Endotracheal Intubation - Virginia Commonwealth University

May 4, 2004 

Tubes, Lines, and Vents in the ICU: 

Endotracheal Intubation 

Mechanical Ventilation 

Central Venous Catheterization 

Arterial Catheterization 

Swan Ganz Catheterization 

Curt Sessler, MD 

Professor of Medicine 

Medical Director of Critical Care 

Virginia Commonwealth University Health System

Endotracheal Intubation: Outline 

• Anatomy 

• Preparation 

» Patient evaluation 

» Equipment / Medications 

• Pre-intubation patient management 

• Procedure of intubation 

• Difficult airway

Goals of Endotracheal 

Intubation 

• Secure and protect airway 

• Ventilation 

• Oxygenation

Anatomy for 

Tracheal Intubation 

• Pathway to vocal 

cords: mouth, 

pharynx, larynx 

• Glottis: vocal cords, 

epiglottis, valeculae, 

esophagus

Pre-Intubation Patient 

Evaluation: Critical Issues 

• Difficult mask fit / bag-mask ventilation 

• Difficult intubation 

• Medical conditions which influence 

choice of medications 

• Alternative airway options

Pre-Intubation Evaluation: 

‘NDOTRAC’ 

Parameter Abnormality Action 

N Neck Short Difficult* 

D Dentition Loose teeth Caution w blade 

O Oral cavity Small, limited view Difficult* 

T Tongue Large Difficult, curved blade 

R ROM Limited Fiberoptic 

A Adam’s apple Prominent (anterior) straight b 

C Chin Receding Difficult* 

* consider awake intubation, alternatives, backup

Equipment for Intubation 

• Laryngoscope: 

handle, straight & 

curved blades 

• Endotracheal tubes 

• Airways 

• Water soluble 

lubricant 

• Stylet 

• Syringe 

• Suction equipment 

• Oxygen 

• Bag and mask 

• Pulse oximetry 

• ET CO2 detector 

• Tape / benzoin 

• Cardiac monitor 

• Defibrillator 

• Medications

Patient Preparation 

• Open airway by placing 

patient in sniffing position 

• Lift at chin or angles of 

jaw

Patient Preparation 

• Towel / blanket beneath 

head / upper shoulders 

• Provide effective mask 

ventilation with 100% O2 

» May need oral airway 

» May need PEEP valve 

• Apply pressure to cricoid cartilage

Visualize Vocal Cords 

• Align axes of pharynx, larynx, mouth 

• Place towels beneath head to align larynx & pharynx 

• Using laryngoscope, hyperextend at C1-C2 vertebra

Orotracheal Intubation 

• Position patient in sniffing 

position, hyper-extend at C1-C2 

• Laryngoscope blade is inserted 

into the right corner of the mouth 

and advanced halfway as 

moved to the midline 

» Tongue swept out of the way 

» Epiglottis visualized


• Curved blade: tip of blade 

advanced above epiglottis 

• Straight blade: tip of 

blade advanced under 

epiglottis 

• Laryngoscope lifted to 

visualize cords


• ET tube tip is passed 

between cords until cuff is 

beyond cords

How to Hold the 

Endotracheal Tube?

Steps in Orotracheal 

Intubation 

• Insert blade 

• Visualize epiglottis 

• Reposition blade 

and visualize 

vocal cords 

• Insert ET tube

Rapid Sequence Intubation 

(RSI) 

• Short acting sedatives and neuromuscular 

blocking agent to facilitate immediate 

intubation in unstable patient 

• Features 

» Adequate sedation and amnesia 

» Rapid muscle relaxation 

» Reduced risk of aspiration 

» Reduced rise in ICP

Induction Agents 

• Smooth rapid amnestic 

• Short duration of action 

• Stable hemodynamics 

• Few side effects 

•Etomidate (Amidate) 

•Midazolam (Versed) 

•Thiopental (Pentothal) 

•Methohexital (Brevitol) 

•Ketamine (Ketalar)

Nasotracheal Intubation 

• Patient selection 

» Must be spontaneously breathing 

• Useful alternative to orotracheal intubation 

» Cervical spine injury 

» Avoid IV sedatives and NMBA 

• Contra-indications: apnea, upper airway foreign 

body, bleeding diathesis, epiglottitis, CSF rhinorrhea / 

head trauma, nasal polyp or abscess

Nasotracheal Intubation: 

Technique 

• Determine nasal patency, consider 

applying vasoconstricting agent 

• Insert nasal airway coated 

with topical anesthetic / 

lubricant


Technique 

• With patient sitting upright, ET tube is 

inserted and advanced towards the back of 

the head above the hard pallet 

• ET tube advanced toward cords while 

listening for breath sounds


Technique 

• Endotracheal position confirmed by breath 

sounds through ET tube, cough. 

• Methods to improve successful placement 

» head in sniffing position 

» protrude tongue 

» cricoid pressure 

» maintain slight downward pressure if meeting 

resistance and patient cannot speak: tip likely is 

against cords and will pass when pt breathes

Endotracheal Intubation: 

Complications 

• Trauma: teeth, mouth, 

pharynx, nasopharynx, 

trachea 

• Esophageal intubation 

» Avoid by measuring 

exhaled CO2 (bag for 

5-10 breaths to confirm)


Complications 

• Bronchial intubation 

» Confirm bilateral = BS 

» Confirm ET tube position 

• Reflex response to airway 

stimulation: 

» Tachycardia, hypertension, 

increased ICP resulting in MI, 

• Aspiration of gastric contents 

• Hypotension: dehydration, 

poor LV function 

22 cm 

27 cm

Difficult Airway: 

Esophageal Tracheal Tube 

Manually (blindly) inserted. 

Double lumen tube with 2 

cuffs. One tube (arrow) 

opens to multiple holes 

between cuffs and is used 

to ventilate if tip is in 

esophagus. Other lumen 

opens beyond distal cuff 

and is used to ventilate if 

tip is placed in trachea. 

Blanda. J Crit Illness 2000

Difficult Airway: 

Laryngeal Mask 

Manually (blindly) 

inserted. Slightly 

inflate cuff and insert 

to fit over the larynx. 

Inflate tube and bag.

Cricothyroidotomy / 

Transtracheal Ventilation


Summary 

• Preparation for intubation 

» Patient assessment 

» Equipment 

» Intubation 

• Endotracheal intubation procedure 

» Pre-intubation 

» Procedure 

• Difficult airway management

Endotracheal Intubation - Virginia Commonwealth University

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