7. ^* For complete obstruction in an unconscious patient, where thrusts are ineffective, use Magill forceps with direct laryngoscopy before ventilation to facilitate removal of the obstruction (Walls, 2004) or surgical cricothyroidotomy.

Figure 4-1 Abdominal thrusts for the standing or sitting victim of choking.

Figure 4-2 Chest thrusts for the pregnant or obese victim of choking.

Figure 4-3 Abdominal thrusts for the supine, unconscious victim of choking.

AGE-SPECIFIC CONSIDERATIONS

Infant (Younger Than Age 1 Year)

1. Kneel or sit with the infant in your lap, and hold the infant prone with the head slightly lower than the chest. Support the infant’s head and jaw with your hand (Figure 4-4).

2. Deliver up to five forceful back slaps between the shoulder blades using the heel of your hand.

3. Turn the infant supine, supporting the head and neck and keeping the infant’s head lower than the trunk.

4. Give up to five quick downward chest thrusts in the same location as for chest compressions, just below the nipple line. Thrusts should be delivered at a rate of about one per second with enough force to dislodge the foreign body (AHA, 2005b, 2002c; ACEP and AAP, 2004).

5. Steps 1 through 4 are continued until the object is expelled or the infant loses consciousness.

6. If the infant becomes unresponsive, open the airway, remove any object you can see, and begin CPR. Each time the airway is opened for breaths, assess for an object and remove it if seen. If nothing is seen, continue with CPR (AHA, 2005a).

7. ^* For complete obstruction in which ventilation is not possible, use Magill forceps with direct laryngoscopy to facilitate removal of the obstruction (ACEP and AAP, 2004) or perform a cricothyroidotomy (see Procedure 15).

Figure 4-4 Back blows and chest thrusts for foreign body obstruction in an infant.

COMPLICATIONS

1. Abdominal pain, ecchymosis

2. Nausea, vomiting

3. Fractured ribs

4. Injury to underlying abdominal or chest organs

PROCEDURE 5 Oral Airway Insertion

Donna York Clark, RN, MS, CFRN, CMTE

The oral airway is also known as an oropharyngeal airway, OPA, Guedel airway, or Berman airway.

INDICATIONS

To maintain airway patency for patients in the following situations:

1. An unconscious spontaneously breathing patient with an airway obstruction caused by an impaired gag reflex and a loss of tone to the submandibular muscles.

2. Unsuccessful airway opening by other maneuvers, such as the head tilt, the chin lift, and the jaw thrust.

3. A patient ventilated by a bag-mask device. The oral airway elevates the soft tissues of the posterior pharynx, easing ventilation and minimizing gastric insufflation.

4. An orally intubated patient who bites/clenches the endotracheal tube; the oral airway is used as a bite block.

5. An unconscious patient during suctioning, to facilitate the removal of a patient’s oral secretions (AHA, 2005).

CONTRAINDICATIONS AND CAUTIONS

1. Insertion of an oral airway in a conscious or semiconscious patient stimulates the gag reflex and may stimulate airway spasm or cause the patient to retch and to vomit (AHA, 2005).

2. Incorrect placement of an oral airway may compress the tongue into the posterior pharynx and cause further obstruction (Vrocher & Hopson, 2004).

3. An airway that is too small may push the tongue into the oropharynx and cause an obstruction, and an airway that is too large may obstruct the trachea (Vrocher & Hopson, 2004).

4. Failure to clear the oropharynx of foreign material before insertion of the airway may result in aspiration.

5. To avoid vomiting and aspiration, the oropharyngeal airway should be removed immediately after the patient regains a gag reflex.

EQUIPMENT

Oropharyngeal suction equipment

Oropharyngeal airway

Tongue blade

PATIENT PREPARATION

1. Place the patient in a supine position.

2. Suction blood, secretions, or other foreign material from the patient’s oropharynx.

3. Select the appropriately sized oropharyngeal airway. Table 5-1 lists usual airway sizes by age. Align the tube on the side of the patient’s face, so the airway extends from the level of the central incisors with the bite block portion parallel to the hard palate. The tip of the appropriate size airway will meet the angle of the jaw (AAP, 2006).

Table 5-1 Oral Airway Sizing by Age

Age	Oral Airway Size
Premature infant	000
Neonate	00
Full-term infant	0
1-3 yr	1
3-8 yr	2
Large child, small adult	3
Medium adult	4
Large adult	5, 6

PROCEDURAL STEPS

1. Use a tongue blade to depress and displace the tongue forward. Insert the airway with the curve pointing up, and advance it over the tongue into the oropharynx (Figure 5-1).

