Introduction
Endotracheal tube (ETT) intubation is a critical, often life-saving procedure used to secure a patient’s airway and ensure adequate ventilation. It involves inserting a flexible plastic tube into the trachea through the mouth or nose, typically under direct visualization with a laryngoscope
Definition
It is a procedure in which an ET tube is inserted through the nose or mouth into the trachea.
Purposes
- To promote airway patency.
- To prevent aspiration of gastric content.
- To provide continuous ventilator assistance.
- To provide an alternative route for administration of medications (adrenaline).
- To assist when the patient has difficulty in breathing
Indications
- Inability to maintain the tone of the airway in conditions such as the following:
- Edema of the upper airway secondary to anaphylaxis.
- Trauma of the face and neck with oropharyngeal bleeding.
- Inability to have spontaneous ventilation despite the prolonged respiratory effort in case of:
- COPD.
- Status asthmaticus.
- Poor oxygenation in case of diffuse pulmonary edema.
- Acute respiratory distress syndrome (ARDS).
- Pneumonia.
- Cyanide toxicity.
- Carbon monoxide toxicity.
- Clinically deteriorating conditions such as the following:
- CNS depression.
- Neuromuscular disease.
- Septic shock.
- Stab wound in the neck with hematoma.
- Intracranial hemorrhage with changes in mental status.
- Cervical spine fractures.
Contraindications
- Complete obstruction of the upper airway in which surgical airway is the only remedy.
- Complete loss of facial and oropharyngeal landmarks.
- Cervical spine injury which necessitates complete immobility.
| Multisystem Approach Assessment | ||
| Assessment | Observation | Abnormal Findings |
| Respiratory system | Expansion of the thorax. Effort of breathing. Breathing pattern and the symmetry of breathing. Auscultating the lungs to assess ventilation and abnormal lung sounds. Oxygen saturation level. A review of chest radiological investigations. Awareness of the arterial blood gas analysis. Percussion which determines the integrity of the underlying lung tissue. The mode of ventilation, the level of oxygen, the PEEP level, the inspiration/ expiration ratio (I:E), the preset tidal volume, preset pressures, respiratory rate. | Airway obstruction-paradoxical chest and abdominal movements. Use of the accessory muscles of respiration. Central cyanosis- late sign of airway obstruction. Airway- noises gurgling, snoring, grunting, hoarseness, wheeze, stridor, silent. |
| Cardiovascular system | Heart/pulse rate. Heart rhythm [as evident on the electrocardiogram (ECG)] and quality. Blood pressure. Peripheral edema and perceived level of exertion at rest and with activity. | Cardiovascular and respiratory conditions present with similar signs and symptoms. |
| Gastrointestinal system | Oral dentures, ill-fitting tooth, swallowing ability. Abdominal distension. Reduced bowel sounds. Bloating. Increased visible peristalsis. Liver function test. | The supine position predisposes to Gastroesophageal reflux and aspiration pneumonia. GI bleeding. Immobility associated with gastric stasis and constipation. |
| Neurological system | Level of consciousness (generally measured using the Glasgow Coma Scale). Pupils (size, reactivity, and equality). Tendon reflexes. Muscle tone (any spasticity or rigidity). Skin sensation. Cerebral perfusion pressure (CPP). Intracranial pressure (ICP). Radiological imaging [cranial computed tomography scan (CT) or magnetic resonance imaging (MRI)]. | A unilateral fixed dilated pupil is indicative of pressure on the oculomotor nerve and must be investigated urgently. Bilaterally fixed and dilated pupils (sustained severe ICP and cerebral edema) which are sensitive to hypoxia and often a sign of brainstem death. |
| Musculoskeletal system | Assessment of functional tasks includes bed mobility including rolling, maintaining supine position to sit, sitting over the edge of the bed, and out-of-bed mobility. | Patient’s functional strength will guide the need for further testing. |
| Integumentary system | Pliability (i.e., texture), skin color, presence of scar tissue and skin integrity. | Skin breakdown.Ecchymosis.Pressure injuries. |
| Renal system | Renal function test-creatinine.Measurement of fluid balance including urine output that affects cardiac output. | Anasarca.Edema.Pitting edema. |
