Endotracheal intubation involves passing a plastic tube through the mouth or nose into the trachea to secure a patent airway. The primary goals are protecting the lungs from aspiration, maintaining adequate gas exchange, and providing mechanical ventilation for compromised patients.
Before attempting intubation, nurses and doctors must assemble and check all necessary equipment using the S.O.A.P.E.M. mnemonic: Suction, Oxygen, Airway equipment, Pharmacy, Equipment for monitoring, and Mechanical ventilator.
Pre-oxygenation is critical. The clinician replaces the nitrogen in the patient's functional residual capacity with 100% oxygen, buying valuable time during the procedure when the patient is not breathing. The bag-valve-mask device must be tested alongside suction apparatus set to high negative pressure. Laryngoscope blades (both curved Macintosh and straight Miller) require functional bulb checks to ensure bright light during laryngoscopy.
Pharmacological agents used during intubation include sedatives, induction agents, and neuromuscular blocking agents.
Nurses must monitor vital signs closely during drug administration, watching for sudden hypotension caused by induction agents or malignant hyperthermia triggered by succinylcholine.
The operator positions the patient with the neck flexed and head extended (sniffing position) to align the airway axes. The laryngoscope is held in the left hand and introduced into the right side of the mouth, sweeping the tongue to the left. The blade advances until the tip sits in the vallecula or covers the epiglottis directly.
Lifting the laryngoscope upward and forward reveals the vocal cords. The endotracheal tube enters through the right side of the mouth, passing under direct vision through the cords until the cuff disappears past them. The stylet is removed, the cuff is inflated with air, and ventilation begins.
Accidental esophageal intubation is a fatal error if not caught immediately. Clinicians use multiple methods to confirm correct placement within the trachea:
Once confirmed, the tube is secured using tape or commercial holders to prevent accidental extubation. The centimeter mark at the lip or teeth must be documented every shift.
Oral hygiene is vital to prevent ventilator-associated pneumonia (VAP). Nurses perform regular suctioning of subglottic secretions and maintain the head of the bed elevated between 30 and 45 degrees. Cuff pressure must be monitored regularly, keeping it between 20 and 30 cmH2O to prevent mucosal ischemia or tracheal necrosis.
Endotracheal intubation carries risks ranging from minor dental damage to life-threatening emergencies. Early complications include trauma to teeth, lips, or vocal cords, and mainstem bronchus intubation (usually the right).
Late complications involve tracheal stenosis and vocal cord paralysis. When an intubated patient deteriorates suddenly, nurses use the D.O.P.E. mnemonic to troubleshoot:
Extubation is the removal of the endotracheal tube once the patient can breathe independently and protect their airway. Clinical readiness is assessed through spontaneous breathing trials, adequate cough reflex, and reversal of neuromuscular blockades.
During removal, the nurse suctions the pharynx, deflates the cuff, and pulls the tube in one smooth motion during peak inspiration. Supplemental oxygen is administered immediately afterward. Nurses monitor closely for stridor, a high-pitched sound indicating laryngeal edema, which requires prompt medical intervention.