Are you ready to learn about all about the Intubation procedure and intubating patient? If so, then you’re in the right place, because that is what this study guide is all about.
As a Respiratory Therapist, this is a procedure that you will perform (or assist with) very often. That is why it’s extremely crucial that you develop a full understanding of the intubation procedure as a student. Not to mention, you will need to know this information for the TMC Exam as well. So if you’re ready, let’s go ahead and dive right in.
What is Endotracheal Intubation?
Endotracheal intubation is an emergency medical procedure that is performed on patients with altered level of consciousness or an impaired breathing pattern.
By conducting this procedure, the healthcare provider can help maintain an open airway and prevent respiratory arrest. In addition, endotracheal intubation allows for continuous medical intervention while prolonging the life of the patient.
How does the Intubation Process Work?
An intubation is helpful because it provides a way to provide mechanical ventilatory support to the patient in order to keep them stable while the underlying cause is treated.
In a typical endotracheal intubation, patients are given anesthesia and a muscle relaxant in order to minimize discomfort and relax the muscles of the airways. During the procedure, a laryngoscope (device designed for visualization of the vocal cords) is used to hold the tongue aside.
A flexible plastic tube will then be inserted into the trachea through the patient’s mouth. The tube will be then secured by inflating the small cuff around it.
Pressure is often applied to the patient’s Adam’s apple to significantly lower the risk of aspiration of stomach contents. With that being said, we’ll discuss the intubation procedure in more detail later on in this guide — so keep reading.
Normally, pediatric patients require a much smaller ET tube than older adults, and inserting the tube may require skills and experience because ET tube placement in smaller airways needs a higher degree of precision.
In some cases, health care providers use a fiber optic scope, a device used to enhance/enlarge images, to allow better visualization and easy insertion during the process.
Indications for Intubation:
This emergency medical procedure is indicated for the following:
- To open the airways so that the patient can receive a sufficient amount of oxygen, prescribed medication, or anesthesia.
- To protect the patient’s lungs.
- To help patients who stopped breathing or those with impaired breathing pattern.
- It helps patients who require a mechanical ventilator achieve spontaneous breathing.
- It is indicated for patients with head injury who cannot breathe on their own.
- It is performed on patients who require sedation for a period of time to allow recovery from a debilitating medical injury or serious illness.
- Collapsed lung
- Heart failure
- Inhalation injury accompanied by severe inflammation of the vocal cords
- Intestinal or stomach bleeding
- Massive bleeding from the esophagus
- Pulmonary Contusion
- Respiratory arrest
- Respiratory failure
What is an Endotracheal Tube?
The ET tube is then connected to a ventilator or a bag valve mask (BVM) to provide patients with continuous oxygen delivery. The process of inserting an ET tube into the airways of the patient is known as endotracheal intubation.
For example, if the ID is 8 mm, the tube size is also 8.
Also, ET tubes can either be cuffed or uncuffed. Cuffed ET tube requires an injection of pressurized air into the balloon to create a seal against the inside walls of the airway. On the other hand, an uncuffed ET tube is recommended for children less than 8 years old to prevent narrowing of the trachea.
What are the Steps of the Intubation Procedure?
- Verify the doctor’s order.
- Ask the family or relatives of the patient to sign an informed consent.
- Prepare all necessary materials close at hand (assorted ET tube sizes, laryngoscope handle, blades, 10 ml syringe, water-soluble lubricant, tape, BVM, suction equipment, and stethoscope).
- Wash hands and put on sterile gloves.
- Check the endotracheal cuff for any signs of leaks.
- Gently insert stylet into the ET tube.
- Connect blade to battery base and check if flight is fully functioning. Make sure to have backup blades of different types and sizes close at hand.
- Using BVM, preoxygenate the patient with 100% oxygen to prevent hypoxemia (low oxygen levels).
- Administer sedatives or opioids as appropriate.
- Ask an assistant to continuously apply cricoid pressure to prevent aspiration of gastric contents.
- Assess for patient’s ability to mask ventilate.
- Administer appropriate neuromuscular blockade (paralyzes affected skeletal muscles) for easy insertion.
- Firmly hold the laryngoscope with your left hand.
- Using the cross finger technique (thumb and index finger of a gloved hand on opposite rows of teeth) to open the patient’s mouth.