Articles
| Articles | Purpose |
| Intubation tray containing endotracheal tube of appropriate size. 7.5 mm is the “universally accepted” size for an unknown victim. Men: 8.0-mm tube may be appropriate. Females: 7.0-mm tube. | To ventilate the patient. |
| Stylet-a wire. | To stiffen the ET tube during passage. |
| Laryngoscope with appropriate straight/curved blade (with batteries). | To visualize the area. |
| Oral airway | To prevent biting of tube. |
| Magill’s forceps | To guide an endotracheal tube from the pharynx into the larynx. |
| Suction catheter | To remove the secretions. |
| Suction apparatus | To apply suction. |
| Oxygen source and tubing | To provide oxygen support. |
| Disposable syringe 10 ml. | To inflate the cuff. |
| Xylocaine lubricant jelly | To enhance easy sliding of tube. |
| Towel | To prevent contamination. |
| Sterile gloves, mask | To protect from cross-infection. |
| Ambu bag with mask | To deliver oxygen. |
| Stethoscope | To evaluate air entry during and after intubation. |
| Cotton tape/Dynaplast with scissors | To secure the ET tube. |
| Rolled towel | To support the neck. |
| Induction agent as per the physician’s instruction. Midazolam: Dosage, 0.1-0.3 mg/kg; time to effect more than 15 minutes; hypotension. Etomidate: Rapid onset; no hypotension; no analgesia; concerns with sepsis unjustified. Propofol: 1.5-3 mg/kg; rapid onset; hypotension; no analgesia. Fentanyl or midazolam (sedatives). Succinylcholine (neuromuscular blocking agent): 1-1.5 mg/kg. | Blunts sympathetic responses, provides amnesia, and improves intubating conditions. |
Procedure
| Nursing Action | Rationale | |
| 1. | Explain the procedure to the patient and family. | Enhances cooperation and decreases anxiety. |
| 2. | Assemble and prepare all equipment needed. Assemble laryngoscope and ensure that light is bright.Place ET tube in a sterile field and inflate the cuff.Lubricate the distal end of the tube with water-soluble jelly.Insert the stylet into the ET tube. | To have better visualization during insertion. Prevents contamination and to identify any leakage. For easy sliding of tube when insertion. To easily direct it into the trachea by stiffening the soft tube. |
| 3. | Ensure that all equipment is in working condition. | Improper equipment may interfere with insertion. |
| 4. | Assess for loose teeth/ dentures/foreign body in the throat, if so, remove with Magill’s forceps. | Avoids danger of loose teeth or foreign body causing airway obstruction in unconscious patients. |
| 5. | Position the patient with the head end slightly elevated at 10°. Remove the headboard if possible and needed. Place a rolled towel under the neck. | For easy visualization and introduction of the tube. |
| 6. | Administer premedications (induction agents) as per order. | Decreases secretions, anxiety, and muscle movements. |
| 7. | Spray the anesthetic medicine in the throat if needed. | Decreases the sensation and pain in case of conscious patients. |
| 8. | Hyperoxygenate with 100% oxygen. Seal the mouth and nose with mask and Ambu bag. | Promotes oxygenation. |
| 9. | Apply suction to the oral cavity. | Facilitates easy visualization and prevents aspiration. |
| 10. | Provide a laryngoscope to the doctor. | To visualize the vocal cord. |
| 11. | Hold the laryngoscope in the left hand and insert the blade along the right side of the tongue; with the right thumb and index finger, pull the lower lip away from the patient’s lower teeth. | Moving lips away from teeth prevents injury. |
| 12. | Lift the laryngoscope upward and forward at 45°. Do not change the angle of the blade. | To expose the vocal cords. |
| 13. | After visualizing the vocal cords, insert the ET tube into the right side, while continuously visualizing the vocal cords. | To ensure that the tube is not passed into the esophagus. |
| 14. | When the other person applies mild pressure on the cricoid cartilage, slowly and gradually insert the tube downward till it reaches beyond the cords. | To lower the trachea and to enhance easy passage of the tube. |
| 15. | Once it reaches beyond the cords, remove the laryngoscope and withdraw the stylet, the tube when inserted should have 22-cm marking at the incisor teeth. | To promote ventilation. |
| 16. | Confirm the correct position of the ET tube by bilateral chest movement. Auscultation of chest. Capnometer/CO₂ calorimetric device. Rising/stable O₂ saturation. | To ensure correct placement of the tube. |
