# Elective Endotracheal Intubation

## Overview

This module describes the elective endotracheal intubation of patients without risk factors for aspiration, where techniques minimising time between induction and intubation are less critical than in Rapid Sequence Induction.

## Indications

Fasted patients with no risk factors for aspiration requiring:

1. General anaesthesia for invasive procedures.

2. Invasive ventilation due to respiratory compromise.

3. Airway protection due to loss of protective reflexes.

## Contraindications

1. Risk factors for aspiration. See Rapid Sequence Induction.

2. Weigh up the risks and benefits in patients with severe orofacial trauma, cervical spinal injury, and patients who may be ventilated non-invasively.

## Patient information & consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“I need to give you medication to make you sleep for a procedure. I have to protect your airway while you are asleep, so I will put a tube down your throat, through which I will give you oxygen for breathing.”

### What can my patient expect?

“You will be asleep, so you will not feel anything when I insert the tube. Your throat may feel a bit dry or sore and you may have a hoarse voice when you wake up. This should go away quickly.”

### What is my patient’s role?

“It’s very important that you tell me honestly when last you ate, and whether you have used any recreational drugs. Tell me if you have allergies or any medical conditions. Try to stay relaxed as I give you the medication putting you to sleep.”

## Preparation

This procedure requires an assistant, and:

1. Oxygen, suction & a ventilator

2. Monitoring: blood pressure, ECG, sats, capnography

3. IV access (two large bore IVs in emergency intubations)

4. Airway trolley, which should contain:

   1. Non-sterile gloves
   2. Laryngoscope (and backup) & 2 different sizes of laryngoscope blades (checked & working)
   3. Endotracheal tubes (ETT)
   4. Lubricant
   5. 10 ml syringe
   6. Bougie
   7. Bag valve mask respirator (BVMR) and PEEP valve
   8. A mask of the correct size
   9. HEPA or HME filter (attached to BVMR)
   10. Oxygen tubing
   11. Oropharyngeal airway devices
   12. Supraglottic airway devices
   13. Tape in strips for ETT securing
   14. Choice of induction agents, paralytics, and opioids
   15. Stethoscope

A difficult airway trolley should also be available with supraglottic airways (LMA).

## Site & Positioning

The patient should be in the “sniffing” position, with the ear aligned to the sternal notch. This may require building a ramp with pillows and blankets to raise the patient’s head.

## Procedure

Use medical asepsis with non-sterile gloves. Wear N95 masks as for aerosol-generating procedures.

1. Perform hand hygiene and don non-sterile gloves.

2. Assess the patient for a potential difficult airway and

   cervical spine precautions
   cervical spine precautions

   Where cervical spine injury is suspected, maintain C-spine protection with jaw-thrust during pre-oxygenation.
   During intubation, maintain manual inline stabilisation from the front.

   .

3. Attach monitoring, gain IV access and draw up your choice of drugs.

   * Be aware that ketamine comes in different concentration vials: 10, 50, and 100 mg/ml.

4. Prepare the ventilator.

5. While assessing and preparing, an assistant should

   preoxygenate
   preoxygenate

   Use 100% oxygen at 8-10 L/min, using the bag valve mask or ventilator circuit with a good seal, for 3-5 minutes or until ETO2 is a minimum of 80%, or ideally 90%. It is not ideal to use a rebreather mask for preoxygenation, because you cannot achieve a good seal.

   the patient, watching for good chest rise.

6. Once you are ready to intubate, confirm equal chest rise, auscultate, and explain to the assistant what you expect from them.

7. Open and lubricate the endotracheal tube. Inflate and deflate the cuff to ensure patency. Preload bougie into ETT.

8. Check & connect suction, put ready for use under patients right shoulder.

9. Inject your choice of drugs and await

   paralysis
   paralysis

   For a standard dose of rocuronium, paralysis can take 3 minutes. While awaiting paralysis, ventilate the patient with BVMR to prevent desaturation. In the theatre setting, also commence the inhalation agent to prevent awareness upon intubation.

