What are the steps involved in the intubation procedure?

Step-by-Step Intubation Procedure

Intubation must be approached as a carefully planned procedure with preparation for potential complications, as all patients in intensive care units should be considered at risk of complicated intubation. 1

Pre-Intubation Assessment

Airway Assessment

• Evaluate for difficult airway risk factors using the MACOCHA score (score ≥3 predicts difficult intubation) 2
• Assess airway anatomy:
  • Mallampati classification
  • Neck mobility
  • Mouth opening
  • Identify cricothyroid membrane using "laryngeal handshake" technique
• Consider body habitus (BMI >30 increases risk 2×, BMI >40 increases risk 4×) 2

Physiological Assessment

• Evaluate cardiorespiratory status
• Optimize hemodynamics before proceeding
• Identify patients who cannot safely tolerate hypoxemia (epilepsy, cerebrovascular disease, coronary artery disease) 1

Equipment Preparation

• Assemble and check all equipment:
  • Laryngoscope (Macintosh blade preferred for first attempt)
  • Appropriately sized endotracheal tube
  • Stylet/bougie
  • Suction equipment
  • Bag-valve-mask with oxygen source
  • End-tidal CO2 detector
  • Backup devices (video laryngoscope, supraglottic airway)
• Assign clear roles to team members 2
• Discuss backup plans (Plan A, B, C, D) for failed intubation 2

Patient Positioning

• Position patient with head elevated 25-30° when tolerated 2
• Use firm bed mattress for optimal cricoid pressure application if needed 2
• Consider "sniffing position" (neck flexion, head extension) for optimal glottic visualization

Pre-Oxygenation

• Pre-oxygenate with 100% oxygen for 3-5 minutes
• Aim for SpO2 >95% before proceeding
• Consider non-invasive ventilation or high-flow nasal oxygen for patients with respiratory failure

Medication Administration

• Administer appropriate medications in sequence:
  1. Premedication (if indicated)
  2. Induction agent
  3. Neuromuscular blocking agent (rocuronium 0.6 mg/kg is standard dose) 3
• For rapid sequence intubation, rocuronium 0.6-1.2 mg/kg provides excellent intubating conditions in most patients within 2 minutes 3

Intubation Procedure

1. Wait for adequate muscle relaxation (typically 45-60 seconds with rocuronium) 3
2. Hold laryngoscope in left hand
3. Insert laryngoscope into right side of mouth
4. Sweep tongue to left
5. Advance blade to vallecula (Macintosh) or posterior to epiglottis (Miller)
6. Lift laryngoscope forward and upward (avoid levering)
7. Apply external laryngeal manipulation if needed (BURP maneuver)
8. Visualize vocal cords
9. Insert endotracheal tube through vocal cords with right hand
10. Advance tube until cuff disappears past vocal cords
11. Hold tube firmly while removing laryngoscope
12. Inflate cuff with minimum air needed to seal airway

Confirmation of Placement

1. Check for bilateral chest rise
2. Auscultate bilateral breath sounds and over epigastrium
3. Confirm with end-tidal CO2 detection (most reliable method)
4. Secure tube properly
5. Obtain chest X-ray for confirmation of position

Post-Intubation Management

• Initiate post-intubation sedation promptly (within 15 minutes) 2
• Verify ventilation, oxygenation, and cardiovascular stability
• Document procedure details, including:
  • Laryngoscopic view obtained
  • Number of attempts
  • Complications encountered
  • Tube size and depth

Common Pitfalls to Avoid

• Delayed recognition of respiratory failure
• Inadequate preparation for difficult airway
• Multiple intubation attempts without changing approach
• Failure to call for help early
• Proceeding despite borderline respiratory status 2
• Using succinylcholine in patients with neuromuscular disorders 2

Management of Complications

• Severe hypoxemia: Immediately ventilate with bag-mask and 100% oxygen
• Hypotension: Administer fluid bolus and/or vasopressors
• Failed intubation: Follow difficult airway algorithm, consider supraglottic airway device (maximum two insertion attempts) 2
• Front-of-neck access if oxygenation cannot be maintained (surgical technique preferred over needle cricothyroidotomy) 2

By following this systematic approach to intubation, clinicians can minimize the risk of complications and improve patient outcomes in this critical procedure.