Endotracheal Intubation
Endotracheal (ET) intubation involves the oral or nasal insertion of a flexible tube through the larynx into the trachea for the purposes of controlling the airway and mechanically ventilating the patient. Performed by a doctor, anesthetist, respiratory therapist, or nurse educated in the procedure, ET intubation typically occurs in emergencies, such as cardiopulmonary arrest or in diseases such as epiglottitis. However, intubation may also occur under more controlled circumstances, such as just before surgery or in patients who can’t clear their secretions effectively. In these situations, ET intubation requires patient teaching and preparation.
Advantages of the procedure include establishing and maintaining a patent airway, protecting against aspiration by sealing off the trachea from the digestive tract, permitting removal of tracheobronchial secretions in patients who can’t cough effectively, and providing a route for mechanical ventilation. Disadvantages include bypassing normal respiratory defenses against infection, reducing cough effectiveness, and preventing verbal communication.
The two routes for ET intubation are the oral or nasotracheal routes. Oral ET intubation allows direct visualization of the vocal cords, which the ET tube must pass through to be in correct
position. It’s preferred over nasotracheal intubation because nasotracheal intubation increases the risk for sinusitis, which may increase the risk of ventilator-associated pneumonia.1 Nasotracheal intubation is more comfortable than oral intubation, but it’s also more difficult to perform because the vocal cords—which the ET tube needs to pass through to be in correct position—can’t be directly visualized. Because ET the tube passes blindly through the nasal cavity, the procedure causes greater tissue trauma, increases the risk of infection by nasal bacteria introduced into the trachea, and risks pressure necrosis of the nasal mucosa. However, exact tube placement is easier, and the risk of dislodgment is lower. The cuff on the ET tube maintains a closed system that permits positive-pressure ventilation and protects the airway from aspiration of secretions and gastric contents.
position. It’s preferred over nasotracheal intubation because nasotracheal intubation increases the risk for sinusitis, which may increase the risk of ventilator-associated pneumonia.1 Nasotracheal intubation is more comfortable than oral intubation, but it’s also more difficult to perform because the vocal cords—which the ET tube needs to pass through to be in correct position—can’t be directly visualized. Because ET the tube passes blindly through the nasal cavity, the procedure causes greater tissue trauma, increases the risk of infection by nasal bacteria introduced into the trachea, and risks pressure necrosis of the nasal mucosa. However, exact tube placement is easier, and the risk of dislodgment is lower. The cuff on the ET tube maintains a closed system that permits positive-pressure ventilation and protects the airway from aspiration of secretions and gastric contents.
Nasotracheal intubation is contraindicated in patients with facial fractures or suspected basilar skull fractures and after cranial surgery, such as transsphenoidal hypophysectomy.2
Equipment
Two ET tubes (one spare) in appropriate size (normal female size is 7 to 8 mm; normal male size is 8 to 9 mm) ▪ 10-mL syringe ▪ stethoscope ▪ sedative ▪ paralytic agent ▪ local anesthetic spray ▪ overbed or other table ▪ water-soluble lubricant ▪ adhesive or other strong tape or commercial tube holder ▪ skin preparation product ▪ sterile gloves ▪ gloves ▪ goggles and other personal protective equipment ▪ suction equipment ▪ handheld resuscitation bag with sterile swivel adapter ▪ humidified oxygen source ▪ carbon dioxide detector or waveform capnography ▪ oral care equipment.
For Direct Visualization Intubation
Lighted laryngoscope with a handle and blades of various sizes, both curved and straight ▪ oral airway or bite block ▪ Optional: prepackaged intubation tray, stylet.
For Blind Nasotracheal Intubation
Mucosal vasoconstricting agent.
Preparation of Equipment
Gather the individual supplies or use a prepackaged intubation tray, which will contain most of the necessary supplies. Select an ET tube of the appropriate size.
Perform hand hygiene and put on sterile gloves.3,4,5 Using sterile technique, open the package containing the ET tube and, if desired, open the other supplies on an overbed table. Then, to ease insertion, you may lubricate the first 1″ (2.5 cm) of the distal end of the ET tube with the water-soluble lubricant, using sterile technique. Do this by squeezing the lubricant directly on the tube. Use only water-soluble lubricant because it can be absorbed by mucous membranes.
Next, attach the syringe to the port on the tube’s exterior pilot cuff. Slowly inflate the cuff, observing for uniform inflation. Then use the syringe to deflate the cuff.
A stylet may be used to stiffen the tube. The entire stylet may be lubricated. Insert the stylet into the tube so that its distal tip lies about ½″ (1.3 cm) inside the distal end of the tube. Make sure the stylet doesn’t protrude from the tube to avoid vocal cord trauma. Prepare the humidified oxygen source and the suction equipment for immediate use. If the patient is in bed, remove the headboard to provide easier access.
Implementation
Nursing Alert
Intubation performed during cardiac arrest shouldn’t delay initial cardiopulmonary resuscitation (CPR) and defibrillation for ventricular fibrillation.6
Verify the doctor’s order, if appropriate.
Confirm the patient’s identity using at least two patient identifiers, if possible, according to your facility’s policy.7
Assess the patient’s immediate history to see whether he has a suspected spinal cord injury or underwent cranial surgery to make sure the proper intubation method is chosen.2
Determine when the patient last had something to eat. Using a handheld resuscitation bag may further increase abdominal distention and increase the risk of aspiration.2
Assess the patient’s level of consciousness, level of anxiety, and respiratory status to determine whether the patient needs sedation, a paralytic agent, or both.2
Assess the patient’s oral cavity for dentures or any loose teeth; remove them if possible because they might obstruct the airway.2
Explain the procedure to the patient or his family, if able, to allay the patient’s and family’s anxiety.
If the patient doesn’t already have an IV catheter established, insert one to administer sedation or other emergency medications if needed.2 (See “IV catheter insertion and removal,” page 421.)
Administer the sedative, as ordered, to decrease respiratory secretions, induce amnesia or analgesia, and help calm and relax the conscious patient.
Administer the paralytic agent, as ordered, to stop muscle movement and ease insertion of the ET tube.
Hyperventilate the patient with 100% oxygen using a handheld resuscitation bag for at least 3 to 5 minutes; continue until the tube is inserted to prevent hypoxia.2
For Direct Visualization Intubation
Place the patient supine in the sniffing position so that the mouth, pharynx, and trachea are extended. If cervical spine injury is suspected, have an assistant maintain the patient’s head in a neutral position with the spine immobilized.2
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