How to Properly Intubate
Rapid sequence intubation (RSI) with videolaryngoscopy as the first-line technique, full neuromuscular blockade, and meticulous preoxygenation is the recommended approach for emergency intubation in critically ill adults. 1
Pre-Intubation Assessment
Rapidly assess for difficult airway features even in urgent situations, including risk of difficult intubation, difficult mask ventilation, and aspiration. 1 Perform the "laryngeal handshake" technique to identify and mark the cricothyroid membrane before induction. 1 Consider the MACOCHA score ≥3, which predicts difficult intubation in critically ill patients. 1
Assess cardiorespiratory status as hemodynamic optimization improves outcomes—note the degree of cardiovascular instability and respiratory compromise. 1
Team Assembly and 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 The most experienced operator available should perform the intubation. 1, 2
Prepare backup equipment immediately available at bedside: 1
- Supraglottic airways
- Cricothyrotomy kit
- Videolaryngoscope with multiple blade sizes
- Bougie or stylet
- Suction equipment
Draw up vasopressors before induction (epinephrine, norepinephrine) as positive pressure ventilation can precipitate severe hypotension in hypovolemic patients. 1, 2
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" with lower cervical spine flexed and upper cervical spine extended (face horizontal). 1
For obese patients, use ramping technique with external auditory meatus level with sternal notch—obesity increases complications 4-fold (BMI >40 kg/m²) and 22-fold risk of life-threatening events compared to non-obese patients. 2
Preoxygenation
Use a tight-fitting facemask with 10-15 L/min 100% oxygen for 3 minutes. 1 Apply a two-handed technique to minimize leak, confirmed by presence of a capnograph trace. 1 Measure end-tidal oxygen concentration >85% to confirm adequate preoxygenation. 1
Preoxygenation with noninvasive ventilation prevents hypoxemia during intubation in critically ill patients with respiratory failure. 3 Avoid hypoxemia (Grade 1A recommendation), but also avoid hyperoxemia except in imminent exsanguination. 2
Induction and Neuromuscular Blockade
Administer full neuromuscular blockade to maximize first-pass success. 1 Rocuronium 0.6 mg/kg IV provides intubating conditions in median 1 minute with most patients intubated within 2 minutes, providing 31 minutes of clinical relaxation. 4 For rapid sequence intubation, rocuronium 0.6-1.2 mg/kg provides excellent or good intubating conditions in 99% of patients within 60-90 seconds. 4
Intravenous induction using full neuromuscular blockade is optimal in most critically ill patients—do not use inhalational techniques as this results in slow, difficult induction complicated by upper airway obstruction, hypoxemia, and hypercarbia. 2
Laryngoscopy and Intubation Technique
Use videolaryngoscopy as the first-line technique to increase first-pass success and potentially prevent esophageal intubation. 1, 3 Videolaryngoscopy is superior to direct laryngoscopy, leading to better glottic view, higher success rate, and fewer complications. 2
Use of a stylet is superior to intubation with an endotracheal tube alone and is comparable to use of a bougie. 3 When using direct laryngoscopy in cervical spine injury, use a bougie as manual-in-line stabilization worsens laryngeal view. 2
Limit laryngoscopy attempts and minimize time between induction and intubation. 1, 2 If intubation is anticipated to be difficult, use "double set-up" technique: mark the cricothyroid membrane before induction, then one operator attempts intubation while a second operator is primed to perform front-of-neck access (FONA) if required. 2
Confirmation of Tube Placement
Use waveform capnography as the most reliable method with 100% sensitivity and specificity—this is the gold standard for confirming tracheal placement. 1 Use continuous waveform capnography in addition to clinical assessment. 1 When waveform capnography is unavailable, use colorimetric CO₂ detectors as initial confirmation. 1
Perform post-intubation chest X-ray to confirm appropriate tracheal tube insertion depth and identify complications such as pneumothorax or inadvertent endobronchial intubation. 2
Ventilation Strategy
Maintain normoventilation (Grade 1B recommendation). 2 Avoid hyperventilation except as a life-saving measure in the presence of signs of cerebral herniation (Grade 2C). 2 Once intubated, fluid administration is usually required concurrently as positive intrathoracic pressure can induce severe hypotension in hypovolemic patients. 2
Special Circumstances
Cervical Spine Injury
Perform RSI using manual-in-line stabilization with removal of at least the anterior part of the cervical collar to facilitate mouth opening and cricoid force application. 2 Use videolaryngoscopy with a low threshold as it increases intubation success with minimal cervical movement. 2
Burns and Thermal Injury
Dyspnea, desaturation, and stridor are indications for urgent intubation. 2 Modified RSI is usually the most appropriate technique. Avoid succinylcholine from 24 hours post-injury to avoid hyperkalaemia. 2 Use an uncut tracheal tube to allow for subsequent facial swelling. 2
COVID-19 or High-Risk Infectious Patients
Perform intubation in an airborne isolation room with appropriate PPE: fit-tested N95 mask, protective whole-body garment, two layers of gloves, goggles/face shield, and waterproof gown. 2 Install high-efficiency breathing circuit filters between the mask and circuit. 2 Use videolaryngoscopy to increase distance between the patient's airway and operator. 2 Minimize the number of personnel present. 2
Obese Patients
Dose rocuronium based on actual body weight, not ideal body weight—obese patients dosed according to ideal body weight had longer time to maximum block, shorter clinical duration, and did not achieve comparable intubating conditions. 4
Common Pitfalls to Avoid
Never attempt awake intubation in critically ill patients without: 2
- Suitably skilled and experienced clinician
- Careful head-up positioning
- Minimal sedation (if needed)
- Adequate topical anesthesia
- Active peroxygenation (e.g., high-flow nasal oxygen)
- Clear plan for failure
Avoid delayed intubation when clear indications exist: airway obstruction, altered consciousness (GCS ≤8), hemorrhagic shock, hypoventilation, or hypoxemia. 2 Endotracheal intubation or alternative airway management should be performed without delay in these situations (Grade 1B). 2
Do not administer oxygen via airway exchange catheters during tracheal tube exchange as even low flow oxygen risks barotrauma if the catheter tip is placed or migrates beyond the carina. 2