What are the steps for intubation?

Steps for Intubation

Intubation should follow a systematic, stepwise approach prioritizing pre-intubation assessment, team preparation, patient optimization, videolaryngoscopy as first-line technique, and continuous monitoring to minimize life-threatening complications that occur in nearly 40% of critically ill patients. 1, 2

Pre-Intubation Assessment

• Rapidly assess for difficult airway features even in urgent situations, including risk of difficult intubation, difficult mask ventilation, and aspiration 1
• Apply the MACOCHA score (≥3 predicts difficult intubation in critically ill patients) to identify patients at higher risk 1, 3
• Perform the "laryngeal handshake" technique to identify the cricothyroid membrane before beginning 1
• Use the 1-2-3 rule for rapid airway examination: 1 finger mouth opening, 2 fingers thyromental distance, 3 fingers mandibular space—this allows identification of potential difficulty within one minute 4
• Assess degree of cardiorespiratory disturbance as hemodynamic optimization improves outcomes 1

Team Assembly and Equipment Preparation

• Conduct a pre-intubation checklist and team briefing with clear role assignments and shared strategy for Plans A (primary intubation), B/C (rescue ventilation), and D (emergency surgical airway) 1
• Ensure the most experienced operator available performs the intubation 1
• Prepare vasopressors immediately (epinephrine, norepinephrine drawn up and ready) 1
• Have backup equipment ready including supraglottic airways and cricothyrotomy kit 1
• Call for the difficult airway cart and additional help from colleagues with airway expertise when difficulty is anticipated 4

Patient Positioning

• Position the patient head-up 25-30° when tolerated to improve upper airway patency and increase functional residual capacity 1
• Use the "sniffing position": flex lower cervical spine and extend upper cervical spine with face horizontal 1
• Apply ramping technique for obese patients with external auditory meatus level with sternal notch 1

Preoxygenation

• Use a 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
• Measure end-tidal oxygen concentration >85% to confirm adequate preoxygenation 1
• Consider preoxygenation with noninvasive ventilation as this prevents hypoxemia during intubation in critically ill patients 2

Induction and Paralysis

• Administer neuromuscular blockade to maximize first-pass success 1
• Use rocuronium 0.6 mg/kg IV for standard intubation, which provides intubation conditions in median time of 1 minute with most patients intubated within 2 minutes 5
• For rapid sequence intubation, use rocuronium 0.6 to 1.2 mg/kg which provides excellent or good intubating conditions in most patients in less than 2 minutes 5
• Dose obese patients based on actual body weight, not ideal body weight, as dosing by ideal body weight results in inadequate intubating conditions 5

Laryngoscopy and Intubation

• Use videolaryngoscopy as the first-line technique to increase first-pass success and potentially prevent esophageal intubation 1, 2
• Use a stylet with the endotracheal tube as this is superior to tube alone and comparable to bougie use 2
• Limit laryngoscopy attempts and minimize time between induction and intubation 1
• Administer positive pressure ventilation between induction and laryngoscopy to prevent hypoxemia 2
• Avoid multiple repeated attempts as progressive laryngeal edema and hemorrhage will develop, potentially losing the ability to ventilate via mask 6

Confirmation of Tube Placement

• Use continuous waveform capnography as the most reliable method with 100% sensitivity and specificity 1
• Combine capnography with clinical assessment for tube placement confirmation 1
• Use colorimetric CO₂ detectors as initial confirmation when waveform capnography is unavailable 1

Post-Intubation Management

• Secure the endotracheal tube carefully to prevent displacement 7
• Maintain neutral head position after intubation; avoid neck flexion (pushes tube deeper) and extension (pulls tube out) 7
• Document the airway assessment findings, intubation technique used, and any difficulties encountered 7

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

• Perform intubation in an 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 the number of personnel present 1
• Use videolaryngoscopy to increase distance between patient's airway and operator 1

Critical Pitfalls to Avoid

• Do not administer a fluid bolus before induction as this does not prevent hypotension 2
• Never perform multiple repeated intubation attempts without reassessing and implementing rescue strategies 6
• Do not ignore the environment at intubation—equipment, monitoring, and assistance may be inadequate compared to the operating room 8
• Recognize that half of critically ill patients with difficult airways experience life-threatening complications including hypoxemia, hypotension, or cardiac arrest 3, 2
• Have a backup plan that permits ventilation and re-intubation with minimum difficulty and delay should extubation fail 8