2. As an alternative procedure for adults and adolescents, insert the airway upside down (with the curve pointing toward the back of the patient’s head) into the mouth. As the tip of the airway reaches the posterior wall of the pharynx, rotate the airway 180 degrees to the proper position.

3. The distal tip of the airway should lie between the base of the tongue and the back of the throat. The flange of the tube should sit comfortably on the lips.

4. Reassess the airway patency, and auscultate the lung for equal and clear breath sounds during ventilation.

Figure 5-1 Correct placement of oropharyngeal airway using a tongue blade to displace the tongue.

AGE-SPECIFIC CONSIDERATION

For pediatric patients, depress and displace the tongue forward with a tongue blade and insert the airway (described in step 1 above). Do not insert an upside-down airway and then rotate it (described in step 2 above), because this technique may injure the soft tissue of the oropharynx (AAP, 2006).

COMPLICATIONS

1. Trauma to the lips, tongue, teeth, and oral mucosa

2. Vomiting and aspiration (Vrocher & Hopson, 2004)

3. Complete airway obstruction (AHA, 2005)

REFERENCES

American Academy of Pediatrics (AAP). Pediatric education for prehospital professionals, 2nd. Boston: Jones and Bartlett, 2006.

American Heart Association (AHA). Textbook of advanced cardiac life support. Dallas: Author, 2005.

Vrocher D., Hopson L. Basic airway management and decision-making. In: Roberts J.R., Hedges J.R. Clinical procedures in emergency medicine. 4th ed. Philadelphia: Saunders; 2004:53–68.

PROCEDURE 6 Nasal Airway Insertion

Donna York Clark, RN, MS, CFRN, CMTE

Nasal airways are also known as nasopharyngeal airways and nasal trumpets.

INDICATIONS

The nasal airway is indicated in the following situations:

1. There is a question of patency of the posterior nasopharynx with intact upper airway reflexes.

2. Bag-mask ventilation is ineffective because of difficulty maintaining a patent airway; use of a nasopharyngeal airway may facilitate ventilation. The nasal airway may be used in combination with the oropharyngeal airway in this setting.

3. Insertion of an oropharyngeal airway is technically difficult or impossible because of massive trauma around the mouth, such as mandibulomaxillary wiring.

4. To decrease soft tissue trauma when frequent nasotracheal suctioning is necessary (AHA, 2005; Vrocher & Hopson, 2004).

CONTRAINDICATIONS AND CAUTIONS

1. The insertion of a nasal airway may stimulate the gag reflex and cause the patient to vomit.

2. If the tube is too long, it may enter the esophagus and cause gastric insufflation and hypoventilation (AHA, 2005).

3. Epistaxis may occur and may lead to aspiration of blood.

4. Nasal airways should not be used in patients who have extensive facial trauma or a basilar skull fracture.

EQUIPMENT

Nasopharyngeal suction equipment

Water-soluble lubricant or anesthetic jelly

Nasopharyngeal airway

PATIENT PREPARATION

1. Place the patient in a supine position or high Fowler’s position.

2. Select the nostril that appears to be the largest and most open. Assess the nasal passages for trauma, foreign body, septal deviation, or polyps.

3. Prepare suction equipment for use.

PROCEDURAL STEPS

1. Select an appropriately sized nasal airway. Use the largest airway that will pass easily through the naris. Sizing is labeled by a number indicating the inside diameter in millimeters, and sizes are available for neonates through adults. An endotracheal tube can be used if the correct size nasopharyngeal airway is not available. Measure the length of the nasopharyngeal airway from the tip of the nose to the tragus of the ear (ENA, 2004).

2. Vasoconstriction of the mucous membranes may be indicated. Agents commonly prescribed for this purpose include phenylephrine (Neo-Synephrine) or cocaine spray or liquid (Vrocher & Hopson, 2004).

3. Lubricate the tube with water-soluble gel or anesthetic jelly.

4. Pass the airway along the floor of the nostril with the bevel facing the nasal septum (Figure 6-1). Direct the airway posteriorly and rotate it slightly toward the ear until the flange rests against the nostril. Note that all nasal airways have a bevel that is angled for insertion into the right naris. The airway may be used in the left naris. Place the airway in the left naris with the bevel facing the nasal septum. The nasopharyngeal airway curvature will be opposite of the natural nasal curvature. Once the airway tip has reached the correct position, rotate the airway 180 degrees.

