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Tracheal Intubation

By Charles D. Bortle, EdD, Director of Clinical Simulation, Office of Academic Affairs, Einstein Medical Center

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Most patients requiring an artificial airway can be managed with tracheal intubation. Orotracheal intubation, typically done via direct laryngoscopy, is preferred in apneic and critically ill patients because it can usually be done faster than nasotracheal intubation, which is reserved for awake, spontaneously breathing patients or for cases when the mouth must be avoided.

Before Intubation

Maneuvers to create a patent airway and to ventilate and oxygenate the patient are always indicated before attempting tracheal intubation. Once a decision to intubate has been made, preparatory measures include

Ventilation with 100% oxygen denitrogenates healthy patients and significantly prolongs the safe apneic time (effect is less in patients with severe cardiopulmonary disorders).

Strategies to predict difficult laryngoscopy (eg, Mallampati scoring, thyromental distance testing) are of limited value in emergencies. Practitioners should always be prepared to use an alternate technique (eg, laryngeal mask airway, bag-valve-mask ventilation, surgical airway) if laryngoscopy does not work.

During cardiac arrest, chest compressions should not be halted for intubation attempts. If practitioners cannot intubate while compressions are being done (or during the brief pause that occurs during compressor changes), an alternate airway technique should be used.

Suction should be immediately available with a rigid tonsil-tip suction device to clear secretions and other material from the airway.

Anterior cricoid pressure (Sellick maneuver) has previously been recommended before and during intubation to prevent passive regurgitation. However, current literature suggests that this maneuver may be less effective than once thought and may compromise laryngeal view during laryngoscopy.

Drugs to aid intubation, including sedatives, muscle relaxants, and sometimes vagolytics, are typically given to conscious or semiconscious patients before laryngoscopy.

Tube Selection and Preparation for Intubation

Most adults can accept a tube with an internal diameter of 8 mm; these tubes are preferable to smaller ones because they

  • Have lower airflow resistance (reducing the work of breathing)

  • Facilitate suctioning of secretions

  • Allow passage of a bronchoscope

  • May aid in liberation from mechanical ventilation

For infants and children 1 yr, uncuffed tube size is calculated by (patient’s age + 16)/4; thus, a 4-yr-old should have a (4 + 16)/4 = 5 mm endotracheal tube. The tube size suggested by this formula should be reduced by 0.5 (1 tube size) if a cuffed tube is to be used. Reference charts (see Guide to Pediatric Resuscitation—Mechanical Measures) or devices such as the Broselow pediatric emergency tape or Pedi-Wheel can rapidly identify appropriate-sized laryngoscope blades and endotracheal tubes for infants and children.

For adults (and sometimes in children), a rigid stylet should be placed in the tube, taking care to stop the stylet 1 to 2 cm before the distal end of the endotracheal tube, so that the tube tip remains soft. The stylet should then be used to make the tube straight to the beginning of the distal cuff; from that point, the tube is bent upward about 35° to form a hockey stick shape. This straight-to-cuff shape improves tube delivery and avoids blocking the operator’s view of the vocal cords during tube passage. Routinely filling the distal endotracheal tube cuff with air to check the balloon is not required; if this technique is used, care must be taken to remove all the air before tube insertion.

Insertion Technique for Intubation

Successful intubation on the first attempt is important. Repeated laryngoscopy ( 3 attempts) is associated with much higher rates of significant hypoxemia, aspiration, and cardiac arrest. In addition to correct positioning, several other general principles are critical for success:

  • Visualizing the epiglottis

  • Visualizing the posterior laryngeal structures (ideally, the vocal cords)

  • Not passing the tube unless tracheal insertion is ensured

The laryngoscope is held in the left hand, and the blade is inserted into the mouth and used as a retractor to displace the mandible and tongue up and away from the laryngoscopist, revealing the posterior pharynx. Avoiding contact with the incisors and not placing undue pressure on laryngeal structures are important.

The importance of identifying the epiglottis cannot be overstated. Identifying the epiglottis allows the operator to recognize critical airway landmarks and correctly position the laryngoscope blade. The epiglottis may rest against the posterior pharyngeal wall, where it blends in with the other pink mucus membranes or gets lost in the pool of secretions that invariably exists in the cardiac arrest patient’s airway.

Once the epiglottis is found, the operator may pick it up with the tip of the blade (the typical straight blade approach) or advance the tip of the blade into the vallecula, pressing against the hyoepiglottic ligament, to indirectly lift the epiglottis up and out of the line of sight (the typical curved blade approach). Success with the curved blade depends on the proper positioning of the blade tip in the vallecula and the direction of the lifting force (see Figure: Bimanual laryngoscopy.). Lifting the epiglottis by either technique reveals the posterior laryngeal structures (arytenoid cartilages, interarytenoid notch), glottis, and vocal cords. If the tip of the blade is too deep, laryngeal landmarks may be entirely bypassed, and the dark, round hole of the esophagus may be mistaken for the glottis opening.

