What are the steps for intubation?

Intubation Steps

For emergency intubation in critically ill adults, follow a systematic approach: assess the airway, prepare equipment and team, optimize positioning and preoxygenation, perform rapid sequence intubation with videolaryngoscopy, and immediately confirm tube placement with waveform capnography. 1

Pre-Intubation Assessment

Rapidly assess for difficult airway features even in urgent situations:

• Evaluate risk of difficult intubation, difficult mask ventilation, and aspiration 1
• Perform the "laryngeal handshake" technique to identify the cricothyroid membrane 1
• In obtunded patients, assess body habitus, submental airway dimensions, and patient records 1
• Consider MACOCHA score ≥3 which predicts difficult intubation in critically ill patients 1
• Note degree of cardiorespiratory disturbance as hemodynamic optimization improves outcomes 1

Team Assembly and Preparation

Conduct a pre-intubation checklist and team briefing:

• Assign clear roles to team members 1
• Share strategy for Plans A, B/C, and D (primary intubation, rescue ventilation, emergency surgical airway) 1
• Ensure most experienced operator available performs the intubation 2
• Have vasopressors drawn up and immediately available (epinephrine, norepinephrine) 2
• Display the difficult airway algorithm prominently 1
• Prepare backup equipment including supraglottic airways and cricothyrotomy kit 1

Patient Positioning

Optimize positioning before induction:

• Position patient head-up 25-30° when tolerated to improve upper airway patency and increase functional residual capacity 1, 3
• Use "sniffing position": flex lower cervical spine and extend upper cervical spine (face horizontal) 1, 3
• For obese patients, use ramping technique with external auditory meatus level with sternal notch 1, 3
• For suspected cervical spine injury, tilt entire bed head-up rather than flexing neck 3
• Ensure bed mattress is as firm as possible to optimize head extension and cricothyroid membrane access 1, 3

Preoxygenation

Maximize oxygen reserves before induction:

• Use tight-fitting facemask with 10-15 L/min 100% oxygen for 3 minutes 1
• Apply two-handed technique to minimize leak, confirmed by presence of capnograph trace 1
• In hypoxemic patients, use non-invasive ventilation (NIV) with CPAP 5-10 cm H₂O and supported breaths (tidal volume 7-10 mL/kg) 1, 4
• Measure end-tidal oxygen concentration >85% to confirm adequate preoxygenation 1
• Consider apneic oxygenation with nasal cannula during laryngoscopy 1

Monitoring

Establish standard monitoring before induction:

• Continuous pulse oximetry, waveform capnography, blood pressure, heart rate, and ECG 1
• End-tidal oxygen concentration monitoring when available 1

Induction and Intubation

Perform rapid sequence intubation with neuromuscular blockade:

• Use videolaryngoscopy as first-line technique to increase first-pass success and potentially prevent esophageal intubation 1, 4
• Administer neuromuscular blockade to maximize first-pass success 2
• Limit laryngoscopy attempts and minimize time between induction and intubation 1
• Use a stylet or bougie, which is superior to endotracheal tube alone 4
• For cuffed tubes, monitor cuff pressure and limit to 20 cm H₂O 1, 2
• Intubation should be performed by experienced operators to minimize repeated attempts 1

Note: Administration of positive pressure ventilation between induction and laryngoscopy prevents hypoxemia during intubation 4. Fluid bolus before induction does not prevent hypotension 4.

Confirmation of Tube Placement

Immediately confirm correct tube position using multiple methods:

• Waveform capnography is the most reliable method with 100% sensitivity and specificity in cardiac arrest victims 1, 2
• Use continuous waveform capnography in addition to clinical assessment 1
• When waveform capnography unavailable, use colorimetric CO₂ detectors as initial confirmation method 1
• Clinical assessment alone is insufficient; always use confirmation devices 1

Failed Intubation Management

If first attempt fails, follow systematic rescue plan:

• Limit total attempts to minimize trauma and hypoxemia 1, 5
• After failed intubation, insert second-generation supraglottic airway device to restore oxygenation 1, 5
• Consider video- or fiber-optically guided intubation through supraglottic airway rather than blind techniques 5
• If both intubation and supraglottic airway fail with impossible mask ventilation, proceed immediately to scalpel cricothyroidotomy 1, 5
• Default option when intubation fails but oxygenation maintained: wake the patient 5

Special Considerations for COVID-19 or High-Risk Infectious Patients

Apply enhanced precautions for aerosol-generating procedures:

• Perform intubation in airborne isolation room 1
• Use appropriate PPE: fit-tested N95 mask, protective whole-body garment, two layers of gloves, goggles/face shield, waterproof gown 1
• Install high-efficiency breathing circuit filters between mask and circuit 1
• Minimize number of personnel present 1
• Use videolaryngoscopy to increase distance between patient's airway and operator 1

Common Pitfalls to Avoid

• Never perform more than 2-3 intubation attempts as repeated attempts increase trauma, edema, and hypoxemia risk 1, 5
• Do not rely on clinical assessment alone for tube confirmation; failure to use capnography contributes to airway-related deaths 2
• Avoid excessive cuff pressures exceeding 20 cm H₂O for endotracheal tubes or 40 cm H₂O for supraglottic airways 1
• Do not delay cricothyroidotomy in "cannot intubate, cannot oxygenate" situations; scalpel cricothyroidotomy is the preferred rescue technique 1, 5
• Never assume adequate preoxygenation without objective measurement; critically ill patients desaturate rapidly 1