Sunday, April 18, 2021

Endotracheal intubation




Gloves, face shield, suction, Laryngoscope and blade, Endotracheal tube (of required size) with stylet, bag and mask apparatus, 10 cc syringe for checking air leak, oral or nasal airway, tape for holding the tube


  1. Check the equipment before starting the procedure- if the light on the laryngoscope is functioning and check the ET tube for air leaks by filling it up with 10cc air (the balloon should be tense) Insert the stylet in the ET tube to give it proper form. Make sure the stylet doesn’t protrude outside the tube.

  1. Position the patient in the “sniffing” position- flexion at the neck and extension at the head.

  1. Place a pillow or towel roll under the occiput to elevate it. (It aligns the 3 axes- pharyngeal, laryngeal and oral to facilitate better visualisation of the vocal cords.)


  1. Pre-oxygenate if possible (1-3 min 100% Oxygen)

  1. Stand behind the head of the patient. The head of the patient should be at the lower end of your sternum. Open mouth and inspect: remove any dentures/debris, suction any secretions.

  1. Check for proper sedation by the laxity of jaw.

  1. Hold the handle in your left hand (non-dominant hand), blade down, pointing away from you. 

  1. Retract the lips with your right hand. 

  1. Insert the laryngoscope blade to the right of patient’s tongue. Gradually move the blade towards the centre of the mouth pushing the tongue to the left.

  1. Advance the laryngoscope gradually to visualize the epiglottis. 

  1. If MacIntosh- Place the tip of the blade into the vallecula between the base of the tongue and the epiglottis and lift anteriorly to expose the vocal cords.

If Millers- Place the tip of the blade just past the epiglottis and lift anteriorly to expose the vocal cords.

THE LIFT- When the tip of blade is properly positioned lift the laryngoscope upwards and forwards/away at a 45-degree angle. Direct the force of your lift along the axis of the laryngoscope handle in direction of the ceiling over the patient’s feet.

  1. Hold the preselected tube in your right hand like a pencil, curve forward. Pass the tube to the right of the blade, past the right side of the tongue. The tube should not obstruct the view of the vocal cords.

  1. Pass the tube through the vocal cords until the balloon disappears into the trachea. Remove the stylet and advance the tube until the balloon is 3-4cm beyond the vocal cords. The marking of the tube at the incisors will show 21-24cm when tube is in position 

  1. Remove the laryngoscope and inflate the balloon with 10cc air to prevent air leaking during ventilation. Attach the tube to bag and mask apparatus and ventilate.

  1. Place the end tidal CO2 detector. Colour change will be seen within first 6 breaths.

  1. Confirm the position of the tube by auscultating over the lungs and epigastrium. Listen for the presence and equality of breath sounds over both lung fields and for the absence of gurgling sounds over the stomach. (to check for accidental oesophageal intubation)

  1. If not in correct position deflate the cuff and remove the tube resort to Bag and Mask Ventilation, repeat the intubation process from the beginning. If the tube is in too far, the right lung will be ventilated only by the right main bronchus (decreased left lung breath sounds). Deflate the cuff and withdraw the tube 2-3 cm re-inflate the tube and recheck the position (symmetrical breath sounds)

  1. When the tube position is confirmed, tie it in place with cotton tape and attach it to the ventilating apparatus.


  • When inserting the stylet give the ET tube a form of a “hockey stick”- 30-35-degree angle anterior before the balloon. If it’s too straight it risks oesophageal intubation and if too angled will get hung up on the vocal cords.


  • Grasp laryngoscope firmly but don’t clench your fist because this decreases control and causes early fatigue.


  • Wrist must remain rigid during laryngoscopy.


  • Keep your elbows in. Lift on a line connecting the patient’s head with the intersection of the opposite ceiling and the wall. It won’t be straight, but keeping your arm straighter and fairly rigid it gives you the strength of your shoulders to lift the head. It prevents you from using the teeth as a fulcrum — dangerous for the teeth. And it allows you to use binocular vision for depth perception.


  • With your shoulders relaxed and your arms by your sides you can lift the jaw easily without rotating the blade back onto the teeth.


  • If vocal cords are not visualised- Perform the “Sellecks Manoeuvre” -apply cricoid pressure, make your assistant place their thumb on one side of the cricoid ring and their index or ring finger on the other. Pushing down firmly to force the cricoid forces the vocal cords downward and often into the field of view. It also compresses the oesophagus between the cricoid cartilage and the cervical vertebrae and prevents passive regurgitation of gastric contents.

  • Pass the tube into the larynx through the cords in one smooth motion. If the patient is breathing, time the forward thrust for inspiration when the cords are fully open. During expiration, the tube may bounce off the closing cords into the oesophagus.



1)NEJM link (Similar to steps written; 11:50 min video)

2) (2:21 minute video)


Written by our guest author: Chitra Wadekar
Illustrations by Devi Bavishi



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