5. If resistance is met, a slight rotation of the tube may facilitate passage as the device reaches the hypopharynx. Insertion should never be forced.

6. Reassess the airway patency.

Figure 6-1 Correct placement of nasopharyngeal airway. (Courtesy of P. Rosen, MD.)

COMPLICATIONS

1. Epistaxis

2. Aspiration

3. Hypoxia secondary to aspiration or improper placement

4. Contraindications include suspected basilar skull fracture, facial trauma, or nasal obstruction that prevents easy insertion of airway (ENA, 2004).

REFERENCES

American Heart Association (AHA). American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 112(suppl. IV), 2005.

Emergency Nurses Association (ENA). Emergency nursing pediatric course provider manual, 3rd. Des Plaines, IL: Author, 2004.

Vrocher D., Hopson L. Basic airway management and decision-making. In: Roberts J.R., Hedges J.R. Clinical procedures in emergency medicine. 4th ed. Philadelphia: Saunders; 2004:53–68.

PROCEDURE 7 Laryngeal Mask Airway

Donna York Clark, RN, MS, CFRN, CMTE

The laryngeal mask airway (LMA) resembles an endotracheal tube with a spoon-shaped mask at one end. The spoon-shaped mask has an inflatable collar that forms a seal around the larynx (Murphy, 2004; Walls, 2006) (Figure 7-1).

Figure 7-1 Dorsal view of the laryngeal mask airway (LMA) showing position in relation to pharyngeal anatomy.

(Courtesy of LMA North America, Inc.)

The LMA provides a reliable and more secure means of ventilation than the face mask. Training in the insertion of the LMA is less complex than that for endotracheal intubation, and there may be advantages over intubation in the prehospital setting, where access to the patient is limited. Although some risk of aspiration is present, studies have shown that emesis is more likely with mask ventilation than with the LMA (Walls, 2006).

The LMA is manufactured solely by Laryngeal Mask Company Limited (San Diego, CA). Four types of LMA devices are produced: the LMA Classic (a reusable LMA), the LMA Unique (a disposable LMA designed like the classic), the LMA Fastrach (designed to facilitate tracheal intubation with an endotracheal tube), and the LMA ProSeal (LMA, 2003).

The LMA ProSeal is designed to do the following (Brain, Verghese, and Strube, 2000; LMA, 2006; Vrocher & Hopson, 2004):

• Improve the laryngeal seal without increasing mucosal pressures

• Separate the respiratory and alimentary tracts

• Provide higher airway seal pressures for use with positive-pressure ventilation

However, the ProSeal is intended for use in the operating room, and the procedure for the placement and use of this product is beyond the scope of this chapter.

INDICATIONS

1. The LMA is used as an alternative to a face mask during manual ventilation. The LMA is not intended to be used instead of intubation for continued ventilation (LMA North America, 2005; Murphy, 2004; Urocher and Hopson, 2004; Walls, 2006). It may be used in the operating suite for short procedures when lighter anesthesia levels are preferred.

2. In an emergency, the LMA may serve as a temporary route for gas exchange in failed intubation scenarios until definitive airway control is achieved (Murphy, 2004; Pollack, 2001; Walls, 2006). A laryngoscope is not required and the insertion technique allows the user to rapidly obtain an airway for ventilation. Studies have shown that the LMA provides equivalent ventilation compared with the endotracheal tube (AHA, 2005).

CONTRAINDICATIONS AND CAUTIONS

1. The patient must have absent glossopharyngeal and laryngeal reflexes and be unresponsive.

2. The LMA does not constitute definitive airway control. It does not protect the airway from gastric content aspiration and should be used only in a patient with an empty stomach.

3. The LMA is not indicated for patients with decreased pulmonary compliance, because the low-pressure seal that is formed around the larynx may not allow adequate ventilation (Murphy, 2004).

4. Obstructive or abnormal lesions of the oropharynx.

EQUIPMENT

LMA (Table 7-1 provides sizing information.)

Water-soluble lubricant

Syringe

Tonsil-tip suction

Bag ventilation system

Oxygen source and connecting tubing

Tape or securing device

For intubating LMA (Fastrach): accompanying silicone-tipped endotracheal tube

Table 7-1 Laryngeal Mask Airway Sizing and Cuff Inflation Volumes

Patient Weight	Recommended LMA Size	Maximum Cuff Inflation Volume
Less than 5 kg	1	Up to 4 ml
5-10 kg	1.5	Up to 7 ml
10-20 kg	2	Up to 10 ml
20-30 kg	2.5	Up to 14 ml
Greater than 30 kg	3	Up to 20 ml
Normal-size and large adults	4	Up to 30 ml
Large adults	5	Up to 40 ml

Modified from LMA North America (2005). Laryngeal mask airway instruction manual. San Diego: Author.

