What are the immediate steps post-intubation (insertion of an endotracheal tube)?

Post-Intubation Management Protocol

Immediately after intubation, confirm proper tube placement through multiple methods including waveform capnography, bilateral chest rise assessment, and securing the tube at the appropriate depth to prevent complications and reduce mortality.

Immediate Post-Intubation Confirmation Steps

Primary Confirmation (Must Do)

1. Confirm tracheal intubation with continuous waveform capnography (Class I, LOE C) 1
2. Inflate the cuff with air to a measured pressure of 20-30 cmH2O 1
3. Start mechanical ventilation only after cuff inflation and ensure no leak 1
4. Assess for bilateral chest movement by watching for equal bilateral chest wall expansion 1
5. Record the depth of tube insertion prominently on documentation and at bedside 1

Secondary Confirmation

• Listen for absence of gastric insufflation sounds over stomach 1
• If uncertain about placement, perform direct laryngoscopy to visualize tube position 1
• In hospital settings, obtain chest x-ray to verify tube is not in a bronchus 1
• Consider lung ultrasound if doubt exists about bilateral lung ventilation 1

CAUTION: Auscultation of the chest may be difficult when wearing PPE and risks contamination, so visual confirmation methods are preferred 1

Securing and Maintaining the Airway

1. Secure the tube properly using an appropriate method 1
2. Maintain the patient's head in neutral position - neck flexion may push the tube further into the airway, while extension may pull it out 1
3. Pass a nasogastric tube after intubation is complete to minimize later interventions 1
4. Use closed tracheal suction system whenever available 1
5. Monitor and record tube depth at every shift to minimize displacement risk 1

Troubleshooting Post-Intubation Complications (DOPE)

If an intubated patient's condition deteriorates, immediately consider:

• D: Displacement of the tube - Check position, may require re-intubation
• O: Obstruction of the tube - Suction to clear secretions or kinks
• P: Pneumothorax - Assess and treat if present
• E: Equipment failure - Check ventilator and circuit connections 1

Additionally, in patients with severe bronchoconstriction, consider auto-PEEP as a cause of deterioration 1.

Managing Specific Complications

Tracheal Tube Cuff Leak

1. Pack the pharynx while administering 100% oxygen
2. Pause the ventilator immediately before re-intubation
3. Prepare for re-intubation 1

Accidental Extubation

1. Don appropriate PPE before attending to the patient, regardless of clinical urgency
2. Follow standard re-intubation protocols 1

When Circuit Disconnection is Required

1. Ensure adequate sedation
2. Consider neuromuscular blockade
3. Pause the ventilator so ventilation and gas flows stop
4. Clamp the tracheal tube
5. Separate the circuit with the HME filter still attached to patient
6. Reverse procedure when reconnecting 1

High-Risk Periods for Tube Displacement

Extra vigilance is required during:

• Patient repositioning (especially prone positioning)
• Turning patients
• Nasogastric tube manipulation
• Tracheal suctioning
• Oral care
• Sedation holds 1

Pitfalls to Avoid

1. Unrecognized esophageal intubation (occurs in ~3.3% of emergency intubations) can lead to hypoxemic complications and death 2
2. Undetected bronchial intubation (occurs in ~2.7% of emergency intubations) can cause unilateral ventilation 2
3. Relying solely on clinical signs without capnography can lead to missed tube misplacement 3
4. Delayed detection of auto-PEEP in patients with severe bronchoconstriction can cause hemodynamic compromise 1
5. Inadequate tube security leading to unplanned extubation during patient movement 1

Remember that proper post-intubation management is critical for preventing complications that can significantly impact patient morbidity and mortality. Consistent use of capnography, visual confirmation techniques, and vigilant monitoring of tube position are essential components of safe airway management.