| 17. | Attach the Ambu bag with oxygen connection to the ET tube and continue the bagging to ventilate. | To promote ventilation. |
| 18. | Inflate the cuff with 10 mL of air. | To prevent dislodgement of the tube. |
| 19. | Insert an oral airway and apply ET suctioning if necessary. | To maintain patency and prevent aspiration. |
| 20. | Secure the ET tube in position with adhesive tape. | To prevent dislodgement of the tube. |
| 21. | Ensure that chest X-ray is taken. | To confirm the correct position of the tube. |
| 22. | Connect the patient to ventilator. | To provide continuous ventilation. |
| 23. | Position the patient comfortably. | To promote comfort. |
| 24. | Monitor vital signs. | To identify any changes in oxygenation and ventilation. |
| 25. | Auscultate the lung fields, observe ET tube kinking, change in the position of the tube, chest movement, and overinflation of the cuff. | To assess the air entry in both lung fields. |
| 26. | Assess ABG periodically. | To monitor the oxygenation. |
| 27. | Check the cuff pressure using manometer. Normal cuff pressure is 20-25 mmHg and 25-35 cm H₂O. | Avoid overinflation and underinflation of the ET tube (overinflation-tracheal injury and ulceration: underinflation-dislodgement of the tube, aspiration). |
| 28. | Document the following: Date and time of intubation. Preprocedural assessment. Endotracheal tube, type, and size. Level of endotracheal tube inserted. Cuff pressure. Unusual occurrences/complications during the procedure. Sputum sample collected. Condition during and post procedure. Follow-up nursing/doctor’s orders. | For further reference and planning of care. |
| Extubation | ||
| 29. | Arrange the necessary articles at the bedside. | To protect the airway in emergency situation. |
| 30. | The patient should be in an upright sitting position. | This helps to expand the lungs. |
| 31. | Perform endotracheal and oral suctioning. | To remove all secretions. |
| 32. | Assist the physician to deflate the cuff, ask the patient to take a deep breath and exhale for smoothly taking out the ETT. | To improve the patient’s own breathing. |
| 33. | The patient should be placed on supplemental oxygen afterward. | To prevent hypoxia. |
| 34. | The patient should be observed very carefully over the next few hours. | To prevent reintubation. |
| Postextubation management | ||
| 35. | Monitor the following: Adequate oxygenation.Secretion management.Encourage the sitting-up position and mobility.Carefully introduce oral feeding. | Facilitates easy visualization and prevents further complication. |
| 36. | Document the following in flow sheet: Date and time of extubation.Vital parameters, intake and output, ABG, SpO2, and patient’s response. | For future reference and planning of care. |
Special Considerations
Assisting with endotracheal intubation requires careful preparation and adherence to best practices to ensure patient safety and successful airway management. Here are some special considerations:
- Ensure all necessary equipment is available, including a laryngoscope, endotracheal tubes (ETT), suction devices, and bag-valve mask.
- Verify the ET tube size based on the patient’s age and condition.
- Check the cuff integrity by inflating and deflating it before use.
- Use the sniffing position to align the airway for optimal visualization.
- In trauma patients, maintain inline spinal motion restriction to prevent further injury.
- Identify potential difficult airways using tools like the Mallampati score.
- Be prepared with alternative airway devices (e.g., supraglottic airways) if intubation is challenging.
- Provide 100% oxygen via a bag-mask device before intubation to prevent hypoxia.
- Monitor pulse oximetry throughout the procedure to detect desaturation early.
- Hand the correct-sized ET tube to the provider promptly.
- Apply cricoid pressure if needed to reduce aspiration risk.
- Ensure suction is ready to clear secretions or blood obstructing the airway.
- Confirm tube placement using auscultation, capnography, and chest X-ray.
- Secure the ET tube with tape or a tube holder to prevent displacement.
- Monitor for complications such as laryngeal injury or accidental extubation.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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