- Gently insert the blade into the right side of the mouth of the patient, pushing the tongue to the left.
- Advance the blade until it reaches the base of the tongue. The tip of the curved blade should be accurately secured in front of the epiglottis (flap in the throat) in the valecula (depression just behind the root of the tongue). Adjust the the tip of the straight blade so that it is under the epiglottis.
- Lift the handle to visualize the vocal cords.
- Using the stylet, grasp the ET tube.
- Slowly insert the ET tube along the right side of the mouth until the cuff can no longer be seen.
- Secure the ET tube in place by holding it firmly.
- Withdraw the blade.
- Remove the stylet.
- Using the syringe, inflate the ET tube cuff with 5-10 ml of air to secure it in place.
- Using the stethoscope, check for bilateral breath sounds and absence of breath sounds over the epigastrium (upper central region of the abdomen). If assessment indicates that the ET tube is not in the correct position, deflate the ET tube cuff using the syringe, remove the ET tube, resume mask ventilation with 100% oxygen, and then prepare to reinsert. If breath sounds cannot be heard on the left, deflate the ET tube cuff using the syringe, withdraw the ET tube 1-2 cm, and reassess for proper placement.
- Palpate the visible dip in between the neck and the two collarbones (suprasternal notch) to feel for the ET cuff. If felt, it means that the ET tube is in proper position.
- Assess for any abnormalities in the vital signs.
- Secure the ET tube with a tape.
- Connect the ET tube to the mechanical ventilator and observe for continuous rise and fall of the chest.
- If necessary, use a portable chest X-ray to determine proper ET tube placement.
- Clean and return used materials and then wash hands.
After the endotracheal tube is secured in place and the patient is connected to a mechanical ventilator, the health care provider will continue to monitor the condition of the patient, the tubing, and settings.
Orotracheal vs Nasotracheal Intubation
Orotracheal intubation is indicated for the maintenance of a patent airway of critically ill patients with multisystem disease or injuries. In addition, it is also indicated for the control of the airway of patients undergoing general anesthesia.
- Place the patient in the sniffing position, with a small cushion behind the head.
- Ask an assistant to apply continuous cricoid pressure during the procedure to prevent aspiration of gastric contents.
- Select a laryngoscope blade size that is appropriate for the patient.
- Open the patient’s mouth using the cross finger technique.
- Slowly insert the laryngoscope blade along the right side of the patient’s tongue. Lean back as you do this for better visualization.
- Hold the ET tube in your fingers like a dart and slowly insert through the arytenoids (pair of cartilages at the back of the larynx) until it reaches the rings of the trachea.
- Pull back the ET tube until its black stripe is at the corner of the mouth of the patient.
- Remove the laryngoscope from the mouth of the patient.
- Confirm correct placement of the ET tube.
- Secure the tube with a tape once correct placement is determined.
This technique may be used without extending the head of the patient, therefore it is recommended for patients with spine injuries and clenched teeth.
Nasotracheal intubation is performed using the following steps:
- Apply anesthesia to the nasal passages and posterior pharynx.
- Select the appropriate ET tube size and test the balloon cuff by inflating it.
- Lubricate the ET tube.
- Select the nares with the largest pathway to the pharynx.
- Slowly insert the ET tube over the superior surface of the hard palate.
- Advance the ET tube further until you can hear the patient’s breath coming through the tube. Make sure to advance the ET tube during inhalation so that it will go through the trachea. If the placement is correct, the patient will exhibit coughing mechanism and will not be able to speak.
- Once the tube is correctly placed in the trachea, connect it to the mechanical ventilator.
What Medications are used for Intubation?
- Atropine – This drug works by increasing the heart rate while decreasing bronchial secretions.
- Vecuronium – A small dose of this neuromuscular blocker is given in order to prevent muscle twitching caused by full doses of succinylcholine.
- Succinylcholine – Relaxes the muscles of the airways to facilitate easy insertion of the ET tube.
- Benzocaine – A topical anesthetic used to reduce discomfort associated with endotracheal intubation.
- Etomidate – It is used to sedate patients during the process of intubation.
What Does Rapid Sequence Intubation Mean?
