ACLS Provider: Course

Endotracheal Intubation (ETT)

Endotracheal intubation (ETT) is the gold standard for securing a definitive airway in critically ill or unstable patients. It involves placing a tube into the trachea to allow for controlled oxygenation, ventilation, and airway protection—especially during cardiac arrest, respiratory failure, or reduced consciousness.

Indications

  • Inability to maintain a patent airway (e.g., decreased consciousness, obstruction).
  • Failure of oxygenation or ventilation with less invasive methods.
  • Need for airway protection from aspiration (e.g., stroke, overdose, trauma).
  • Planned for general anesthesia or prolonged respiratory support.

Contraindications

  • None absolute in emergencies—airway must be secured.
  • Relative: Severe facial trauma where alternative routes may be preferred (e.g., surgical airway).

Equipment Preparation

  • Endotracheal tube (ETT) of appropriate size (typically 7.0–8.0 mm for adults).
  • Laryngoscope with functioning light source (Macintosh or Miller blade).
  • Stylet (pre-shaped to aid insertion).
  • Suction device, bag-valve-mask (BVM), oxygen source.
  • CO₂ detector (capnography) for placement confirmation.
  • Securing device or tape.

Insertion Technique

  1. Pre-oxygenate with 100% O₂ using a BVM for at least 30–60 seconds.
  2. Position the patient in the "sniffing position" unless contraindicated (e.g., suspected cervical injury).
  3. Open the mouth and insert the laryngoscope blade along the right side of the tongue.
  4. Lift the epiglottis to expose the vocal cords.
  5. Advance the ETT through the vocal cords until the cuff is just past them (usually 21–23 cm at the lips).
  6. Inflate the cuff with the appropriate volume of air.
  7. Remove the stylet, attach BVM, and begin ventilation.

Confirmation of Placement

  • Primary: Capnography (ETCO₂ waveform) is the most reliable indicator.
  • Secondary: Bilateral breath sounds, visible chest rise, no gurgling or gastric inflation.
  • Chest X-ray (in non-arrest settings): tip of ETT should sit 2–3 cm above the carina.

Potential Complications

  • Esophageal intubation: No ETCO₂, absent breath sounds—requires immediate correction.
  • Right mainstem bronchus intubation: Unilateral chest rise—withdraw tube slightly.
  • Dental or airway trauma: Avoid forceful technique; reassess equipment positioning.
  • Laryngospasm or bronchospasm: May require paralytics or bronchodilators.
  • Ventilator-associated pneumonia: Risk increases with time—monitor and manage appropriately.
Once the endotracheal tube is in place, it's critical not to let the job stop there. During a cardiac arrest, intubation should never delay high-quality CPR—if it risks interrupting compressions, opt for a supraglottic airway instead. Placement must always be confirmed using capnography, and reassessed regularly to ensure continued effectiveness. Once confirmed, the tube should be secured properly, with the depth and method of placement clearly documented. Finally, be prepared to manage the patient’s comfort and safety—this may involve suctioning secretions, administering sedation, or using neuromuscular blockade depending on the clinical context.