What are the immediate post‑intubation steps to confirm endotracheal tube placement, secure the airway, initiate lung‑protective ventilation, provide sedation/analgesia, and start prophylactic measures?

Post-Intubation Care

Immediate Tube Confirmation

Continuous waveform capnography combined with clinical assessment is the most reliable method for confirming correct endotracheal tube placement and must be initiated immediately after intubation. 1

• Waveform capnography demonstrates 100% sensitivity and 100% specificity for confirming correct tube placement in both cardiac arrest and non-arrest patients. 1, 2
• Do not initiate mechanical ventilation until after cuff inflation and initial confirmation. 1
• Clinical assessment should include direct visualization of the tube passing through the vocal cords and observation of bilateral chest wall expansion with ventilation. 1, 3
• Auscultation alone is unreliable (sensitivity 94%, specificity 66-83%) and should never be used as the sole confirmation method, particularly when wearing PPE or in trauma patients. 1, 4
• If waveform capnography is unavailable, colorimetric CO2 detectors may be used as an initial backup method, though they are less accurate than waveform capnography. 1

Critical pitfall: False-negative capnography readings can occur during cardiac arrest with low pulmonary blood flow, after pulmonary embolism, or with severe airway obstruction—in these cases, use a second confirmation method such as direct visualization or esophageal detector device. 1

Airway Securing

Inflate the endotracheal tube cuff to 20-30 cmH2O immediately after intubation, then secure the tube with tape or a commercial device while avoiding neck compression. 1, 5

• Record the tube depth (marked at the teeth or gums) prominently before securing to detect subsequent displacement. 1, 5
• Both adhesive tape and commercial tube holders provide equivalent security during transport. 5
• Avoid tape application that compresses the front and sides of the neck, as this impairs venous return from the brain. 5
• Maintain the patient's head in neutral position after securing, as neck flexion/extension can displace the tube by several centimeters. 5, 3
• Obtain a chest radiograph when feasible to confirm the tube tip is positioned 3-5 cm above the carina in the mid-tracheal region. 1, 3

Ventilation Initiation

For cardiac arrest patients with an advanced airway, deliver one breath every 6 seconds (10 breaths/min) without pausing chest compressions at 100-120 compressions/min. 6

• Avoid hyperventilation (>25 breaths/min), as it raises intrathoracic pressure and impairs venous return and cardiac output. 6
• For non-arrest patients, target normocapnia with end-tidal CO2 of approximately 4.0-4.5 kPa (30-35 mmHg). 6
• In severe asthma or COPD, use lung-protective ventilation with smaller tidal volumes (6-8 mL/kg), slower respiratory rate, shorter inspiratory time (flow rate 80-100 L/min), and longer expiratory time (I:E ratio 1:4 or 1:5) to prevent auto-PEEP and barotrauma. 1
• Automatic transport ventilators are useful during prolonged resuscitation but always have a bag-valve-mask device available as backup. 6

Sedation and Analgesia

Sedation is often required after intubation to optimize ventilation, decrease ventilator dyssynchrony, minimize auto-PEEP, and reduce barotrauma. 1

• Expert consultation should be obtained for optimal sedation management in mechanically ventilated patients. 1
• Continue to administer inhaled albuterol treatments through the endotracheal tube in asthmatic patients, as delivery may have been inadequate before intubation. 1

Prophylactic Measures

Pass a nasogastric tube after tracheal intubation is complete and ventilation established to minimize the need for later interventions. 1

• If COVID-19 status is unknown, collect a deep tracheal sample using closed suction for testing, as upper airway samples may be false negative. 1
• Ensure portable suction delivering >40 L/min flow and >300 mmHg vacuum is immediately available with sterile suction catheters of various sizes. 6

Continuous Monitoring

Maintain continuous waveform capnography throughout the entire resuscitation and transport period. 1, 6

• Monitor oxygen saturation, heart rate, and blood pressure continuously. 6, 3
• Re-assess tube position whenever the patient is moved, as patient movement is the most important factor associated with unplanned extubation. 6, 5
• Observe bilateral chest rise with each ventilatory effort. 6

Troubleshooting Acute Deterioration (DOPE Mnemonic)

If the intubated patient's condition deteriorates, immediately assess using the DOPE mnemonic: 1, 5

• Displacement: Verify tube depth and capnography waveform; check if the tube has migrated into the esophagus or right mainstem bronchus. 1, 5
• Obstruction: Suction the tube to eliminate mucous plugs or kinks. 1, 5
• Pneumothorax: Assess for asymmetric chest expansion and consider needle decompression if tension pneumothorax is suspected. 1, 5
• Equipment failure: Check the ventilator and circuit for leaks or malfunction. 1, 5
• Auto-PEEP (specific to asthma/COPD): Separate the patient from the ventilator circuit to allow passive exhalation and dissipation of high end-expiratory pressure. 1

Critical pitfall: In asthmatic patients, breath stacking from incomplete expiration can cause auto-PEEP, leading to hyperinflation, tension pneumothorax, and hypotension—this requires immediate disconnection from the ventilator to allow passive exhalation. 1