Overview
Endotracheal intubation is a critical airway management procedure that involves the placement of a cuffed tube through the mouth or nose into the trachea to establish a secure airway. This procedure is fundamental to anesthesia practice and is essential for airway protection, mechanical ventilation, and general anesthesia administration.
Endotracheal intubation is the gold standard for airway management in anesthesia. It provides definitive airway protection, allows for positive pressure ventilation, prevents aspiration, and enables the delivery of volatile anesthetics. Mastery of this skill is crucial for anesthesia residents as it forms the foundation of safe anesthetic practice.
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Indications
Airway protection during surgical procedures requiring muscle relaxation
Mechanical ventilation support in acute respiratory distress
Prevention of aspiration in patients with altered consciousness
Advanced life support and airway management
Emergency airway management in trauma patients
Rescue airway when LMA or other SGA fails
Procedures lasting more than 2-3 hours
Surgery requiring prone positioning
Contraindications
Absolute Contraindications
Relative Contraindications
📋 Equipment Checklist
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Pre-procedure Preparation
Preparation involves thorough patient assessment including airway evaluation (Mallampati classification, thyromental distance, neck mobility), equipment check (laryngoscope, endotracheal tubes, stylet, suction), preoxygenation with 100% FiO2 for 3-5 minutes, and ensuring adequate monitoring (ECG, SpO2, EtCO2).Step-by-Step Procedure
Step 1: Preoxygenation
Administer 100% oxygen via face mask for 3-5 minutes to achieve nitrogen washout and create oxygen reservoir in functional residual capacity. This provides 6-8 minutes of apnea time.
⚠️ Common Mistakes to Avoid:
- Inadequate preoxygenation time
- Poor mask seal
- Not using high flow oxygen
💡 Pro Tip:
Use high flow oxygen (15L/min) and ensure proper mask seal. Monitor SpO2 and aim for 100% saturation.
Step 2: Patient Positioning
Position patient in sniffing position: head extended, neck flexed, and shoulders elevated. This aligns the oral, pharyngeal, and laryngeal axes for optimal laryngoscopic view.
⚠️ Common Mistakes to Avoid:
- Poor positioning
- Inadequate neck extension
- Not elevating shoulders
💡 Pro Tip:
Use a pillow under the head and ensure the external auditory meatus is level with the sternal notch.
Step 3: Laryngoscopy Technique
Hold laryngoscope in left hand, insert blade along right side of mouth, sweep tongue to left, advance blade to vallecula (Macintosh) or epiglottis (Miller), lift upward and forward at 45-degree angle.
⚠️ Common Mistakes to Avoid:
- Using teeth as fulcrum
- Inadequate lifting force
- Poor blade positioning
💡 Pro Tip:
Lift the laryngoscope upward and forward, not backward. Use your arm strength, not wrist strength.
Step 4: Vocal Cord Visualization
Identify vocal cords, posterior commissure, and arytenoid cartilages. Grade the view using Cormack-Lehane classification (Grade 1-4).
⚠️ Common Mistakes to Avoid:
- Not identifying landmarks
- Confusing epiglottis for vocal cords
- Poor lighting
💡 Pro Tip:
Look for the white vocal cords and the dark space between them. Use external laryngeal manipulation if needed.
Step 5: Tube Insertion
Insert endotracheal tube through the vocal cords under direct visualization. Advance until the cuff is 2-3 cm below the vocal cords.
⚠️ Common Mistakes to Avoid:
- Esophageal intubation
- Too deep insertion
- Not watching tube pass cords
💡 Pro Tip:
Watch the tube pass through the vocal cords. The tube should be at 21-23 cm at the teeth for adults.
Step 6: Position Confirmation
Confirm tube position using multiple methods: auscultation of bilateral breath sounds, EtCO2 waveform, chest rise, and absence of gastric sounds.
⚠️ Common Mistakes to Avoid:
- Relying on single method
- Not checking bilateral breath sounds
- Ignoring EtCO2
💡 Pro Tip:
Always use multiple confirmation methods. EtCO2 is the most reliable immediate indicator.
Step 7: Cuff Inflation and Securing
Inflate cuff to 20-30 cm H2O pressure, secure tube with tape or commercial holder, and connect to ventilator or breathing circuit.
⚠️ Common Mistakes to Avoid:
- Over-inflation of cuff
- Poor tube securing
- Not checking cuff pressure
💡 Pro Tip:
Use a cuff pressure manometer. Over-inflation can cause tracheal ischemia.
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Post-procedure Care
Post-intubation care includes confirming tube position with multiple methods (auscultation, EtCO2, chest X-ray), securing the tube, setting appropriate ventilator parameters, monitoring for complications, and documenting the procedure details.Complications & Management
| Complication | Incidence | Signs | Management | Prevention |
|---|---|---|---|---|
| Esophageal intubation | 2-5% | No breath sounds, gastric distension, no EtCO2, low SpO2 | Remove tube immediately, reoxygenate, reattempt with better technique | Always confirm position with multiple methods, watch tube pass through cords |
| Dental trauma | 1-3% | Tooth damage, bleeding, loose teeth, lip trauma | Document injury, consult dentist, provide dental referral | Gentle technique, avoid using teeth as fulcrum, use proper blade size |
| Vocal cord injury | 1-2% | Hoarseness, stridor, voice changes, sore throat | Monitor symptoms, consider steroids, ENT consultation if severe | Gentle technique, avoid multiple attempts, proper tube size |
| Hypoxemia | 5-10% | Low SpO2, bradycardia, cyanosis, agitation | Stop procedure, bag-mask ventilation, reoxygenate, consider backup plan | Adequate preoxygenation, limit attempts to 30 seconds, have backup ready |
| Hypertension/tachycardia | 10-20% | Elevated blood pressure, increased heart rate, arrhythmias | Deepen anesthesia, consider beta-blockers, monitor for ischemia | Adequate anesthesia depth, smooth induction, proper premedication |
| Endobronchial intubation | 3-8% | Unilateral breath sounds, asymmetric chest rise, high airway pressure | Withdraw tube 2-3 cm, reconfirm position, check bilateral breath sounds | Proper tube depth, use depth markers, confirm bilateral breath sounds |
Clinical Pearls
Always have a backup plan for difficult airways - know your difficult airway algorithm.
Use proper positioning - the sniffing position is crucial for successful intubation.
Confirm tube position with multiple methods - never rely on a single confirmation technique.
Monitor for complications post-intubation - especially in the first 24 hours.
Document intubation details including attempts, view grade, and complications.
Practice difficult airway algorithms regularly - muscle memory saves lives.
Be prepared for failed intubation scenarios - have a clear backup strategy.
Limit laryngoscopy attempts to 30 seconds to prevent hypoxemia.
Use appropriate tube size - 7.0-8.5 for adults, smaller for women and Asians.
External laryngeal manipulation can improve laryngoscopic view significantly.