PATIENT PREPARATION

1. Preoxygenate the patient with bag-mask ventilation.

2. If necessary, administer sedation, as prescribed. Deep sedation or an unconscious state is required for LMA use (Murphy, 2004).

3. Position the patient with the head extended and the neck flexed (except in patients with potential cervical spine injury). During LMA insertion, it may be helpful to push the patient’s head from behind to maintain this position.

PROCEDURAL STEPS

LMA Classic, LMA Unique

1. ^* Inflate the cuff to check for leaks and deflate it to form a spoon shape (Figure 7-2).

2. ^*Coat the posterior surface of the LMA with a water-soluble lubricant.

3. ^*Grasp the LMA by positioning your index finger in the crease between the airway tube and the laryngeal mask.

4. ^*Insert the LMA with the cuff tip gliding against the posterior pharyngeal wall.

5. ^*Using your index finger to push the LMA, apply slight backward (toward the ears) pressure and follow the anatomic curve.

6. ^*Advance the mask until resistance is noted at the hypopharynx (Figure 7-3).

7. ^*Remove the index finger while applying slight pressure to the airway tube for the prevention of dislocation (Figure 7-4).

8. ^*Inflate the cuff with air; the volume varies with the LMA size (see Table 7-1). During inflation, release the LMA to ensure that placement is maintained as the cuff expands.

9. Assess the LMA placement. The following signs indicate an appropriate placement:

a. A slight outward movement of the airway tube with cuff inflation

b. A slight swelling at the cricoid region

c. No visible cuff in the oral cavity

d. Equal bilateral breath sounds and chest rise and fall

e. Pulse oximetry readings that indicate adequate oxygenation

10. Ventilate the patient with a bag-valve and supplemental oxygen.

11. Secure the LMA with tape or a securing device; a bite block may be used (LMA, 2005).

Figure 7-2 LMA cuff properly deflated for insertion.

(Courtesy of LMA North America, Inc.)

Figure 7-3 Maintaining pressure with the finger on the tube in the cranial direction, advance the mask until definite resistance is felt at the base of the hypopharynx.

(Courtesy of LMA North America, Inc.)

Figure 7-4 Hold the outer end of the airway while removing the index finger.

(Courtesy of LMA North America, Inc.)

Intubating LMA (Fastrach)

1. ^* Deflate the cuff of the mask and apply a water-soluble lubricant to the posterior surface. Distribute the lubricant over the anterior hard palate.

2. ^*Place the curved metal tube in contact with the chin and the mask tip flat against the palate before advancing.

3. ^*Rotate the mask into place with a circular motion, maintaining pressure against the palate and the posterior pharynx.

4. ^*Inflate the mask. Without holding the tube or handle, inflate cuff to a pressure of 60 cm H₂O (Murphy, 2004).

Intubating through the intubating LMA (Fastrach) (LMA, 2005; Murphy, 2004)

LMA North America educational literature states that the Fastrach should be used in situations when blind intubation is anticipated. The LMA Instruction Manual states the success rate using the LMA Classic varies from 20% to 100% depending on the person’s skill and experience (LMA North America, 2005).

1. ^* Validate endotracheal tube (ETT) cuff integrity.

2. ^*Deflate the ETT cuff, lubricate the ETT, and pass it through the intubating LMA tube. Rotate and move the ETT up and down to ensure adequate distribution of water-soluble lubricant.

3. ^*Advance the ETT to the 15-cm depth indicator. This position signifies passage of the tip of the ETT through the epiglottic opening of the LMA.

4. ^*Use the handle to gently lift the device 2 to 5 cm. A slight resistance is felt as the ETT is advanced.

5. ^*Advance until intubation is complete.

6. Inflate the ETT cuff and confirm intubation (see Procedure 8).

7. ^*Remove the LMA. Remove the ETT connector, and gently ease the intubating LMA out over the ETT into the oral cavity while using the stabilizer rod to hold ETT in position as the LMA is pulled over the tube.

8. ^*Remove the stabilizer rod and hold onto the ETT at the level of the incisors.

