What is the standard intubation protocol for an adult or pediatric patient with no significant pre-existing conditions or allergies?

Standard Intubation Protocol for Adult and Pediatric Patients

Pre-Intubation Preparation and Assessment

All intubations must begin with a standardized pre-intubation checklist and team briefing to ensure equipment readiness, role assignment, and shared strategy for Plans A through D. 1

Team Assembly and Briefing

• Assemble the intubation team with clearly assigned roles: team leader, airway operator, medication administrator, and hemodynamic monitor 1
• Conduct a pre-intubation brief sharing the strategy for Plans A, B/C, and D, inviting team input on whether additional expertise is needed 1
• Display the intubation algorithm prominently at bedside 1

Equipment Verification

• Ensure immediate availability of laryngoscope (both direct and video), endotracheal tubes of multiple sizes, stylet/bougie, suction, and backup airway devices 2
• Verify waveform capnography is ready and functional—this is mandatory for all intubations as failure to use capnography contributes to >70% of ICU airway-related deaths 1
• Have difficult airway equipment immediately accessible including videolaryngoscope, flexible bronchoscope, and supraglottic devices 3

Patient Positioning

• Position patient with head elevated 25-30 degrees and neck in "sniffing position" (lower cervical spine flexed, upper cervical spine extended) when tolerated 1
• For obese patients, use ramping to align external auditory meatus with sternal notch, with face horizontal 1
• Ensure bed mattress is firm to optimize cricoid force and access to cricothyroid membrane 1

Preoxygenation Protocol

Preoxygenation with 100% oxygen for 3 minutes using a tight-fitting facemask at 10-15 L/min is essential, with CPAP (5-10 cm H₂O) added for hypoxemic patients. 1

• Use a two-handed mask technique to minimize leak, confirmed by presence of capnograph trace 1
• Measure adequacy using end-tidal oxygen concentration (target >85%) 1
• For patients with respiratory failure, apply NIV with CPAP and supported breaths (tidal volume 7-10 mL/kg) 1
• Avoid "Hudson-type" facemasks with or without reservoir as they are inadequate 1

Medication Protocol for Rapid Sequence Induction

Use intravenous induction with full neuromuscular blockade—specifically rocuronium 0.6-1.0 mg/kg based on actual body weight—as this significantly reduces intubation complications in critically ill patients. 2, 4

Induction Agent Selection

• Ketamine 2 mg/kg IV is preferred for hemodynamically unstable patients as it avoids hypotension associated with other agents 5
• Propofol 1.5-2.5 mg/kg IV can be used in hemodynamically stable patients 4

Neuromuscular Blocking Agent

• Rocuronium 0.6-1.0 mg/kg IV (dosed on actual body weight) is preferred over succinylcholine due to fewer side effects while providing excellent intubating conditions within 60-90 seconds 2, 4
• For obese patients, dose rocuronium based on actual body weight, not ideal body weight, as ideal body weight dosing results in inadequate intubating conditions 4
• Rocuronium 0.6 mg/kg provides clinical relaxation for median 33 minutes in adults 4

Hemodynamic Management

• Assign a dedicated team member to monitor and manage hemodynamic status throughout the procedure 1
• Administer rapid infusion of 500 mL crystalloid before or during intubation in absence of cardiac failure to mitigate hypotension risk 1
• Have vasopressors immediately available as cardiac arrest occurs in approximately 2% of ICU intubations 1

Intubation Technique

Limit laryngoscopy attempts to a maximum of three blade insertions, with videolaryngoscopy preferred over direct laryngoscopy as it increases first-pass success rates. 2

Laryngoscopy Approach

• Each blade entry into the mouth constitutes one attempt—limit to three total attempts 2
• Use videolaryngoscopy when operator is skilled, as it is superior to direct laryngoscopy 2
• Attempt intubation within 60-90 seconds of medication administration 4

Tube Placement Confirmation

• Immediately confirm tracheal placement with continuous waveform capnography—never assume tracheal placement without capnography confirmation 1, 2
• Observe for six consecutive capnograph waveforms before considering tube placement confirmed 1
• Perform post-intubation chest X-ray to confirm appropriate tube depth and identify complications (though this does not confirm tracheal placement) 1

Failed Intubation Protocol

• After three failed attempts, declare "failed intubation" and immediately move to rescue strategies (Plan B/C) 2
• Never attempt more than three laryngoscopy attempts as progressive laryngeal edema and hemorrhage will develop 6
• Have a second operator primed to perform front-of-neck airway (FONA) if required 1

Pediatric-Specific Modifications

For pediatric patients, bag-mask ventilation is acceptable during cardiac arrest, though endotracheal intubation enables uninterrupted chest compressions. 1

Pediatric Dosing

• Rocuronium 0.6 mg/kg provides time to maximum block in approximately 1 minute across all pediatric age groups 4
• For infants 3-12 months: rocuronium 0.6 mg/kg provides median 41 minutes of clinical relaxation 4
• For children 1-12 years: rocuronium 0.6 mg/kg provides median 26 minutes of clinical relaxation 4

Pediatric Airway Considerations

• Pediatric airway anatomy differs from adults, making intubation more difficult for providers who do not routinely intubate children 1
• Supraglottic airways may be easier to place than endotracheal tubes but do not provide definitive airway protection 1
• No significant difference exists between endotracheal intubation and bag-mask ventilation for favorable neurological outcomes in pediatric out-of-hospital cardiac arrest 1

Post-Intubation Management

Continuous waveform capnography monitoring is mandatory for all intubated patients, with regular assessment for "airway red flags" including absent or changed capnograph waveform. 1, 2

Immediate Post-Intubation Care

• Document tracheal tube depth at the teeth/lips on bedside chart and verify each shift 1
• Maintain cuff pressure at 20-30 cm H₂O (higher inspiratory pressures may require higher cuff pressures) 1
• Monitor for complications including hypotension, desaturation, and tube displacement 2

Ongoing Monitoring Requirements

• Watch for "airway red flags": absence or change of capnograph waveform, increasing airway pressure, reducing tidal volume, or inability to pass suction catheter 2
• Assume apparent cuff leak is partial extubation until proven otherwise 1
• Regular tracheal suction and humidification reduce avoidable tube blockage 1

High-Risk Interventions

• During patient turns, physiotherapy, transfers, or insertion of devices near the airway, nominate an experienced team member solely to safeguard the airway 1
• For high-risk airways, sedation holds require careful risk assessment due to self-extubation risk 1

Critical Safety Considerations

• Identify and mark the cricothyroid membrane using "laryngeal handshake" technique before induction in all patients 1
• For difficult airways, place bedhead signage identifying airway difficulty and describing the intended airway plan 1
• If airway has been traumatized, observe for bleeding, swelling, and surgical emphysema as pharyngeal or esophageal injury may lead to life-threatening sepsis 1
• Maintain 35-degree head-up positioning post-intubation to reduce airway swelling 1