- To assist in providing a definitive airway when IF supraglottic device is CLEARLY unable to provide oxygenation or adequate ventilation after essential troubleshooting has occurred.
- Intact gag reflex
- No waveform capnography available
- Patients smaller than a small adult
- Endotracheal intubation requires a high level of proficiency for early success and expertise and is de-emphasised (i.e. not always necessary).
- Non-drug assisted intubation carries risk
- ETI MUST be performed by the most competent clinician to optimise first pass success and timely ventilation.
- Always consider patient factors when determining your course of action, utilise the Vortex concept.
- This skill must be undertaken without interrupting chest compressions.
- Check ETT placement whenever the intubated patient is moved. As a rule the officer ventilating is to control patient movements.
- Should etCO2 provide a consistent waveform with a max. reading of ≤10mmHg complete DOPES check. If no fault found in the circuit strongly consider removal of ETT due to high risk of oesophageal intubation. Ventilate patient and replace with supraglottic airway device.
- Regular EtCO2 recordings and confirmation of waveform is mandatory.
Compressions MUST NOT be interrupted for ETI.
- All relevant infection control methods to be utilised.
- Prepare equipment required:
- End Tidal CO2 (etCO2)connected
- Endotracheal Tube (ETT)
- 10mL syringe
- BVM (do not discard mask – keep clean)
- Cobbs connector
- Laryngoscope and blade
- Lubricant
- OPA
- Oxygen
- Stethoscope
- Bougie and Stylet
- Tape to secure
- Select tube size from sealed package (use diameter of patients 5th finger as a guide).
- Inflate the ETT cuff gently to check for leaks and then deflate.
- Apply lubricant to the cuff.
- Assemble the laryngoscope and check the light is bright, white and steady.
- Prepare Bougie (preferred option) or Stylet
Bougie Introduced ETT
- This is a 2-person skill. If unachievable –1-person ‘Kiwi-grip’ technique is not supported.
- Place support under the head or the patient’s head in a sniffing the morning air position. In trauma the patient’s head should be placed (where practicable) in the neutral position with inline mobilization prior and during the intubation attempt.
- Preload ETT over Bougie if 1-person approach.
- Ensure airway is clear using suction and assess and plan intervention as per Principles of Advanced Airway Management
- Pre-oxygenate the patient – this does not mean over-ventilate
- Insert the blade into the patient’s mouth, through the midline, identifying uvula, then epiglottis and then posterior structure/cords.
- Bring the cords into direct view gently.
- If cords are not visible, laryngeal manipulation or head elevation can be used (where appropriate) to bring the cords into view but this MUST NOT be facilitated by the compressor in cardiac arrest.
- Guide the angled tip (facing up and away) of the Bougie/tube in via the right side of the mouth to give better control of the tip over the vertical plane.
- Pass the Bougie directly into the Trachea 4-6cm via the base of the larynx; you may feel “bumping” as the tip passes over the tracheal rings. Be Gentle – there is a risk of perforation of the soft structures by the tip.
- Maintain the position of the Bougie in the Trachea and with assistance slide the ETT down Bougie past the vocal cords under direct view. If resistance is felt on passing cords a 90° anticlockwise rotation may assist. Stop as soon as the cuff is completely past the vocal cords. Aligning the black indicator line with the vocal cords.
- Note and record the distance of the tube at the teeth. In adults, 24cm for males or 22cm for females as a guide.
- Attach a 10mL syringe and gently inflate the cuff until an adequate seal is achieved.
- Note: this should not exceed 10mL; excess cuff inflation causes tissue ischaemia.
Stylet Introduced ETT
- Apply lubricant to the stylet if required.
- Insert stylet into ETT and bend the hook end over to prevent it from protruding from the cuffed end of the ETT.
- Shape the ETT as required.
- Place patient’s head in a sniffing the morning air position. – In trauma the patient’s head should be placed (where practicable) in the neutral position with inline mobilisation performed by an assistant prior and during the intubation attempt.
- Ensure airway is clear.
- Pre-oxygenate the patient.
- Hold the laryngoscope with the left hand (image 1).
- Insert the blade into the patient’s mouth, through the midline, observe anatomy.
- Advance the blade by placing the tip into the vallecula by following the direction of the uvula to identify the epiglottis.
- Maintain this angle and lift the laryngoscope in the direction of the handle (1) DO NOT use teeth as fulcrum.
- Identify the arytenoid cartilage and vocal cords.
- Hold the stylet ETT with the right hand and insert from the right of the patient’s mouth.
- Slowly guide between the vocal cords under direct vision, stop as soon as the cuff has completely passed the cords (aligning black indicator line with vocal cords).
- Note and record the distance of the tube at the teeth, and time of confirmed placement.
- Remove the laryngoscope.
- Attach a 10mL syringe and gently inflate the cuff until an adequate seal is achieved.
- Note: this should not exceed 10mL; excess cuff inflation causes tissue ischaemia.
- Hold tube firm and remove the stylet.
Confirmation of ETT placement
- Be mindful of excess pauses in compressions
- Ventilate and visualise chest rise and fall equally.
- Auscultate stomach and lungs to confirm equal air entry.
- Connect end-tidal CO2 detector, and observe for a waveform.
- If rise and fall is isolated to the right side the ETT is in the right main stem bronchus. Slightly deflate the cuff and withdraw the ETT 1-2cm, then re-inflate and re-assess.
- The correct placement of the tube is the responsibility of both officers, and a minimum of 3 of the following tests are to be conducted preferably in the following order to minimize pausing of chest compressions
- Positive visual placement through the cords.
- EtCO2 waveform capnography.
- Observation of equal rise and fall.
- Auscultation of equal air entry (no more than 5 seconds pause off the chest)
- If placement is not confirmed, deflate cuff and remove the ETT.
Securing the ETT
- Using either linen or adhesive tape secure the ETT in position.
- Place a bite block in situ, in the form of an OPA.
- Stabilise the head and neck.
- Document ETT depth at teeth.
Perform ventilation assessment and document checks:
- Visualised ETT passing through vocal cords
- Misting of tube
- Adequate rise and fall of chest
- Auscultation of epigastric area first and subsequently both left and right lungs.
- End tidal CO2 waveform and reading in mmHg
Extubation procedure:
- Remove the bite block (OPA).
- Remove securing tape.
- Suction oropharynx.
- Deflate the cuff.
- Allow patient to cough the tube out.
- If the patient does not cough the tube out, ventilate and remove the ETT.
- Monitor the patient.
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