Chapter 16 
Indications for Endotracheal
Intubation
PAUL A. BAKER    ARND TIMMERMANN
I. Introduction
II. Endotracheal Intubation for Resuscitation
III. Endotracheal Intubation for Prehospital
Care
IV. Endotracheal Intubation for Emergency
Medicine
I.  INTRODUCTION
Endotracheal intubation is placement of an endotracheal
tube (ETT) into the trachea as a conduit for ventilation
or other lung therapy. The benefits of endotracheal intu-
bation are shown in Box 16-1. Historically, endotracheal
ventilation arose as a means of resuscitation by a trache-
ostomy and progressed with the development of the ETT,
which provided protection of the lungs from aspiration.
The eventual discovery of inhalation anesthesia facili-
tated surgical applications requiring a secure airway,
controlled ventilation, and lung therapy. This chapter
reviews these primary indications for endotracheal intu-
bation in the context of resuscitation, prehospital airway
management, emergency medicine, intensive care, and
anesthesiology.
II.  ENDOTRACHEAL INTUBATION   availability of appropriate equipment, and the skill of the
FOR RESUSCITATION
In 1543, Andreas Vesalius, a Belgian anatomist, was prob-
ably the first to perform endotracheal intubation by
inserting a cane tube through a tracheostomy into the
trachea of a pig. This landmark development allowed
controlled ventilation and laid the foundation for subse-
quent advances in resuscitation. Endotracheal intubation
for human resuscitation was first performed in 1754 by
an English surgeon, Benjamin Pugh, who orally intubated
an asphyxiated neonate with his air pipe. This was fol-
lowed in 1788 by Charles Kite, another English surgeon,
who reported the use of his curved metal cannula, which
he introduced blindly into the trachea of several drown-
ing victims from the river Thames.1
Endotracheal intubation remains the gold standard for
maintaining an airway and providing ventilation in
patients requiring cardiopulmonary resuscitation (CPR).2
Although alternative ventilation techniques have been
340
V. Endotracheal Intubation for Intensive Care
VI. Endotracheal Intubation for Anesthesia
VII. Conclusions
VIII. Clinical Pearls
successfully used, including bag-mask ventilation and
supralaryngeal airway (SLA) devices, and there is no evi-
dence to support any specific technique for airway main-
tenance and ventilation during CPR,2 there are many
advantages of endotracheal intubation during resuscita-
tion. Endotracheal intubation provides ventilation during
continuous chest compressions without interruption,3
protection against aspiration, minimal gastric inflation,
and a clear airway for effective ventilation (particularly
in the presence of low lung compliance and high resis-
tance). Disadvantages include unrecognized esophageal
or endobronchial intubation,4 prolonged intubation
attempts, ETT dislodgement, and hyperventilation. These
problems are particularly prevalent among inexperienced
practitioners.
The best airway technique for resuscitation depends
on the patient’s needs and clinical circumstances, the
rescuer.2,5 Solutions to these problems involve training in
airway management, appropriate selection of airway
devices, and patient monitoring.
Endotracheal intubation for resuscitation of the
newborn is indicated if bag-mask ventilation has been
prolonged or is ineffective or if chest compressions are
indicated. Care and experience is required to avoid
trauma and esophageal intubation. Endotracheal intuba-
tion may also be indicated for tracheal obstruction due
to meconium or other causes in nonvigorous infants
when suction is required; however, routine intubation
and suctioning of vigorous infants born through meco-
nium liquor are not recommended.6,7
Drowning victims who suffer cardiopulmonary arrest
require early reversal of hypoxemia and airway protec-
tion, ideally with a cuffed ETT.8 A range of ventilation
techniques has been suggested for victims of drowning.
Endotracheal intubation has the advantage of providing
a clear secure airway with positive-pressure ventilation
 CHAPTER 16  Indications for Endotracheal Intubation      341
BOX 16-1  Benefits of Endotracheal Intubation
1. A patent airway by oral, nasal or tracheal routes
2. Controlled ventilation with up to 100% oxygen
3. Ventilation with high airway pressure
4. Airway protection from aspiration
5. Removal of secretions
6. Lung isolation
7. Administration of medication including anesthetic gases
(PPV) in the presence of low lung compliance and high
airway resistance.
