Endotracheal tube (ETT) insertion (intubation)
How to insert an endotracheal tube (intubation) for doctors and medical students
What is an endotracheal tube?
- A fexible plastic tube with cuff on end which sits inside the trachea (fully secures airway – the gold standard of airway management)
- Attached to ventilation bag/machine
- Use:
- Ventilation during anaesthetic for surgery (if muscle relaxant is required, long case, abdominal surgery, or head positing may be required)
- Patient can’t protect their airway (e.g. if GCS <8, high aspiration risk or given muscle relaxation)
- Potential airway obstruction (airway burns, epiglottitis, neck haematoma)
- Inadequate ventilation/oxygenation (e.g. COPD, head injury, ARDS)
- Rapid sequence induction (RSI) intubation
- Procedural variation using rapid anaesthetisation with cricoid pressure to prevent aspiration while airway is quickly secured
- Used for patients at risk of aspiration e.g. non-fasted patients
- Size: 8mm diameter for men, 7mm diameter for women
How to insert an endotracheal tube (ETT)
- Equipment required for ET tube insertion
- Laryngoscope (check size – the blade should reach between the lips and larynx – size 3 for most patients), turn on light
- Cuffed endotracheal tube
- Syringe for cuff inflation
- Monitoring: end-tidal CO2 monitor, pulse oximeter, cardiac monitor, blood pressure
- Tape
- Suction
- Ventilation bag
- Face mask
- Oxygen supply
- Medications in awake patient: hypnotic, analgesia, short-acting muscle relaxant (to aid intubation)
Video on how to insert an endotracheal tube
- Laryngoscope technique
- Give medications if required
- Pre-oxygenate patient with high concentration oxygen for 3-5mins
- Position patient
- Neck flexed to 15˚, head extended on neck (i.e. chin anteriorly), no lateral deviation
- Stand behind the head of the patient
- Open mouth and inspect: remove any dentures/debris, suction any secretions
- Holding laryngoscope in left hand, insert it looking down its length
- Passing the tongue
- Slide down right side of mouth until the tonsils are seen
- Now move it to the left to push the tongue centrally until the uvula is seen
- Advance over the base of the tongue until the epiglottis is seen
- Insertion technique
- Apply traction to the long axis of the laryngoscope handle (this lifts the epiglottis so that the V-shaped glottis can be seen)
- Insert the tube in the groove of the laryngoscope so that the cuff passes the vocal cords
- Remove laryngoscope and inflate the cuff of the tube with ̴ 15ml air from a 20ml syringe
- Attach ventilation bag/machine and ventilate (~10 breaths/min) with high concentration oxygen and observe chest expansion and auscultate to confirm correct positioning
- Consider applying CO2 detector or end-tidal CO2 monitor to confirm placement
- Secure the endotracheal tube with tape
- if it takes more than 30 seconds, remove all equipment and ventilate patient with a bag and mask until ready to retry intubation