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 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}

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:

• Inadequate oxygenation and ventilation
• Altered mental status (e.g., head injury, drug overdose) for airway protection
• 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, 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

• 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 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

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• If the clinical situation permits, explain the equipment and the procedure to the patient and family, including the reason for intubation and the expected duration of intubation.
• If the clinical situation permits, 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. Perform hand hygiene. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Assess the patient’s immediate history of trauma when a spinal cord injury is suspected or when the patient has had cranial surgery.
5. Assess the patient’s nothing-by-mouth (NPO) status.
6. Assess the patient’s level of consciousness, level of anxiety, and respiratory difficulty.
7. Assess the patient’s oral cavity for presence of dentures, loose teeth, or other possible obstructions and remove if appropriate.
8. Assess the patient’s vital signs, including oxygen saturation.
9. 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
10. Collaborate with the practitioner to determine the appropriate-size ET tube and type of laryngoscope blade needed for the procedure.
11. 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.

   Rationale: Connecting the catheter to the tubing prepares for oropharyngeal suctioning as needed.

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.² Deflate the cuff completely.

      Rationale: Inflating and deflating the cuff verifies that the tube cuff is patent without leaks and prepares the tube for insertion.

   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.

      Rationale: Recessing the stylet from the distal end of the tube prevents damage to the vocal cords and trachea.

   3. Connect the laryngoscope blade to the handle and check the bulb for brightness.

PROCEDURE

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids. Don gown, mask, and eye protection or face shield if the risk of splashing exists.
2. Verify the correct patient using two identifiers.
3. If time allows, explain the procedure and ensure that the patient agrees to treatment.
4. 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.

      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.

5. Suction the patient’s mouth and pharynx as needed.
6. Administer sedative medications and/or paralytic medications as ordered.
7. Insert an oropharyngeal airway as indicated.

   Rationale: An oral airway assists in maintaining upper airway patency.

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

8. Preoxygenate the patient for 3 to 5 minutes with 100% oxygen via a nonrebreather mask if ventilations are adequate or via a manual resuscitation bag (MRB) with a face mask connected to a 100% 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.

   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.

9. Assist the practitioner with intubating the patient as directed.
   1. Have an MRB with a face mask connected to a 100% oxygen source ready for hyperoxygenation and manual ventilation.³

      Rationale: The patient must be oxygenated and ventilated between intubation attempts.

   2. Inflate the cuff with air until a leak is no longer heard.

      Rationale: Inflation volumes vary depending on the manufacturer, the tube size, and the size of the patient’s airway.

10. While manually ventilating the patient with 100% oxygen, assist the practitioner with confirmation of tube placement as evidenced by the presence of bilateral breath sounds and the absence of breath sounds over the stomach.³

    Rationale: Once an advanced airway is inserted, the practitioner should immediately perform a thorough assessment to ensure that the tube is properly positioned.

    1. Auscultate the patient over the epigastrium.

       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.

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

       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.

    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.

          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.

       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).

       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.

11. 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. Withdraw the tube 1 to 2 cm.³
    3. Reevaluate the patient for correct tube placement.

       Rationale: When correctly positioned, the tube tip should be halfway between the vocal cords and the carina.

12. Connect the ET tube to the oxygen source, MRB, or mechanical ventilator.
13. For oral intubation only, insert a bite block along the ET tube. Secure the bite block separately from the tube to prevent tube dislodgment.

    Rationale: A bite block prevents the patient from biting down on the ET tube.

14. Assist the practitioner with securing the ET tube. Use a hydrocolloid dressing on the patient’s cheeks to protect the skin.

    Rationale: Securing the ET tube prevents inadvertent dislodgment of the tube.

    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.
15. Reevaluate the patient for correct tube placement.

    Rationale: Reevaluating correct tube placement verifies that the tube was not inadvertently repositioned when securing it.

16. For oral intubation, observe the position of the tube at the patient’s teeth or gums; for nasal intubation, observe the position of the tube at the patient’s naris 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 biological female patients and 23 cm for biological male patients.³

17. Suction the ET tube and pharynx as needed.

    Rationale: Suctioning removes secretions that may obstruct the tube or accumulate on top of the cuff.

18. 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

    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).

19. Discard supplies, remove PPE, and perform hand hygiene.
20. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Assess the patient’s respiratory status.

   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

2. Maintain tube stability using tape or a commercially available ET tube holder.

   Rationale: Securing the tube prevents tube movement and dislodgment.

   Reportable conditions: Unplanned extubation or tube movement from original position

3. Monitor and record the position of the tube at the patient’s teeth or naris using the centimeter markings on the tube as a reference.

   Rationale: Monitoring and recording the tube’s position assists with identifying tube migration.

   Reportable condition: Tube movement from original position

4. Measure ET tube cuff pressure every shift, maintaining ET tube cuff pressure between 20 and 30 cm H₂O.⁴

   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

5. Suction the ET tube, as needed.

   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

6. Inspect the nares or oral cavity while the patient is intubated.

   Rationale: Inspecting the nares or oral cavity allows for the detection of skin breakdown and necrosis.

   Reportable conditions: Redness, necrosis, skin breakdown

7. Assess, treat, and reassess pain.

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). Chapter 2: Airway and ventilatory management. In ATLS: Advanced trauma life support: Student course manual (10th ed., pp. 22-41). Chicago: Author. (Level D)
2. 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. (Level D)
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. La Vita, C.J. (2021). Chapter 37: Airway management. In R.M. Kacmarek, J.K. Stoller, A.J. Heuer (Eds.), Egan’s fundamentals of respiratory care (12th ed., pp. 748-787). St. Louis: Elsevier.
5. McDonald, M.L. (2020). Chapter 4: Airway and ventilation. In Emergency Nurses Association (ENA), TNCC: Trauma nursing core course: Provider manual (8th ed., pp. 47-70). Burlington, MA: Jones & Bartlett Learning. (Level D)
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 September 1, 2023, from https://www.ahajournals.org/doi/10.1161/CIR.0000000000000916 (Level A)

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

AACN Levels of Evidence

• Level A - Meta-analysis of quantitative studies or metasynthesis of qualitative studies with results that consistently support a specific action, intervention, or treatment
• Level B - Well-designed, controlled studies, with results that consistently support a specific action, intervention, or treatment
• Level C - Qualitative studies, descriptive or correlational studies, integrative reviews, systematic reviews, or randomized controlled trials with inconsistent results
• Level D - Peer-reviewed professional organizational standards with clinical studies to support recommendations
• Level E - Multiple case reports, theory-based evidence from expert opinions, or peer-reviewed professional organizational standards without clinical studies to support recommendations
• Level M - Manufacturer’s recommendations only

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

Published: November 2023