If identifying structures is difficult, manipulating the larynx with the right hand placed on the anterior neck (allowing the right and left hands to work together) may optimize the laryngeal view (see Figure: Bimanual laryngoscopy.). Another technique involves lifting the head higher (lifting at the occiput, not atlanto-occipital extension), which distracts the jaw and improves the line of sight. Head elevation is inadvisable in patients with potential cervical spine injury and is difficult in the morbidly obese (who must be placed in a ramped or head-elevated position beforehand).

In an optimal view, the vocal cords are clearly seen. If the vocal cords are not seen, at a minimum, the posterior laryngeal landmarks must be viewed and the tip of the tube must be seen passing above the interarytenoid notch and posterior cartilages. Operators must clearly identify laryngeal landmarks to avoid potentially fatal esophageal intubation. If operators are not confident that the tube is going into the trachea, the tube should not be inserted.

Once an optimal view has been achieved, the right hand inserts the tube through the larynx into the trachea (if operators have been applying anterior laryngeal pressure with the right hand, an assistant should continue applying this pressure). If the tube does not pass easily, a 90° clockwise twist of the tube may help it pass more smoothly over the anterior tracheal rings. Before withdrawing the laryngoscope, operators should confirm that the tube is passing between the cords. Appropriate tube depth is usually 21 to 23 cm in adults and 3 times the endotracheal tube size in children (for a 4.0-mm endotracheal tube, 12 cm; for a 5.5-mm endotracheal tube, 16.5 cm). In adults, the tube, if inadvertently advanced, typically migrates into the right mainstem bronchus.

Bimanual laryngoscopy.

Pressure is applied on the neck opposite the direction of lift of the laryngoscope. Arrows show the direction for lift of the laryngoscope and for anterior neck pressure.

Alternative Intubation Devices

A number of devices and techniques are increasingly used for intubation after failed laryngoscopy or as a primary means of intubation. Devices include

  • Video laryngoscopes

  • Mirror laryngoscopes

  • Laryngeal mask airways (LMAs) with a passage that allows tracheal intubation

  • Fiberoptic scopes and optical stylets

  • Tube introducers

Each device has its own subtleties; practitioners who are skilled in standard laryngoscopic intubation techniques should not assume they can use one of these devices (especially after use of muscle relaxants) without becoming thoroughly familiarized with it.

Video and mirror laryngoscopes enable practitioners to look around the curvature of the tongue and usually provide excellent laryngeal views. However, the tube requires an exaggerated bend angle to go around the tongue and thus may be more difficult to manipulate and insert.

To pass an endotracheal tube through a laryngeal mask airway, practitioners must understand how to optimally position the mask over the laryngeal inlet; there are sometimes mechanical difficulties passing the endotracheal tube.

Flexible fiberoptic scopes and optical stylets are very maneuverable and can be used in patients with abnormal anatomy. However, practice is required to recognize laryngeal landmarks from a fiberoptic perspective. Compared with video and mirror laryngoscopes, fiberoptic scopes are more difficult to master and are more susceptible to problems with blood and secretions; also, they do not separate and divide tissue but instead must be moved through open channels.

Tube introducers (commonly called gum elastic bougies) are semirigid stylets that can be used when laryngeal visualization is suboptimal (eg, the epiglottis is visible, but the laryngeal opening is not). In such cases, the introducer is passed along the undersurface of the epiglottis; from this point, it is likely to enter the trachea. Tracheal entry is suggested by the tactile feedback, noted as the tip bounces over the tracheal rings. An endotracheal tube is then advanced over the introducer. During passage over a tube introducer or bronchoscope, the tube tip sometimes catches the right aryepiglottic fold. Rotating the tube 90° counterclockwise often frees the endotracheal tube tip and allows it to pass smoothly.


The stylet is removed and the balloon cuff is inflated with air using a 10-mL syringe; a manometer is used to verify that balloon pressure is < 30 cm water. Properly sized endotracheal tubes may need considerably < 10 mL of air to create the correct pressure.

After balloon inflation, tube placement should be checked using a variety of methods, including

  • Inspection and auscultation

  • Carbon dioxide detection

  • Esophageal detector devices

  • Sometimes chest x-ray

When a tube is correctly placed, manual ventilation should produce symmetric chest rise, good breath sounds over both lungs, and no gurgling over the upper abdomen.

