Assisting with endotracheal intubation is a high-stakes, time-sensitive nursing responsibility that ensures airway patency and supports life-saving interventions.
It refers to assisting in passing of a slender hollow tube into the trachea through nose or mouth using aseptic technique to facilitate artificial ventilation and resuscitation.
Purposes for endotracheal intubation
- To treat acute respiratory failure, persistent hypoxemia and persistent rise in pco2
- To ensure adequate oxygenation.
- To provide ventilatory assistance when indicated.
- To maintain patent airway.
Indication
- Central nervous system depression.
- Neuromuscular disease.
- Chest wall injury.
- Upper airway obstruction.
- Anticipated upper airway obstruction (edema, soft tissue swelling due to head and neck trauma. Postoperative head and neck surgeries decreased level of consciousness).
- Aspiration prophylaxis.
- Fracture of cervical vertebrae and spinal cord injury.
Complication
- Laryngeal/tracheal injury.
- Pulmonary infection and sepsis.
- dependence on artificial airway.
Articles
1. Sandbag/towel roll.
2. Suction apparatus with tubing.
3. Suction catheter (Fr-14).
4. Ambu bag and mask.
5. Oxygen source and tubing.
6. Laryngoscope with appropriate size blade.
7. Magill’s forceps
8. Endotracheal tubes (ETs) of appropriate size
9. Intubation adjuncts: Stylet, bougie, laryngeal mask airway (LMA).
10. Medications:
- Medication for intubation (Given by anesthetist): Atropine (0.01 mg-0.02 mg/kg) (Usually minimum dose of 0.1 mg/kg to prevent paradoxical bradycardia). 0.9% normal saline flush (dated and timed).
- Induction agents: Thiopentone (3-5 mg/kg), Ketamine (2 mg/kg), Propofol (2-3 mg/kg).
- Muscle relaxants: Suxamethonium (1.5 mg-2 mg/kg), Pancuronium/Vercuronium (0.1-0.3 mg/kg), Atracurium besylate (0.5 mg/kg).
- Rapid induction pack (Available in ward fridges for emergency use): Suxamethonium (50 mgs/mL) 2 mL. ampoul Thiopentone (25 mg/mL) 20 mL ampoule, Ketamine (10 mg/mL) 20 mL vial, Pancuronium (2mg/mL) 2mLampoule x
11. Xylocaine gel.
12. Disposable syringe 10 ml..
13. Cotton tape/Dynaplast.
14. Sterile gloves.
15. Face mask.
Procedure
| Nursing Action | Rationale | |
| 1 | Before procedure Explain the procedure to the patient if conscious and get consent from the patient and relatives | |
| 2 | Gather all the articles required within reach. Test the cuff, pilot balloon and valve of each tube of cuffed endotracheal tube, i.e, micro-cuff tube, prior to use insert a Luer tip syringe into cuff inflation valve and inject enough air to fully inflate the cuff. After test inflation, fully evacuate the air prior to use. Ensure child should be NPO prior to procedure unless emergency. insert NG tube and aspirate tube prior to procedure. Check iv access in patient Monitor baseline vital signs (heart rate, blood pressure, oxygen saturation and respiratory rate Promotes acceptance of procedure and cooperation for procedure from the patient. It ensures patient safety and equipment is working satisfactorily prior to use Ensure suction is working appropriately and attach appropriate size suction tube Wash hands and wear personal protective equipment. | To empty the stomach and prevent aspiration of contents during the procedure To administer medication as per need. |
| 3 | Assess and consult the physician/anesthetist for the need for rapid sequence Induction (usually performed with any patient considered at risk of regurgitating their stomach contents. Muscle relaxant and sedative is administered in rapid sequence. Place the patient in supine position with head extended by keeping sandbag or towel roll under neck. in case of pediatric patient avoid hyperextending or rotating the neck and flexing the head towards the chin. | Promotes access to trachea |
| 4 | Check for loose teeth/dentures or foreign body in throat, if so, remove with Magill’s forceps. | Avoids danger of loose teeth or foreign body causing airway obstruction in unconscious patients. |
| 5 | During procedure Assist the physician/anesthetist in manually ventilating the child with 100%. oxygen, using a rebreathing bag, mask, valve for a minimum of 3 minutes. prior to intubation. Seal mouth and nose with mask and Ambu bag and initiate bagging with oxygen. | To prevent hypoxia |
| 6 | Suction oral cavity | Pharyngeal suction may be required to ensure good visualization of the cords. Provides a clear field of work and prevents aspiration when performing oral tracheal insertion |