9. ^*Remove the LMA completely.

10. Replace the ETT connector.

11. Confirm tube placement (see Procedure 8).

AGE-SPECIFIC CONSIDERATIONS

An appropriately sized LMA is effective for use in infants and children of all weights (see Table 7-1) (LMA, 2006; Luten and Kissoon, 2004). When intubation of the pediatric patient is not possible, the LMA is acceptable for use by skilled providers (AHA, 2005) and LMAs are used routinely with pediatric patients in the surgery suite.

COMPLICATIONS (LMA, 2003; Vrocher & Hopson, 2004; Walls, 2006)

1. Air leak

2. Laryngospasm

3. Desaturation

4. Severe hypercarbia

5. Regurgitation, aspiration

6. Sore throat

7. Laryngeal hematoma

8. Hypoglossal nerve injury

REFERENCES

American Heart Association (AHA). American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 112(suppl. IV), 2005. Available on-line at www.circulationaha.org

Brain A.I.J., Verghese C., Strube P.J. The LMA ProSeal: A laryngeal mask with an oesophageal vent. British Journal of Anaesthesia. 2000;84(5):650–654.

LMA North America (2005). Airway instruction manual. Retrieved December, 13, 2006, from http://www.lmana.com/prod/components/education_center/instructions_for_use.html

Luten R., Kissoon N. Pediatric airway management. In: Walls R., Murphy M., Luten R., Schneider R. Manual of emergency airway management. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:212–227.

Murphy M. Laryngeal mask airway. In: Walls R., Murphy M., Luten R., Schneider R. Manual of emergency airway management. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2004:97–109.

Pollack C. The laryngeal mask airway: A comprehensive review for the emergency physician. Journal of Emergency Medicine. 2001;20(1):53–66.

Vrocher D., Hopson L. Basic airway management and decision-making. In: Roberts J.R., Hedges J.R. Clinical procedures in emergency medicine. 4th ed. Philadelphia: Saunders; 2004:53–68.

Walls R.M. Airway. In: Marx J.A., Hockberger R.S., Walls R.M. Rosen’s emergency medicine: Concepts and clinical practice. 6th ed. Philadelphia: Mosby; 2006:2–26.

PROCEDURE 8 General Principles of Endotracheal Intubation

Donna York Clark, RN, MS, CFRN, CMTE

Endotracheal intubation refers to the procedure of inserting a tube directly into the trachea. The endotracheal (ET) tube (ETT) may be placed through the nose or the mouth. Methods of insertion include visual (using laryngoscopy), blind (through the nose), digital (also blind), or facilitated using a flexible fiberoptic bronchoscope, the Eschmann tracheal tube introducer, a gum elastic bougie, or a lighted stylet. Details of oral and nasal intubation procedures are included in Procedures 10 and 11.

INDICATION

The purpose of intubation is to secure a patent and effective airway. Intubation is the preferred means of airway control because it has the following benefits:

1. Protects the trachea and lungs from aspiration of gastric contents, saliva, or blood and fluid into the upper airway (Vrocher & Hopson, 2004).

2. Provides an airway for mechanical ventilation in the presence of failure of ventilation or oxygenation (Walls, 2004).

3. Allows direct access to the lungs for removal or suctioning of secretions (Walls, 2004).

4. Allows tracheal administration of emergency medications for rapid absorption through the pulmonary tree (AHA, 2005).

CONTRAINDICATIONS AND CAUTIONS

1. There are no absolute contraindications to endotracheal intubation; however, the procedure should be considered carefully when it is performed in a patient with any of the following (Lutes & Hopson, 2004; Vrocher & Hopson 2004; Walls, 2004):

a. Intact gag reflex

b. Potential or actual cervical spine injury

c. Head trauma, increased intracranial pressure, or both

d. Facial fractures

2. Epiglottitis complicates any intubation attempt because of the potential for laryngospasm and complete airway obstruction. Ideally, intubation of the patient with epiglottitis should be performed in the most controlled setting with the most skilled intubator. Contingency planning should include set-up for the performance of a surgical airway.

3. Specific precautions exist for each method of endotracheal intubation. These are discussed in the procedures devoted to nasal and oral intubation.

