The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.
In a patient with a suspected spinal cord injury, inline cervical immobilization of the head 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#ref5">5
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:
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, biological female patients require a 7.0- to 8.0-mm tube and biological male patients require a 7.5- to 9.5-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 skull1 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.5 Nasal intubation should only be considered in spontaneously breathing patients.3 For a patient with suspected spinal cord injuries, inline cervical immobilization of the head 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
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.
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Rationale: Connecting the catheter to the tubing prepares for oropharyngeal suctioning as needed.
Rationale: Inflating and deflating the cuff verifies that the tube cuff is patent without leaks and prepares the tube for insertion.
Rationale: Recessing the stylet from the distal end of the tube prevents damage to the vocal cords and trachea.
Rationale: The sniffing position allows for viewing of the vocal cords by aligning the axes of the mouth, pharynx, and trachea.
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 cervical spine immobilization.
Rationale: An oral airway assists in maintaining upper airway patency.
Use an oropharyngeal airway only in an unconscious patient without a gag reflex.
Rationale: Preoxygenation helps prevent hypoxemia. Gentle breaths reduce the incidence of air entering the stomach (leading to gastric distention), decrease airway turbulence, and distribute ventilation within the lungs more evenly.
Avoid aggressive positive-pressure ventilation with an MRB because this may increase the risk for gastric distention and vomiting.
Rationale: The patient must be oxygenated and ventilated between intubation attempts.
Rationale: Inflation volumes vary depending on the manufacturer, the tube size, and the size of the patient’s airway.
Rationale: Once an advanced airway is inserted, the practitioner should immediately perform a thorough assessment to ensure that the tube is properly positioned.
Rationale: Auscultating over the epigastrium allows identification of esophageal intubation.
If air movement or gurgling is heard, suspect that intubation of the esophagus has occurred.
Rationale: This process assists in verification of correct tube placement into the trachea. Equal breath sounds indicate proper placement of the ET tube.
If diminished breath sounds are heard on one side, suspect that a right mainstem bronchus intubation has occurred.
If symmetric chest wall movement is absent, suspect that a mainstem bronchus or esophageal intubation has occurred.
Rationale: Detection of carbon dioxide confirms proper ET tube placement into the trachea. Carbon dioxide detectors should be used in conjunction with physical assessment findings.
During cardiac arrest (nonperfusing rhythms), there may not be sufficient expired carbon dioxide due to low pulmonary blood flow.
Rationale: Oxygen saturation should stabilize with successful tracheal intubation. Decreasing SpO2 may indicate improper tube placement; however, it may not decrease in a right main bronchus placement of the ET tube.
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.
Rationale: When correctly positioned, the tube tip should be halfway between the vocal cords and the carina.
Rationale: A bite block prevents the patient from biting down on the ET tube.
Rationale: Securing the ET tube prevents inadvertent dislodgment of the tube.
Rationale: Reevaluating correct tube placement verifies that the tube was not inadvertently repositioned when securing it.
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 biological female patients and 23 cm for biological male patients.3
Rationale: Suctioning removes secretions that may obstruct the tube or accumulate on top of the cuff.
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
The trachea and esophagus overlay each other, so a chest radiograph may not always confirm that the tube is in the trachea and not the esophagus. An ET tube placed bronchoscopically may not require chest radiograph verification (follow the organization’s practice).
Reportable conditions: Absent, decreased, or unequal breath sounds, rising arterial carbon dioxide tension, chest-abdominal dyssynchrony, patient-ventilator dyssynchrony, dyspnea, headache, restlessness, confusion, lethargy, rising (early sign) or falling (late sign) arterial blood pressure, activation of expiratory or inspiratory volume alarms on mechanical ventilator
Rationale: Securing the tube prevents tube movement and dislodgment.
Reportable conditions: Unplanned extubation or tube movement from original position
Rationale: Monitoring and recording the tube’s position assists with identifying tube migration.
Reportable condition: Tube movement from original position
Rationale: Maintaining correct cuff pressure helps prevent tracheal injury and aspiration.
Reportable condition: Cuff pressure greater than 30 cm H2O4 or out of a range acceptable to the practitioner
Rationale: Suctioning prevents tube obstruction and resulting hypoxemia.
Reportable conditions: Inability to pass a suction catheter; copious, frothy, bloody secretions; significant change in amount or character of secretions
Rationale: Inspecting the nares or oral cavity allows for the detection of skin breakdown and necrosis.
Reportable conditions: Redness, necrosis, skin breakdown
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: November 2023
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