| 7 | Apply cricoid pressure (Sellick’s maneuver) when prompted by the personnel inserting the ET tube. Press cricothyroid cartilage with thumb and index finger against esophagus. Ensure the intubation equipment (laryngoscope, Magill forceps, endotracheal tube, lubricating jelly on gauze) are within hands reach for the physician. Provide lubricated endotracheal tube with stylet in situ. | Permits clear visualization of oropharynx for insertion. To aid the procedure. Facilitates insertion without chances of injury. |
| 8 | Endotracheal tube is introduced as clinically indicated: Orotracheal intubation for an emergency intubation Nasal intubation for an elective intubation or following stabilization with an oral endotracheal tube. The stylet is removed. The tube, when inserted, should have the 22-c marking at the incisor teeth. | |
| 9 | Verify placement of tube by auscultation, listening/feeling for airflow through tube and observe for bilateral chest movements. Ensure no sounds, i.e., gurgling noted over stomach or gastric distension. Ensure color, oxygen saturations and heart rate are satisfactory. | Confirms tube placement. |
| 10 | Connect Ambu bag with oxygen attached to endotracheal tube and continue bagging. | |
| 11 | Inflate cuff of the endotracheal tube with 10 mL of air. | Prevents chances of tube displacement and aspiration. |
| 12 | Insert an oral airway and apply endotracheal suctioning, if necessary. | |
| 13 | Secure the endotracheal tube in position by using adhesive tape. Tube should be fixed at the midline to prevent pressure ulcer at the angle of mouth Children with burns or scalds to the face will require an alternative method for securing the endotracheal tube. Ensure skin is clean and dry. Apply skin protectant to cheeks as per the hospital policy followed by a colloid dressing strip, i.e, duoderm gel on the cheeks as per the hospital policy. Cut 2 pieces of elastoplast approximately 10-15 cm long into “trouser legs” as clinically indicated. Also a third piece of elastoplast with eyehole (lit) in the middle prior to intubation. Follow procedure for strapping as below: Align the first strip of the Elastoplast over the string and duoderm to the OPPOSITE side of the face to the ETT, The inferior leg of the trouser leg is applied under the nose and onto the duoderm and string on the other side of the face.The superior ‘trouser leg’ is stretched and applied OVER the nose and around the ETT at the lateral edge of the nares at least 2-3 times. Ensure It remains in situ. The procedure is repeated with the second ‘trouser leg’ from the SAME SIDE. The superior trouser leg’ is stretched and applied over the nose. The inferior trouser leg is stretched up from UNDER and around the ETT at least 2-3 times ensuring it remains in situ. Place ETT and nasogastric tube through the eyehole ‘strapping and apply over the previous tapes. Ensure maximum visibility is achieved around the nostril Trim Elastoplast and string as clinically indicated The ETT should be secure from both (right and left) directions of the face Organize re-taping of the ETT by anaesthetist if the ETT position is incorrect on th chest x-ray or if the tapes become wet and loose, Le. (move >0.5 cm). | To protect skin from adhesive stripping and prevent skin breakdown. Routine bonding agents like tincture benzoin is not recommended in infants and adults since it leads to drying of skin and skin breakdown. |
Postprocedural care
- Place patient in lateral position.
- Arrange for chest X-ray to be taken in order to check placement of ET tube.
- Apply endotracheal suctioning if secretions are present.
- Watch for chest movements, ET tube kinking, obstruction with secretion and blood, leakage of tube cuff, change in position of tube and over inflation of cuff.
- Document type and size of tube used chest movements, vital signs and patient’s tolerance of procedure.
- Check ABGs periodically.
Special consideration
- Check cuff pressure using manometer (if available) for detecting underinflation or overinflation of cuff. If under inflated, it can lead to aspiration and displacement of tube. Overinflation can lead to tracheal injury and ulceration leading to stenosis.
- Once cricoid pressure is applied it should not be removed without the consent of intubating person.
- Cricoid pressure should not be applied to a vomiting patient as it can cause esophageal damage.
- Usual side for male ET intubation is 8-9 cm and for women it is 7-8 cm. The tube should be positional about 2 cm above carina as evidenced in the post-intubation chest X-ray.
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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