What are the key steps in the 5-point check during intubation?

The 5-Point Check During Intubation

The 5-point check after intubation is essential for confirming proper endotracheal tube placement and includes: (1) inflating the cuff, (2) confirming placement with capnography, (3) securing the tube, (4) verifying bilateral chest expansion, and (5) documenting tube depth. 1

Key Steps in the 5-Point Check

1. Cuff Inflation

• Inflate the endotracheal tube cuff immediately after placement
• Target pressure: 20-30 cmH₂O
• Ensure there is no air leak around the cuff
• This step must be completed before initiating mechanical ventilation 1

2. Confirmation of Placement

• Confirm tracheal intubation with continuous waveform capnography
• This is the gold standard verification method with 100% sensitivity and specificity in non-arrest patients 2
• Capnography is superior to auscultation (which has only 94% sensitivity and 83% specificity) 2
• Note: In cardiac arrest patients, capnography remains 100% specific but sensitivity drops to 88% 2

3. Tube Securement

• Secure the endotracheal tube firmly to prevent displacement
• This should be done immediately after confirmation of correct placement
• Document the fixation method used 1

4. Bilateral Ventilation Assessment

• Verify equal bilateral chest wall expansion during ventilation
• This is particularly important when auscultation is difficult (e.g., when wearing PPE) 1
• If there's doubt about bilateral ventilation:
  • Consider lung ultrasound or chest x-ray
  • Watch for signs of unilateral intubation (e.g., asymmetric chest movement) 1

5. Documentation of Tube Depth

• Record the depth of endotracheal tube insertion prominently
• Document at the teeth or lips
• This provides a reference point if tube displacement is suspected later
• Make this information clearly visible in the patient's room 1

Important Considerations

Equipment Requirements

• Capnography equipment must be immediately available for all intubations
• The Difficult Airway Society and Association of Anaesthetists strongly recommend capnography as mandatory for confirming tube placement 1
• A difficult airway trolley with appropriate equipment should be accessible 1

Common Pitfalls to Avoid

1. Relying solely on auscultation: This is less reliable than capnography and may risk contamination of equipment in infectious cases 1
2. Initiating ventilation before cuff inflation: This can lead to air leaks and inadequate ventilation 1
3. Delayed confirmation of placement: Unrecognized esophageal intubation can rapidly lead to death or brain damage 2
4. Inadequate tube securement: Can lead to unplanned extubation or tube displacement
5. Failure to document tube depth: Makes it difficult to detect subsequent tube migration

Special Circumstances

• In COVID-19 or other infectious disease patients:
  • Avoid auscultation to prevent contamination
  • Rely more heavily on capnography and visual assessment of chest expansion 1
• In cardiac arrest:
  • Be aware that capnography may have reduced sensitivity (88%)
  • Consider additional confirmation methods if capnography is equivocal 2

By systematically following this 5-point check after every intubation, clinicians can significantly reduce complications related to improper tube placement and ensure optimal patient outcomes.