pp. 337-343). Chicago: Author.
2. American College of Surgeons (ACS). (2018). Chapter 2: Airway and ventilatory management. In ATLS: Advanced trauma life support: Student course manual (10th ed., pp. 22-41). Chicago: Author.
3. Driver, B.E., Reardon, R.F. (2019). Chapter 4: Tracheal intubation. In J.R. Roberts and others (Eds.), Roberts and Hedges’ clinical procedures in emergency medicine and acute care (7th ed., pp. 62-110). Philadelphia: Elsevier.
4. Edminster, E. (2024). Chapter 5: Airway and ventilation. In TNCC: Trauma nursing core course: Provider manual (9th ed., pp. 63-87). Burlington, MA: Jones & Bartlett Learning.
5. Goodrich, C.A. (2024). Procedure 2: Endotracheal intubation (Assist). In K.L. Johnson (Ed.), AACN procedure manual for progressive and critical care (8th ed., pp. 21-34). St. Louis: Elsevier.
6. Panchal, A.R. and others. (2020). Part 3: Adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation, 142(16 Suppl. 2), S366-S468. doi:10.1161/CIR.0000000000000916 Retrieved December 16, 2024, from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000916
7. Scott, J.B. (2025). Chapter 37: Airway management. In J.K. Stoller and others (Eds.), Egan’s fundamentals of respiratory care (13th ed., pp. 742-779). St. Louis: Elsevier.

Adapted from Johnson, K.L. (Ed.). (2024). AACN procedure manual for progressive and critical care (8th ed.). St. Louis: Elsevier.

Clinical Review: Justin J. Milici, MSN, RN, CEN, CPEN, CPN, TCRN, CCRN, FAEN

Published: January 2025