EQUIPMENT

Endotracheal tubes

• 2.5 to 5 mm, uncuffed; 4.5 to 9 mm, cuffed

Laryngoscope handle

Laryngoscope blades

• Curved (sizes 2 to 4)

• Straight (sizes 1 to 4)

Stylets to fit each size of endotracheal tube

10-ml syringe for inflating the cuff of the tube

Lubricating or lidocaine jelly for nasal intubation

Benzocaine, cocaine, or phenylephrine hydrochloride (Neo-Synephrine) drops or spray for nasal intubation (optional)

Medications as prescribed for paralysis and sedation (see Procedure 9)

Tube-securing device (commercially manufactured device or tape)

Stethoscope

Adjuncts as indicated, e.g., bronchoscope, lighted stylet, or elastic gum bougie

Bag-mask device with reservoir connected to 100% oxygen

Additional supportive equipment:

• Suction, complete with tonsil and catheter tips

• Extra laryngoscope bulbs and batteries

• End-tidal carbon dioxide detector for tube position confirmation (optional)

• Esophageal detector device for tube position confirmation (optional) (Figure 8-1)

• Pulse oximeter to monitor oxygen saturation during intubation and to help confirm tube placement (optional)

• Limb restraints (optional)

Figure 8-1 Flotec Esophageal Detector Device.

(Courtesy of Flotec, Inc, Indianapolis, IN.)

PATIENT PREPARATION

1. Preoxygenate the patient with 100% oxygen by using a nonrebreather oxygen mask or a bag-mask device as indicated.

2. Administer sedatives, paralytic agents, or topical anesthesia as prescribed (see Procedure 9, Rapid Sequence Intubation).

3. Restrain the patient as indicated to prevent inadvertent extubation.

PROCEDURAL STEPS

Intubate

The specific steps of intubation depend on the method of insertion used. See Procedures 10 and 11 for specific directions for oral and nasal intubation.

Confirm Tube Placement

No single confirmation technique is completely reliable; therefore, both clinical assessment and other methods should be used to assess appropriate tube placement immediately after insertion as well as after moving the intubated patient (AHA, 2005; Walls, 2004).

1. Epigastric sounds/chest rise: With the first ventilation, auscultate over the epigastric area while observing for chest rise (AHA, 2005). The presence of burping sounds over the epigastrium in the absence of chest rise suggests esophageal placement. Remove the tube immediately, and reoxygenate the patient before attempting intubation again.

2. Breath sounds: Auscultate the right and left axilla, and then the right and left anterior chest for equal bilateral breath sounds. Unilaterally absent or decreased breath sounds (usually on the left) suggest that the tube was advanced into a mainstem bronchus. Withdraw the tube slightly and reassess until breath sounds are equal bilaterally.

3. End-tidal carbon dioxide detection and/or monitoring also helps confirm tube placement (see Procedure 24). These devices are recommended as a secondary technique of tube confirmation in patients with adequate perfusion (AHA, 2005). If the patient is poorly perfused or in cardiac arrest, there may be minimal CO₂ expiration even when the tube is properly placed.

4. Esophageal detector devices: These devices are attached to the ETT, and suction is applied with a bulb or syringe device. If the ETT is in the esophagus, the tissue will collapse around the tube when suction is applied and there will be resistance to filling of the bulb or syringe. If the ETT is in the trachea, the bulb or syringe will fill with air easily. These devices are recommended for secondary confirmation of tube placement for the adolescent or adult patient in cardiac arrest (AHA, 2005).

5. Direct visualization of the tube passing through the cords with the laryngoscope.

6. Bag compliance: Ventilation of the stomach is easier than ventilation of the lungs, whereas tube obstruction, bronchospasm, or tension pneumothorax makes ventilation more difficult.

7. Condensation in the ETT on exhalation suggests that the tube is positioned in the trachea.

8. Transillumination of the neck using a lighted stylet: If the neck glows after intubation with the lighted stylet, the tube is placed correctly in the trachea (Murphy & Hung, 2004).

9. Pulse oximetry: Maintenance of adequate oxygen saturation helps confirm tube placement.

10. Presence of gastric contents in the ETT: Material resembling food present in the tube may indicate esophageal intubation.

11. Cuff palpation may be used to verify the appropriate placement within the trachea in reference to the carina and the bronchi. After the cuff is inflated, and with the patient’s head in a neutral position, gently palpate at the suprasternal notch while holding the pilot balloon in your other hand. Advance or withdraw the tube slightly. When the pilot balloon is maximally distended in response to pressure at the suprasternal notch, the tube is appropriately positioned within the trachea (Kaur & Heard, 2003; Pollard & Lobato, 1995).

12. Chest radiographic documentation of the tube location in the trachea just above the carina.