From the Guidelines
Endotracheal intubation (ETI) should be performed with careful consideration of the patient's airway, using a cognitive aid such as a checklist, and with the administration of supplemental oxygen, as recommended by the Difficult Airway Society guidelines for awake tracheal intubation in adults 1. The steps for ETI involve:
- Preparing all necessary equipment, including a laryngoscope, endotracheal tube, stylet, bag-valve mask, suction, and medications
- Pre-oxygenating the patient for 3-5 minutes with 100% oxygen
- Positioning the patient in the "sniffing position" with neck flexed and head extended
- Using the laryngoscope to expose the vocal cords and insert the endotracheal tube
- Confirming placement with end-tidal CO2 detection, bilateral breath sounds, and chest rise, as recommended by the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1
- Securing the tube and documenting the depth at the teeth It is also important to consider the use of minimal sedation, ideally administered by an independent practitioner, and to limit the number of attempts to three, with one further attempt by a more experienced operator (3 + 1) 1. In addition, the use of waveform capnography or capnometry to confirm and monitor ET tube placement is recommended, as well as the use of a HEPA filter for all ventilation 1. The most critical aspect of ETI is to ensure proper airway management while minimizing hypoxia and aspiration risks, and to confirm correct tube placement using multiple methods, including end-tidal CO2 detection and clinical assessment 1.
From the Research
Steps for Endotracheal Intubation (ETI)
The steps for endotracheal intubation (ETI) can be summarized as follows:
- Pre-operative assessment of the patient 2
- Preparation of the equipment to be used 2
- Preparation of the patient, including antisialogue, sedation, and application of topical anesthesia to the upper airway 2
- Positioning of the patient to establish an adequate airway management 3
- Direct visualization of the glottis and endotracheal tube pass through the vocal cords to confirm the correct position of the tube 3
- Use of devices to confirm the correct position of the endotracheal tube 3
- Laryngoscopy, which can be performed using a direct laryngoscope or a video laryngoscope 4, 5, 6
- Intubation of the trachea, which can be facilitated by the use of a video laryngoscope 4 or other devices such as VieScope 5
Laryngoscopy Techniques
Different laryngoscopy techniques can be used for ETI, including:
- Direct laryngoscopy (DL) 4, 6
- Video-assisted laryngoscopy (VL) 4, 5, 6
- Use of VieScope, a new type of laryngoscope with a straight, transparent, and illuminated blade 5
Intubation Success Rates
The success rates of ETI can vary depending on the technique used and the experience of the operator:
- Video laryngoscope use was associated with a higher probability of successfully intubating the trachea when the view of the vocal cords was incomplete 4
- VieScope had a comparable success rate to GlideScope in difficult airway, but had a significantly longer time until intubation and time until ventilation 5
- Endotracheal intubation with VL by inexperienced operators was faster and associated with fewer adverse events than was DL after a three-month period with no further intubation training 6