Endotracheal Intubation

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General Orotracheal Intubation

Intubation is the process of passing a sterile tube into some portion of a patient’s body. Endotracheal intubation is the process of passing an endotracheal tube (ETT) (Figure 1) through the vocal cords and into the trachea to facilitate ventilation and oxygenation. Endotracheal intubation can be further subdivided into orotracheal (through the mouth) or nasotracheal (through the nose) intubation. Nasotracheal intubation will not be discussed on this page. In general, endotracheal intubation (referred to as “intubation” for brevity for the rest of this page) is performed to allow providers to control the airway of a patient who may be at risk of airway or breathing complications including, but not limited to, aspiration, apnea, exhaustion.

Techniques

There are several techniques for performing orotracheal intubation which will be discussed here, though several are rarely used and will only be peripherally covered.

Direct Laryngoscopy (DL)

The most common form of intubation in the field is by far the utilization of laryngoscopy handles and blades (Figure 2) to allow for a direct view of the vocal cords. Although video laryngoscopy (VL) is becoming more common as portable video laryngoscopes become more readily available to EMS systems, DL generally remains a backup in most protocols should VL fail. Direct laryngoscopy utilizes two common blades, the Macintosh and Miller, which will be covered later in this page.

Video Laryngoscopy (VL)

Video laryngoscopy, as previously mentioned, is becoming more common as an option in the prehospital environment. Many commercial video laryngoscopes (e.g. CMAC, KingVision, GlideScope) (Figure 3) have been produced as portable solutions that allow for prehospital providers to perform VL which has been found to have higher success rates than conventional DL [reference]. Video laryngoscopes have several positives compared to their direct cousins such as better visualization, increased provider safety, shorter intubation times, and ability to record video confirmation of tube placement but are constrained by the need for a clean lens, battery life, and in some cases size of oral opening (e.g. the King Vision’s channeled blade may not fit in some patient’s mouth). Some VL manufacturers provide channeled blades to assist with ETT placement while others have hyperangulated blades that allow for DL should VL fail (e.g. GlideScope).

Flexible bronchoscopes (Figure 4) would also fall into the category of video laryngoscopes when used for intubation but will not be discussed in this page as they are almost never utilized in the prehospital environment due to budget, training, and skill limitations.

Other Techniques

Other techniques of orotracheal intubation exist but are uncommon and will only be discussed rapidly in this section. Blind intubation (with no visualization of the vocal cords or other anatomy) may be performed digitally, where the provider feels for the epiglottis with a finger and attempts ETT placement based upon that finding, or with a lighted Bougie, where an aid with a  bright light is passed through the oral opening (light seen in the middle of the neck externally may indicate tracheal placement).

Upright (face to face) intubation (Figure 5) may also be used in patients whose condition does not allow for supination. These patients may have pathologic (e.g. CHF) or mechanical (e.g. entrapped in vehicle seat) requirements that require a seated or Fowler’s position. Upright orotracheal intubation is performed very differently than normal supine orotracheal intubation and as such will not be discussed on this page. Additional information about upright or face to face intubation can be found here [link to Face to Face Intubation subskill].

Macintosh vs. Miller

The two most common forms of laryngoscopy blade are the Macintosh (curved) and Miller (straight) blades (Figure 6). The blades are used only slightly differently; the Macintosh is placed into the vallecula to lift the epiglottis while the Miller is used to lift the epiglottis itself. Miller blades are commonly used in pediatric patients or patients with a “long and floppy” epiglottis. Mac 3 and Mil 2 are likely to work well in most adult patients with a fairly normal body habitus.

Anatomy of the Endotracheal Tube

BVM adapter, Depth markings, Radiolucent line, internal diameter number, Pilot balloon, distal cuff, Murphy’s eye and Bevel

Intubation aids

Bougie, Rigid and Semi-Rigid Stylettes, Lighted aid

ELM vs Sellick maneuver (cric pressure)

The “Seven Ps”

With or without RSI, just remove some Ps

Confirmation

Talk about positive bilateral lung sounds, absence of epigastric sounds, ETCO2 waveform or capnometry, “misting” in the tube, revisualization of the tube passing through the cords, Xray confirmation

Airway Anatomy

Upper airway map

Talk about the carina and where the distal end of the tube should end up and pathway of air

Relevant Anatomical structures for intubation

The Tongue and Uvula

The Epiglottis and Vallecula

The Arytenoid Cartilage

The Pyriform Fossae

The Vocal Cords

The Esophagus

When to intubate

Indications

Cautions/Contraindications

Complications

Talk about Right mainstem intubation, Trauma, Vagal stimulation

Clinical decision-making/Difficult Airway

LEMON

HEAVEN

When to RSI

How to Intubate

Needed Items

Procedure

Tips to increase first pass success

The “Sniffing" Position

Ear to sternal notch

Provider positioning

Teamwork dynamics

“Dirty” Airway Troubleshooting

Talk about moving to surgical/needle cricothyrotomy if needed

SALAD Maneuver

Bougie Exchange

Documentation

·        “Patient intubated via direct orotracheal intubation with Mac 3 and 7.5 mm ID cuffed ETT. Placement confirmed by continuous waveform capnography, auscultation of bilateral breath sounds and absent epigastric sounds. Placement additionally confirmed by revisualization of tube by Provider 2 and CXR at receiving facility by receiving MD."