Orotracheal Intubation

1. Adequately ventilate/oxygenate.
- pre-oxygenate 3 minutes at 100%

2. Get all equipment ready:
- suction, laryngoscope with working bulb, ETT tube (sizing below)
- end-tidal CO2 detector, stethoscope, end-tidal CO2 detector.
- drugs; induction and paralytic
--> commonly etomidate (0.3 mg/kg IV) and succinylcholine (1.5 mg/kg IV)
--> beware propofol causes hypotension so do not use if hypotensive

3. Check cuff for leak by inflating/deflating.

4. Connect laryngoscope and check bulb is bright.

5. Have assistant manually immobilise head and neck without flexion/extension.
- in-line mobilisation
- cricoid pressure.

6. Hold laryngoscope in left hand.

7. Insert laryngoscope into right side of mouth, displacing tongue to left.

8. Identify epiglottis and vocal cords.
- backward pressure cricoid cartilage can help prevent regurgitation.
- backward upward rightward pressure (BURP) doesn't protect airway, but helps visualise cords.

9. Insert tube into trachea without pressure on teeth or oral tissues.
- size 7 for women, 8 for men (as per size)
- age/4+4 for children.
- teeth at 21-23cm mark, secured.
- using an L-shape configuration may aid placement.
- verify placement with a capnography set

10. Inflate cuff to a good seal - do not over-inflate.
- takes 3-8 ml of air to inflate

11. Check placement with bag-valve-to-tube ventilation.

12. Observe chest excursion.

13. Auscultate to ascertain tube position (chest bilaterally and stomach).
- avoid common complication of mainstem intubation

14. Secure tube.
- and reassess the tube if the pt moves.

15. If not quickly achieved, discontinue and resume ventilation.  Reattempt.

16. Get a chest XR to help determine placement.
- shd be 2-5cm above carina.

17. Attach a CO2 measuring device - reliable.

18. Attach pulse oximetry.

i) oesophageal intubation --> hypoxia.
ii) R bronchus intubation --> L lung collapse.
iii) inability to intubate
iv) induction of vomiting --> aspiration
v) trauma to airway --> bleeding aspiration
vi) damage of teeth
vii) rupture leak of ET cuff
viii) cervical cord injury