■ Failure to maintain or protect the airway
■ Failure of oxygenation or ventilation
■ Anticipated deterioration

■ There are no absolute contraindications.

■ Position the patient.
        - Sniffing position of head
■ Open patient's mouth.
■ Insert blade (using left hand) and sweep patient's tongue to left.
        - Final position - in vallecula if curved blade
        - Underneath epiglottis if straight blade
■ Elevate epiglottis.
        - Lift the blade upward and forward at a 45 degree angle in the direction of the handle.
■ Tracheal manipulation
        - BURP: Backward, Upward, Rightward Pressure on thyroid and cricoid cartilages
        - Bimanual laryngoscopy: Intubator moves trachea into view with right hand. Assistant should then hold trachea in preferred position.
        - Brings the larynx further posterior and superior for better visualization of cords
        - Improves visualization by one full grade, on average
    ■ Insert ET tube through cords. Inflate ET tube balloon.
        ■ Depth at teeth:
            - 23 cm for adult males
            - 21 cm for adult females
            - Children = (0.5  age in years) + 12 cm or 3 the ET tube size.
■ Confirm tube placement.
        - ETCO2 = best method.
        - Gold standard = fiberoptic visualization of tracheal rings through ET tube.
        - Esophageal detector device
            ■ Syringelike aspiration device that is inserted into the end of ET tube
                - No resistance to pulling plunger = tracheal intubation.
                - Resistance = esophageal intubation.
        ■ Other methods: Direct visualization, physical examination, pulse oximetry, CXR
Instructions for Endotracheal Tube Insertion
Step Comments
1. Hold laryngoscope in left hand.  
2. Use right hand to:
Insert the ETT (Figure 30-3) Operate suction catheter Manipulate larynx externally to enhance the visualization
Remove dentures and any obscuring blood, secretions, or vomitus suctioned before insertion of the ETT. Use a properly sized, semirigid, malleable, blunt-tipped metal, or plastic stylet to assist with tube placement. The tip of the stylet should not extend beyond the end of the ETT or exit the Murphy eye.
3. Insert blade into the right corner of the patient's mouth. The flange of the curved Macintosh blade will push the tongue toward the left side of the oropharynx. If the blade is inserted directly down the middle, the tongue can force the line of sight posteriorly, which is a common reason for the putative "anterior larynx."
4. Visualize arytenoids.  
5. Lift epiglottis. Lift the epiglottis directly with the straight blade or indirectly with the curved blade.
6. Expose larynx. Pull laryngoscope handle in the direction that it points (i.e., 90 degrees to the blade). Cocking the handle back, especially with the straight blade, risks fracturing central incisors and is ineffective at revealing the cords.
7. Advance blade incrementally. Look for the arytenoid cartilages to avoid overly deep insertion of the blade, which is a common error.
8. Advance ETT.
ETT must be visualized until the cuff has passed through vocal cords. Correct tube placement is a minimum of 2 cm above the carina (approximately 23 cm in men and 21 cm in women). The base of the pilot tube (a tube with the adapter to inflate the cuff) is usually at the level of the teeth.
9. Check ETT placement.
Listen for bilateral breath sounds. Listen for absence of epigastric sounds.
10. Inflate balloon. Use 5 cc of air.
11. Secure ETT.
Do not impede cervical venous return with umbilical tape or a fixator. Use a modified clove-hitch knot or a commercial fixator to avoid kinking the pilot tube.


Conditions Associated with False Colorimetric or False Capnographic CO2Readings

False Negative Reading Comments
Low pulmonary perfusion - cardiac arrest, inadequate chest compressions during CPR, massive pulmonary embolism  
Massive obesity  
Severe pulmonary edema Secretions may obstruct the tube
False Positive Reading Comments
Recent ingestion of carbonated beverage Will not persist beyond six breaths
Heated humidifier, nebulizer, or endotracheal epinephrine Transient

■ Broken teeth
■ Laryngospasm
■ Mainstem intubation