   .

10. The assistant can hold the endotracheal tube ready, with the syringe nearby to inflate.

11. Insert the

    laryngoscope
    laryngoscope

    Hold the handle in your left hand. Insert the blade in the right side of the mouth and sweep right to left. Pull up and away from you (avoid "scooping" with your wrist), with the tip of the blade in the vallecula, to visualise the vocal cords.

    and attempt to visualise the vocal cords in 30 secs or less. If unsuccessful, re-oxygenate with BVMR before trying again.

12. Pass
    Pass

    Use your right hand. Insert to 10*patient's height in metres + 4; usually 19-22 cm.

    the endotracheal tube through the vocal cords, advancing the thick black line above the cuff to just past the vocal cords. The assistant should inflate the cuff with the 10 ml syringe, releasing cricoid pressure, removing the bougie and attaching the BVMR/ventilator with HEPA filter.

13. Assess the tube placement by observing for equal chest rise, auscultating both lungs for breath sounds, and observing capnography.

14. Strap
    Strap

    the tube in place.

15. Dispose of medical waste safely.

16. Document procedure including drugs used, number of attempts, time of intubation, size and depth of ETT, method of confirmation and any adverse events or difficulties.

17. Confirm tube placement with an X-ray if indicated.

## Troubleshooting

I can’t visualise the cords.

Always re-oxygenate the patient between attempts, providing breaths with the BVMR/ventilator. Call for a senior. If not able to oxygenate, consider a supraglottic airway.

To optimise visualisation, position the patient with ear in line with sternal notch.

1. Check that your laryngoscope provides sufficient light

2. Check your viewing angle. Try straightening your back and bobbing your head up and down

3. Make sure that your laryngoscope is

   lifting the jaw upwards
   lifting the jaw upwards

   Check that your laryngoscope hand is moving upwards, rather than levering the handle towards the patient's feet

   and away from the airway.

4. Ask your assistant to apply backwards, upwards, rightwards pressure to the cricoid cartilage

5. Reposition the blade, which may be too deep

6. Use a different size or shape of laryngoscope blade

7. Ask a more experienced colleague or senior to attempt intubation

8. Use a videolaryngoscope if available and you are familiar

9. Re-optimise the patient if unstable or induction/paralytic effects are wearing off

I can’t oxygenate the patient with BVMR/ventilator breaths.

1. Call for help

2. Reposition the patient using basic head-tilt chin-lift or jaw thrust

3. Place an NPA/OPA

4. Use two handed mask seal

5. Increase PEEP

6. Rule out pneumothorax

7. Insert an LMA if not successful with mask ventilation

I can’t oxygenate the patient, and intubation or difficult airway devices have failed or are unavailable.

This is a can't intubate-can't oxygenate scenario, and front of neck access may be indicated.

I’m not sure how to draw up ketamine.

Ketamine is available in different concentrations; 10, 50, and 100 mg/ml. It is easiest to work with a 10 mg/ml solution, which comes as a 20 ml vial and can be used undiluted. If you have a 50 mg/ml vial (comes in a 10 ml vial), draw up 2 ml in a 10 ml syringe and add 8 ml of normal saline, making a 10 mg/ml solution.

For the 100 mg/ml solution (comes in a 10 ml vial), draw up 1 ml ketamine and add 9 ml normal saline in a 10 ml syringe, making a 10 mg/ml solution. For a 70 kg patient, you may need to draw up two 10 ml syringes, or one 20 ml syringe with 2 ml of ketamine.

Diluting high concentrations of ketamine is safe practice and avoids accidental misdosing.

## Risks

1. Anaesthetic drug reactions such as anaphylaxis

2. Hypoxic brain injury

3. Cardiac arrest ± death due to hypoxia

4. Damage to dentition

5. Airway injuries

6. Aspiration & resultant pneumonia

7. Healthcare worker exposure to infectious substances

## References

1. Alvarado AC, Panakos P. Endotracheal Tube Intubation Techniques. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560730/