Endotracheal Intubation: Indications, Equipment, and Orotracheal Technique
Objective. Students will perform direct laryngoscopy and orotracheal intubation on an adult intubation manikin within 30 seconds of laryngoscope blade insertion, correctly verifying tube placement by at least three methods.
This lesson, its worked examples and its practice questions has not yet been verified by a licensed clinician in the field or by a certification or approval body. It is a study draft and may contain errors. Do not use it to make decisions about any patient or medication. Always follow your instructor, your supervising professional, and current official references and regulations.
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Endotracheal Intubation: Indications, Equipment, and Orotracheal Technique
Endotracheal intubation (ETI) is the placement of a cuffed tube directly into the trachea through the vocal cords, creating a definitive, protected airway. At the paramedic level it is one of the most important — and most demanding — psychomotor skills you will perform in the field.
Why Intubate?
Intubation is indicated when a patient cannot protect or maintain their own airway or when ventilation cannot be achieved by less invasive means. Common indications include:
- Respiratory arrest or failure — the patient is apneic or has dangerously inadequate respiratory effort.
- Cardiac arrest — a definitive airway allows uninterrupted chest compressions and reliable ventilation.
- Severe altered mental status — a Glasgow Coma Scale score of 8 or below is a traditional clinical benchmark for concern about airway protection, though clinical judgment guides the decision.
- Airway burns or angioedema — progressive swelling can close the airway; earlier intubation is safer than waiting.
- Inability to oxygenate or ventilate despite a bag-valve-mask (BVM) and airway adjuncts.
Always weigh the risk of attempting intubation against the benefit. A well-sealed BVM with an oral or nasal airway can maintain oxygenation safely while you prepare or transport.
Equipment You Must Know
Assembling your kit before you need it saves critical seconds. Standard components include:
| Item | Purpose |
|---|---|
| Laryngoscope handle | Powers the blade light |
| Macintosh (curved) blade | Tip seats in the vallecula (space anterior to the epiglottis) |
| Miller (straight) blade | Tip passes beneath the epiglottis and lifts it directly |
| ET tube (sized by patient) | Passes through the cords into the trachea |
| Malleable stylet | Shapes the tube; must not extend beyond the distal tip |
| 10 mL syringe | Inflates the cuff |
| Commercial tube holder or tape | Secures the tube after confirmation |
| BVM | Pre-oxygenation and post-intubation ventilation |
| End-tidal CO₂ (ETCO₂) device | Primary confirmation method |
| Stethoscope | Auscultation confirmation |
| Suction | Clears the airway before and during the procedure |
Before every attempt: check the laryngoscope light (bright and steady), test cuff integrity, lubricate the tube tip, and bend the stylet to a gentle hockey-stick curve.
Orotracheal Intubation: Step-by-Step
1. Pre-oxygenate — ventilate with 100% oxygen via BVM for at least 30 seconds before the attempt whenever time permits. This builds an oxygen reserve.
2. Position — place the patient in the sniffing position (head extended, neck slightly flexed) to align the oral, pharyngeal, and laryngeal axes. On a supine patient, a folded towel under the occiput helps.
3. Open the mouth — use a scissors (cross-finger) technique with your right hand.
4. Insert the laryngoscope — hold the handle in your left hand. Introduce the blade along the right side of the mouth, sweeping the tongue to the left.
5. Advance to the landmark — for a Macintosh blade, advance the tip into the vallecula. For a Miller blade, advance until the tip is under the epiglottis.
6. Lift along the handle axis — apply firm, upward-and-forward force along the axis of the handle (never lever back against the teeth). This exposes the glottis.
7. Visualize the cords — identify the white, triangular vocal cords and the dark opening of the trachea between them.
8. Pass the tube — introduce the ET tube from the right corner of the mouth so you keep the cords in view. Advance until the cuff passes just below the cords (typically the 21–23 cm mark at the lips in most adults).
9. Remove the stylet — hold the tube firmly, pull the stylet straight out.
10. Inflate the cuff — inject enough air to achieve a seal (generally 5–10 mL, but use clinical feel; cuff pressure monitoring is ideal).
11. Confirm placement immediately — see below.
12. Secure the tube — use a commercial holder or tape; document the cm mark at the lips.
Time limit: From blade insertion to ventilation, the attempt should be completed within 30 seconds. If you do not achieve successful placement, withdraw the blade, re-oxygenate with BVM for at least 30 seconds, then reattempt.
Confirming Tube Placement: Three Methods Required
An unrecognized esophageal intubation is a critical, potentially fatal error. You must confirm by at least three independent methods after every intubation:
1. Direct visualization — watch the tube pass between the vocal cords in real time. This is the first check but not sufficient alone.
2. Bilateral breath sounds — auscultate the midaxillary lines bilaterally. Equal sounds suggest tracheal placement. Absent or diminished sounds on the left may indicate right mainstem intubation; withdraw the tube 1–2 cm and recheck.
3. Epigastric auscultation — auscultate over the epigastrium. Gurgling sounds with ventilation indicate esophageal placement; remove the tube immediately, ventilate with BVM, and reattempt.
4. Colorimetric CO₂ detector — attaches between tube and BVM; color changes from purple to yellow confirm CO₂ is present (tracheal placement). Note: in cardiac arrest, CO₂ may be very low; a negative result does not rule out correct placement.
5. Waveform capnography (ETCO₂) — continuous waveform is the gold standard for ongoing confirmation. A consistent waveform with each breath confirms tracheal placement and is required for monitoring throughout transport.
6. Pulse oximetry — SpO₂ that rises or remains high after intubation supports correct placement; however, SpO₂ lags and can stay elevated briefly even with esophageal placement, so it is a supporting — not standalone — method.
Safety Rules You Must Follow
- Never intubate without suction immediately available.
- Never abandon BVM ventilation if intubation is proving difficult. A good BVM seal with an OPA or NPA keeps the patient alive.
- Document every attempt and all confirmation findings on your patient care report.
- Reconfirm after every patient move — lifting, loading, and transport can displace the tube.
- Know your agency's maximum number of intubation attempts protocol before moving to a rescue airway (supraglottic device or surgical airway).
Key terms10
Materials: Intubation manikins (adult), laryngoscope handles, Macintosh and Miller blades (multiple sizes), ET tubes (multiple sizes), malleable stylets, 10 mL syringes, commercial tube holders and tape, colorimetric CO2 detectors, capnography training device or simulation, stethoscopes, stopwatch, patient care report forms
Check: Instructor-timed NREMT-format intubation psychomotor evaluation: student completes all critical steps, tube placed in trachea (not esophagus), confirmed by three methods, within 30 seconds of blade insertion; pass requires zero critical failures per NREMT skill sheet criteria.
Practice check8
Answer each question, then check it. Nothing is recorded; this is your own practice.
