ENDOTRACHEAL INTUBATION (ETT)

 

Endotracheal intubation (ETI) is the gold standard for securing a definitive airway in critically ill or injured patients. It involves inserting an endotracheal tube (ETT) through the mouth or nose, past the vocal cords, and into the trachea to establish an airway for oxygenation, ventilation, and airway protection.

🚨 Why It’s Important:
✅ Provides a secure airway, preventing aspiration.
✅ Enables controlled mechanical ventilation.
✅ Allows direct administration of some emergency medications.
✅ Facilitates airway suctioning to clear secretions.

 

1️⃣ BENEFITS OF ENDOTRACHEAL INTUBATION

🔹 Definitive Airway Security – Prevents airway obstruction and aspiration.
🔹 Facilitates Mechanical Ventilation – Essential for respiratory failure or anesthesia.
🔹 Allows Medication Delivery – Certain emergency medications (epinephrine, atropine, lidocaine, naloxone) can be given via ETT if IV/IO access is unavailable (NAVEL mnemonic).
🔹 Enables Airway Suctioning – Helps clear blood, vomit, and secretions.

🚑 ET intubation is used in emergency medicine, critical care, and anesthesia.

 

2️⃣ INDICATIONS FOR ENDOTRACHEAL INTUBATION

✅ Respiratory Failure – Patient cannot maintain adequate oxygenation or ventilation on their own.
✅ Airway Obstruction – Due to foreign body, swelling (anaphylaxis, burns), secretions, or trauma.
✅ Airway Protection – Prevents aspiration in patients with impaired consciousness (e.g., stroke, overdose, head injury).
✅ Perioperative Airway Control – Used for surgical procedures requiring general anesthesia.
✅ Severe Neurological Injury – For coma, seizures, or brainstem dysfunction impairing airway control.

🚨 If a patient is unable to maintain their airway or ventilation, intubation should be performed immediately!

 

3️⃣ RISKS AND COMPLICATIONS OF ET INTUBATION

❌ Esophageal Intubation

  • Tube mistakenly inserted into the esophagus, leading to gastric insufflation and lack of oxygenation.
  • 🚨 Always confirm placement with capnography!

❌ Vocal Cord Trauma

  • Can occur from aggressive laryngoscopy or repeated intubation attempts.

❌ Bleeding

  • Minor oral or tracheal bleeding can occur due to airway trauma.

❌ Infection (Ventilator-Associated Pneumonia – VAP)

  • The longer the tube is in place, the higher the risk of pneumonia and sepsis.

❌ Right Mainstem Bronchus Intubation

  • If the tube is inserted too far, it may enter the right main bronchus, leading to one-lung ventilation and hypoxia.

🚨 Proper training and confirmation techniques are essential to avoid complications!

 

4️⃣ STEPS OF ENDOTRACHEAL INTUBATION

✅ Step-by-Step Instructions:

1. Preoxygenation

  • Administer high-flow oxygen (100% O₂) for at least 3-5 minutes before intubation.
  • Use a bag-valve-mask (BVM) with oxygen to prevent desaturation.

2. Positioning

  • Place the patient in the “sniffing position”:
    • Head slightly extended
    • Neck slightly flexed
  • If spinal injury is suspected, maintain cervical spine immobilization while intubating.

3. Laryngoscopy

  • Insert a laryngoscope blade (Macintosh or Miller) into the mouth.
  • Lift the epiglottis to visualize the vocal cords and the glottic opening.

4. Passing the Endotracheal Tube (ETT)

  • Insert the ET tube through the vocal cords into the trachea.
  • Advance until the cuff is just past the vocal cords (around 21-23 cm in adults).

5. Inflate the Cuff

  • Inflate the ET tube cuff with the appropriate volume of air (typically 5-10 mL) to create a seal and prevent aspiration.

6. Confirm Placement

🚨 Immediately confirm ET tube placement using multiple methods:
✅ Capnography (ETCO₂ monitoring) – Most reliable method!
✅ Auscultation of bilateral breath sounds (equal chest rise).
✅ Absence of breath sounds over the stomach (to rule out esophageal intubation).
✅ Condensation inside the ET tube.
✅ **Chest X-ray – Should show tube tip 2-3 cm above the carina.

🚨 If ETCO₂ is absent or breath sounds are heard over the stomach, remove the tube and retry intubation!

 

5️⃣ CONFIRMATION OF PLACEMENT

🔹 Multiple confirmation methods should always be used!

✅ Primary Confirmation Methods:
1. Capnography (ETCO₂ Monitoring) – Most Reliable

  • If the ET tube is correctly placed in the trachea, ETCO₂ will be detected.
  • If no CO₂ is detected, the tube may be in the esophagus!

2. Auscultation of Breath Sounds

  • Listen to both lungs – Equal sounds indicate correct placement.
  • If breath sounds are absent on one side, the tube may be too deep in the right mainstem bronchus—retract slightly.
  • If breath sounds are heard over the stomach, the tube is likely in the esophagus—remove and retry.

3. Chest Rise Observation

  • Look for symmetrical chest expansion with ventilation.

4. Condensation in the ET Tube

  • Fogging inside the ET tube suggests correct airway placement.

✅ Secondary Confirmation:

  • Chest X-ray: Confirms the ET tube tip is 2-3 cm above the carina.

🚨 NEVER assume correct placement—always confirm with multiple methods!

 

6️⃣ WHEN TO EXTUBATE

✅ The ET tube should be removed when the patient:

  • Has regained adequate spontaneous breathing and airway protection.
  • No longer requires mechanical ventilation.

🚨 Monitor closely for post-extubation complications like airway swelling or stridor.

 

7️⃣ COMMON PITFALLS & HOW TO AVOID THEM

 
ErrorImpactPrevention
Esophageal IntubationNo ventilation, risk of aspirationAlways confirm placement with ETCO₂!
Right Mainstem Bronchus IntubationOne-lung ventilation, hypoxiaWithdraw the tube slightly if breath sounds are absent on one side.
Cuff OverinflationTracheal injury, impaired blood flowInflate only to recommended volume
Failure to PreoxygenateRapid desaturation, hypoxiaAlways preoxygenate with 100% O₂ for 3-5 min

🚨 Intubation requires skill, proper technique, and continuous monitoring for complications!

 

8️⃣ FINAL TAKEAWAYS: MASTERING ENDOTRACHEAL INTUBATION

✅ ET intubation is the gold standard for securing a definitive airway.
✅ It is indicated for respiratory failure, airway protection, and mechanical ventilation.
✅ Proper positioning (sniffing position) improves success rates.
✅ Capnography (ETCO₂) is the most reliable confirmation method.
✅ Always be prepared for complications (e.g., esophageal intubation, hypoxia, trauma).

🚑 Takeaway: Endotracheal intubation is a life-saving intervention, but proper training, skill, and confirmation techniques are essential for success!