Rapid Sequence Intubation (RSI) is considered as the fastest and most effective airway management technique that makes use of induction agent and muscle relaxant to induce prompt unconsciousness and paralysis, allowing health care providers to insert ET tube with minimal delay.
- Airway burn
- Cervical spine injury (diaphragmatic paralysis)
- Impaired gag reflex
- Major trauma requiring multiple medical interventions
- Penetrating neck injury
- Prolonged transfer
- Swallowing difficulties
What are the Complications of Intubation?
- Aspiration of contents of the mouth or stomach
- Esophageal placement of the tube
- Injury to the mouth, teeth, tongue, thyroid gland, larynx, trachea, vocal cords, or esophagus.
- Lung collapse (pneumothorax)
- Temporary hoarseness
- Allergic reaction to anesthesia
- Breathing difficulties
- Difficulty speaking or swallowing
- Facial swelling
- Fluid buildup
- Pain in the neck
- Severe sore throat
- Spinal cord injuries
- Tracheal stenosis (narrowing of the trachea)
- Tracheoesophageal fistula (abnormal connection between the trachea and esophagus)
- Tracheomalacia (flaccidity of the supporting tracheal cartilage)
- Vocal cord paralysis
So now that you’ve all the way through our study guide on Intubation, that pretty much means that you are now an expert on the topic.
But just to be sure, you can go through the practice questions that are listed below in order to truly solidify this information into your brain. This will definitely help you once it comes test-time.
Intubation Practice Questions:
1. What is endotracheal intubation?
It is the passing of an endotracheal tube through the mouth or nose into the trachea in order to establish and protect the airway as a means to provide mechanical ventilation to the patient.
2. What should you do immediately after intubation?
Verify that the tube is in the trachea by: checking for symmetry of chest expansion, auscultate for bilateral breath sounds, and order a chest X-Ray to confirm proper placement.
3. How much pressure should be in the cuff?
4. What can occur if the cuff’s pressure is too high?
5. What can occur if the cuff’s pressure is too low?
6. How long can a patient be intubated?
No longer than 14-21 days. Tracheostomy may be needed if longer
7. What are some disadvantages for a endotracheal intubation?
Discomfort, decreased cough reflex, thickened secretions, depressed swallowing reflex, increased risk of aspiration, and ulceration of the larynx or trachea.
8. What can happen due to inadvertent removal of the endotracheal tube?
Laryngeal swelling, hypoxemia, bradycardia, hypotension, and death.
9. How can you prevent the inadvertent removal of the endotracheal tube?
Educate the patient and family for the purpose of the tube and restrain the patient.
10. What are some manual airway maneuvers?
Head tilt, chin life, and jaw thrust.
11. What are the indications for the head tilt, chin lift maneuver?
No cervical injury, the patients must have the ability to protect their own airway to prevent aspiration.
12. What are the contraindications for the head tilt, chin lift maneuver?
Patients that are conscious, and those with spinal injuries.
13. Describe how to perform the head tilt, chin lift maneuver?
The patient is in the supine position, place one hand on the patient’s forehead and apply downward pressure with the palm, place the tips of your fingers on the other head under the chin and gently lift while using the same hand to open the mouth by pulling the lip down with the thumb.
14. What are the indications for the modified jaw thrust maneuver?
An unresponsive patient with a possible c-spine injury.
15. What are the contraindications for the modified jaw thrust maneuver?
An awake patient.
16. What are the indications for a nasopharyngeal airway?
When an oral airway is contraindicated or impossible, biting, maxillofacial trauma, responsive patient, and frequent suctioning.
17. What is a contraindication for a nasopharyngeal airway?
Patient intolerance; also basilar skull fracture.
18. What are the indications for an oropharyngeal airway?
To maintain an open airway of unresponsive patients, to aid in ventilation with a bag-mask, to be used as a bite block after ET tube insertion.
19. What are 4 essential components of a bag-valve mask?
Self-refilling bag, mask, oxygen reservoir, and a supplemental oxygen source.
20. What are 3 advantages of bag-valve-mask ventilation?
It can convey a sense of compliance, immediate ventilatory support, and is suitable for spontaneous or apneic patients.
21. What are 2 disadvantages of bag-valve-mask ventilation?
It is difficult to maintain a leak-proof seal and also, gastric distention.