Exhaled air should contain carbon dioxide and gastric air should not; detecting carbon dioxide with a colorimetric end-tidal carbon dioxide device or waveform capnography confirms tracheal placement. However, in prolonged cardiac arrest (ie, with little or no metabolic activity), carbon dioxide may not be detectable even with correct tube placement. In such cases, an esophageal detector device may be used. These devices use an inflatable bulb or a large syringe to apply negative pressure to the endotracheal tube. The flexible esophagus collapses, and little or no air flows into the device; in contrast, the rigid trachea does not collapse, and the resultant airflow confirms tracheal placement.

In the absence of cardiac arrest, tube placement is typically also confirmed with a chest x-ray.

After correct placement is confirmed, the tube should be secured using a commercially available device or adhesive tape. Adapters connect the endotracheal tube to a resuscitator bag, T-piece supplying humidity and oxygen, or a mechanical ventilator.

Endotracheal tubes can be displaced, particularly in chaotic resuscitation situations, so tube position should be rechecked frequently. If breath sounds are absent on the left, right mainstem bronchus intubation is probably more likely than a left-sided tension pneumothorax, but both should be considered.

Nasotracheal Intubation

If patients are spontaneously breathing, this technique can be used in certain emergency situations—eg, when patients have severe oral or cervical disorders (eg, injuries, edema, limitation of motion) that make laryngoscopy difficult. Historically, nasal intubation was also used when muscle relaxants were unavailable or forbidden (eg, prehospital settings, certain emergency departments) and when patients with tachypnea, hyperpnea, and upright positioning (eg, those with heart failure) might literally inhale a tube. However, availability of noninvasive means of ventilation (eg, bilevel positive airway pressure [BiPAP]), improved access to and training in pharmacologic adjuncts to intubation, and newer airway devices have markedly decreased the use of nasal intubation. Additional considerations are problems with nasal intubation, including sinusitis (universal after 3 days), and the fact that tubes large enough to permit bronchoscopy (eg, 8 mm) can rarely be inserted nasotracheally.

When nasotracheal intubation is done, a vasoconstrictor (eg, phenylephrine) and topical anesthetic (eg, benzocaine, lidocaine) must be applied to the nasal mucosa and the larynx to prevent bleeding and to blunt protective reflexes. Some patients may also require IV sedatives, opioids, or dissociative drugs. After the nasal mucosa is prepared, a soft nasopharyngeal airway should be inserted to ensure adequate patency of the selected nasal passage and to serve as a conduit for topical drugs to the pharynx and larynx. The nasopharyngeal airway may be placed using a plain or anesthetic (eg, lidocaine) lubricant. The nasopharyngeal airway is removed after the pharyngeal mucosa has been sprayed.

The nasotracheal tube is then inserted to about 14 cm depth (just above the laryngeal inlet in most adults); at this point, air movement should be audible. As the patient breathes in, opening the vocal cords, the tube is promptly passed into the trachea. A failed initial insertion attempt often prompts the patient to cough. Practitioners should anticipate this event, which allows a second opportunity to pass the tube through a wide open glottis. More flexible endotracheal tubes with a controllable tip improve likelihood of success. Some practitioners soften tubes by placing them in warm water to lessen the risk of bleeding and make insertion easier. A small commercially available whistle can also be attached to the proximal tube connector to accentuate the noise of air movement when the tube is in the correct position above the larynx and in the trachea.

Complications of Tracheal Intubation

Complications include

  • Direct trauma

  • Esophageal intubation

  • Tracheal erosion or stenosis

Laryngoscopy can damage lips, teeth, tongue, and supraglottic and subglottic areas.

Tube placement in the esophagus, if unrecognized, causes failure to ventilate and potentially death or hypoxic injury. Insufflating a tube in the esophagus causes regurgitation, which can result in aspiration, compromise subsequent bag mask valve ventilation, and obscure visualization in subsequent intubation attempts.

Any translaryngeal tube injures the vocal cords somewhat; sometimes ulceration, ischemia, and prolonged cord paralysis occur. Subglottic stenosis can occur later (usually 3 to 4 wk).

Rarely, tracheostomy insertion causes hemorrhage, thyroid damage, pneumothorax, recurrent laryngeal nerve paralysis, injury to major vessels, or late tracheal stenosis at the insertion site.

Erosion of the trachea is uncommon. It results more commonly from excessively high cuff pressure. Rarely, hemorrhage from major vessels (eg, innominate artery), fistulas (especially tracheoesophageal), and tracheal stenosis occur. Using high-volume, low-pressure cuffs with tubes of appropriate size and measuring cuff pressure frequently (every 8 h) to maintain it at < 30 cm water decrease the risk of ischemic pressure necrosis, but patients in shock, with low cardiac output, or with sepsis remain especially vulnerable.

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