22. What technique can you use to clamp the esophagus while bagging so air doesn’t go into the stomach?
Apply cricoid pressure.
23. What are 5 things to do if
Reposition the airway, check for airway obstruction, lift the jaw, suction, and intubate if necessary.
24. What could make it hard to achieve an adequate seal with bag-valve-mask ventilation?
The patient is obese, facial hair, no teeth,
25. What are some reasons for intubation?
Respiratory depression due to drugs, support for gas exchange, increase lung volume, maintain an obstructed airway, foreign body, bleeding, edema, trauma, altered level of consciousness, potential aspiration, and elective (i.e. for surgery).
26. Name the pieces of equipment needed for intubation?
Oral airway, bag-valve mask, flow meter, suction equipment, laryngoscope handle and blades, ET tubes, 10 cc syringe, stylet, tube tape, stethoscope, ETCO2 or colorimetric detector.
27. What are the laryngoscope blade sizes for infants?
28. What are the laryngoscope blade sizes for adults?
29. The laryngoscope blade should reach between what 2 things?
The patient’s lips and larynx.
30. Which type of laryngoscope blade directly lifts the epiglottis upward?
31. Which type of laryngoscope blade indirectly lifts the epiglottis?
32. What are the ET tube sizes for males?
33. What are the ET sizes for females?
34. What are some ways to confirm ET tube placement?
Visualize as it passes through vocal cords, auscultate the stomach then lungs, look for condensation in the tube, look for bilateral chest rise, CO2 colorimetric detector turns yellow (remember: yellow is mellow, gold is good :)), and finally, confirm with a chest x-ray.
35. What are some common errors in intubation technique?
Positioning errors, poor head placement, change bed height, don’t hunch over enough, don’t push on teeth, placing the tube too deep.
36. What are the estimated depths for ET tube placement for males and female?
22 cm for males, and 21 cm for females.
37. What are the indications for nasal intubation?
This procedure is more comfortable for awake patients, long-term intubation, less tube movement, surgical access to mouth needed, c-spine injury, facial fracture, and to avoid the risk of hypotension.
38. What are 4 contraindications for nasal intubation?
Nasal fracture, basilar skull fracture, nose bleeds, and sinusitis.
39. What are 5 complications of nasal intubation?
Nosebleeds, submucosal dissection, inflammation, edema, and the stimulation of gag reflexes.
40. The patient’s vocal cords are most open during when?
Inspiration; so that is when you should advance the ET tube for nasal intubation.
41. When placing a nasal airway, make sure to monitor what 6 things?
RR, HR, BP, SpO2, LOC, ETCO2
42. What are the 4 ways to provide supplemental oxygen to the patient while performing a nasotracheal intubation?
Nasal cannula placed in the other nare, face mask over mouth, oxygen tubing near the patient’s mouth, and a nasal airway in other nare hooked to oxygen.
43. What are some things to try if the passage of the nasotracheal tube into the trachea is difficult?
Turn the patient’s head to the side, change the degree of flexion or extension, apply cricoid pressure, push larynx toward
44. What are the 3 ways to achieve patient comfort during intubation?
Relief of anxiety, pain, and promote rest/sleep.
45. When should you avoid sedation?
In shock, airway obstruction, or respiratory failure.
46. If the patient doesn’t receive enough sedation, this can cause what 3 things?
Poor cooperation resulting in trauma and aspiration, difficulty performing intubation, and hypertension.
47. If the patient gets too much sedation, it is life-threatening and can cause what 4 things?
Hypoventilation, apnea, cardiac arrest, and a decrease or loss of protective airway reflexes.
48. What are the two types of drugs used in sedation and what do they do?
Narcotic analgesics are used to relieve pain and Sedative Hypnotics are used to decrease anxiety and induce sleep.
49. What are the three benefits of Narcotic analgesics?
Potent analgesics, moderate sedative properties, and no anxiolytic or amnesic properties.
50. What are the five adverse effects of Narcotic Analgesics?
Nausea, vomiting, constipation, confusion, and respiratory depression.
51. What are three examples of narcotic analgesics?
Morphine, Fentanyl, and Demerol (
52. What is the onset and duration of Morphine?
Onset: 10-15 mins, Duration: 3-6 hours
53. What is the onset and duration of Fentanyl?
The onset is 30 seconds, duration 30-60 minutes.
54. What is the reversal agent for Fentanyl called?
55. What are sedative hypnotics and what do they do?
They are sedatives with anxiolytic, anticonvulsant, and amnesic properties to decrease anxiety and promote sleep (Example: Benzodiazepines).
56. What is the most common sedative hypnotic?
57. What is the onset and duration of Versed?
Onset 1-3 mins, duration 20-45 mins.
58. What is the reversal agent for Versed?
59. What is the onset and duration of the sedative hypnotic Valium (Diazepam)?
Onset: 1-3 mins, Duration: 30 minutes-2 hours.
60. What is the onset and duration of the sedative hypnotic Ativan?
Onset: 30 mins, Duration: 10-20 hours
61. What drug is a sedative and moderate anxiolytic with rapid onset and lipid emulsion?
62. What is the duration of action of Propofol?
63. What produces a temporary loss of sensation or feeling in a confined area of the body?
64. What do inhaled anesthetic agents do?
Aerosolized medication into the oropharynx and lungs to inhibit sensory nerves that carry painful stimuli to the CNS.
65. What are four benefits of Rapid induction?
Easier to perform intubation, relief of side effects associated with awake intubations, minimal change in vital signs, and avoid trauma associated with struggle.
66. What are the side effects associated with awake intubations?
Hypertension, tachycardia, increased ICP in head injury, airway stimulation worsening bronchospasm.
67. What are three adverse effects of Rapid Induction?
Myocardial depression, Hypotension, and the worsening of airway obstruction due to loss of laryngeal muscle tone.
68. The preparation of the patient for Rapid Induction includes monitoring what?
Heart rate and rhythm, respiratory rate and depth, SpO2 and skin color, blood pressure, level of consciousness and airway.
69. How soon should the patient awaken after Rapid Induction?
70. How do you prepare the airway for Rapid induction?
Preoxygenate with 100% FiO2
71. What four things must you keep immediately available during rapid induction?
Suction and yankauer, bag-mask, and a crash cart.
72. What is the criteria for extubation?
Adequate respiratory mechanics, stable VS, Normal electrolytes, Hgb, Hct, adequate UO, no acute processes, adequate LOC, CXR stable, recovery from airway reflexes, recovery from anesthesia.
73. Why is Stridor most likely heard when a patient self-extubates?
Because of the cuff being pulled out while inflated.
74. What is the treatment for mild stridor?
Cool mist, racemic epinephrine, and steroids.
75. What is the treatment for moderate to severe stridor?
76. What is intubation?
The process of the insertion of an endotracheal tube through the mouth (or nose), through
77. What are the 2 ways of Intubation?
Orotracheal intubation (oral), which is most common, and Nasotracheal intubation (nose).
78. What are the Indications for Intubation?
Respiratory failure, anaphylactic, seizure, respiratory insufficiency (or impending failure), somebody not breathing (code blue), heavily sedated, blood gas results showing respiratory acidosis, the need for airway protection.
79. What are the complications of intubation?
Trauma, bleeding if you’re too aggressive, breaking teeth.
80. What are the contraindications to Intubation?
The patient’s living will indicating the desire not to be intubated.
81. What are the components of an Endotracheal (ET) Tube?
15 mm adapter, Pilot Balloon, Cuff, Beveled tip, Curved Body with cm markings, Radiopaque Line, Murphy Eye, and the vocal cord line.
82. What is the 15 mm adapter?
It hooks to common equipment such as the AMBU bag and/or Ventilator.
83. What is the Pilot Balloon?
It is for air insertion/deflation and cuff pressure monitoring.
84. What is the Cuff?
It seals off the lower airway for ventilation and prevents aspiration.
85. What is the purpose of a beveled tip?
Reduces trauma on insertion
86. What is the purpose of the curved body with cm markings?
It indicates the distance from the end of the tube and is used as a landmark for securing.
87. What is the radiopaque line?
A line that is visible on an x-ray to determine tube tip position.
88. What is the Murphy Eye?
It is a safe-guard to ensure the
89. What is the vocal cord line?
It is used to indicate when to stop ET tube insertion.
90. What size ET tube should be used for males?
91. What size ET tube should be used for females?
92. What size ET tube should be used for neonates?
The size is based on their weight.
93. What is the typical tube position for males?
It should be placed 21-23 cm at the lip.
94. What is the typical tube position for females?
It should be placed 19-21 cm at the lip.
95. What are the two types of Laryngoscopes?
Mac and Miller.
96. What type is the Miller blade?
It is a straight blade and directly lifts the epiglottis.
97. What size Miller blades should you use for an adult?
Size 2 and 3
98. Where do you aim with the Miller blade?
Aim over the epiglottis to directly move it out of the way.
99. What type is the Macintosh blade?
It is the curved blade and it indirectly lifts epiglottis by lifting the valeculla.
100. What size Mac blades should you use for an adult?
Size 3 and 4
101. Where do you aim with the Mac blade?
at the vallecula and indirectly lifts the epiglottis out of the way
102. What are the 2 types of laryngoscopes?
Regular – lighted by a small light bulb. Fiberoptic – lighted with a fiberoptic channel.
103. What is the process for using a Laryngoscope and intubation?
Open the airway by placing the head in a “sniffing’ position. Hold the handle in left hand and insert into the right side of the mouth, moving it toward the center, and moving the tongue out of the way to the left. Displace epiglottis based on blade style and lift up and forward. Do not use the teeth as leverage to help lift. Look for the vocal cords and when you can visualize vocal cords, insert the ET tube watching it go through the cords. Stop advancing tube when the cuff has passed the cords by 2 cm or when vocal cords are even with vocal cord line. Stabilize the tube with the right hand and remove laryngoscope.
104. What are the methods for confirming the placement of an ET tube?
105. What is the next step after the ET tube is in place?
After the tube goes in and the laryngoscope out, remove the stylet, inflate the cuff, and confirm the tube position (cm marking).
106. How long should an intubation attempt last?
Intubation attempts should not exceed 30 seconds. Watch the oxygen saturation and manually resuscitate as needed.
107. What color is good for the colorimetry device?
You want it to turn from purple to yellow. Remember: Yellow is Mellow. Gold is Good.
108. What is the best way to confirm tube placement?
109. Where should the tube be placed?
2-6 cm above the carina, Thoracic (T)2-5, Below clavicles, Approximate level of the aortic arch.
110. What are the causes of a difficult airway?
Obesity, mandible malformation, blood/ secretions/ gastric content.
111. What is a common specialized insertion technique?
Apply cricoid pressure to the throat.
112. What is the purpose of the Cuff?
To seal the airways. The goal is to keep cuff pressure below the mucosal capillary.
113. What is the normal cuff pressure in cmH20?
25 cm Hg to 35 cm of water
114. What is the minimal leak test?
When the tube goes in, inflate the balloon then deflate it until you hear a little bit of gargle. Make sure that it is a very slight gargle because you don’t want to damage the airway.
115. What is the purpose of the radiopaque line on the ET tube?
Because you can see the line on the chest x-ray to confirm proper position.
116. What is the purpose of the cm marking on the ET tube?
It is a measurement to see how far the tube is in.
117. What is the purpose of Murphy’s eye?
It is an extra hole on the side of the tube, for just in case you were pushing down and you run into a lot of secretions, the extra hole is there to help the patient breathe through it.
118. What is the purpose of the stylet?
It helps keep the tube’s rigidity and holds in place so it will go
119. Why do we use Lidocaine?
Lidocaine is a numbing agent, so it helps numb the vocal cords to decrease the chances of laryngospasm.
120. What equipment do we need to extubate?
Yankauer, pulse oximeter, towels, oxygen device (for the patient).
121. What is the purpose of the deep breath and cough during extubation?
It helps to open the airway all the way so that the tube won’t cause damage to the vocal cords.
122. What is a common complication of extubation?
So there you have it. That wraps up our study guide and practice questions on Intubation. I hope this information was helpful and you can use it along your journey of becoming a Respiratory Therapist.
I’m confident that if you go through this information (including the practice questions) a few times, you can easily master everything you need to know about Intubation.
And also, by doing so, it will not only help you now but for years to come as you enter your career as a Respiratory Therapist. Thank you so much for reading and as always, breathe easy my friend.