Airway management for electrocution may require
early endotracheal intubation if there are electric burns
around the face and neck causing soft tissue edema and
airway obstruction.8 Chapter 44 provides further details.
III.  ENDOTRACHEAL INTUBATION FOR
PREHOSPITAL CARE
Emergency endotracheal intubation in the prehospital
environment often occurs in unfavorable conditions on
patients who can be critically ill with shock, cardio­
pulmonary arrest, traumatic brain injury (TBI), airway
trauma, or uncorrected respiratory failure. There are no
prospective, controlled trials comparing basic and
advanced prehospital management of adult trauma
patients, but the benefit of endotracheal intubation has
been described in several studies.9-11 Some evidence sug-
gests that clinical outcomes of children who have had
prehospital endotracheal intubation by paramedics are no
better than outcomes of children who have only received
bag-mask ventilation.12 Another study of children,
however, indicates that prehospital endotracheal intuba-
tion performed by a helicopter-transport medical team is
safe and effective, but complications of this procedure
performed by emergency medical service paramedics was
unacceptably high.13
Prehospital endotracheal intubation is recommended
by the international Brain Trauma Foundation guidelines
for all patients with a Glasgow Coma Scale (GCS) score
of 8 or less.14 Early treatment of hypoxia, normoventila-
tion, and prevention of aspiration are associated with
improved outcomes in this group of patients.10 Despite
these recommendations, compliance is low, and some
clinical data have shown an association between early
intubation and increased mortality.15-17
The increased mortality associated with prehospital
intubation may be caused by suboptimal intubation per-
formance and hyperventilation.18 Endotracheal intuba-
tion is significantly more difficult to manage in the
prehospital setting. In a study of 1106 prehospital endo-
tracheal intubations by anesthesia-trained emergency
physicians, trauma patients were more often associated
with difficult airway management and failed intubation
than nontrauma patients.19 In this study, the difficult
airway occurred in 14.8% of prehospital intubations com-
pared with an estimated incidence of 1% to 4% in the
operating room.20 This has prompted some to suggest
techniques such as SLAs or alternatives to direct
laryngoscopy should be used for prehospital airway man-
agement, particularly by less experienced personnel.5,21
Controlled ventilation improves the outcome of TBI,
but prehospital control of PACO2 is inconsistent. In a
randomized, controlled trial of prehospital ventilated TBI
patients, normoventilation occurred in only 12.9% when
capnography was not used, compared with 57.5% for the
monitored group.22 Although capnography is commonly
used and recommended to confirm correct ETT place-
ment and monitor mechanical ventilation, the PETCO2 is
not a reliable indicator of PACO2. Arterial blood gas
monitoring may improve the quality of prehospital
mechanical ventilation, particularly for patients who
require tight control of PACO2 or patients needing lengthy
transportation.23
IV.  ENDOTRACHEAL INTUBATION FOR
EMERGENCY MEDICINE
Management of the airway in the emergency department
(ED) is often a fine balance between urgency and risk.
The time to evaluate the patient, examine the airway, and
prepare an airway plan can be limited because the patient
is deteriorating or in extremis. The patient is often physi-
ologically unstable, at risk for aspiration, uncooperative,
or unconscious but in need of urgent attention. Managing
the airway in the presence of a potentially unstable cervi-
cal spine is common. Medical history is often incomplete
or unobtainable. Preoperative airway assessment may not
be possible in the ED.24 Such risks must be tempered by
the urgency of the clinical situation.
In the ED, the urgency of many clinical situations
means that the benefits of endotracheal intubation out-
weigh the risks. The benefits of endotracheal intubation
for emergency medicine patients are the same as those
for elective surgical patients: provision of a secure airway,
controlled ventilation, airway protection, and removal of
secretions. The risks of endotracheal intubation in criti-
cally ill patients include hemodynamic instability, esoph-
ageal intubation, pneumothorax, and pulmonary
aspiration.25 These risks make it essential that medical
personnel, skilled in airway management and using suit-
able airway equipment, are available to attend the patient.
Risks are heightened when airway management is
required away from the operating room and when mul-
tiple endotracheal intubation attempts are made.26,27 In a
study observing more than 2500 endotracheal intubation
attempts outside the operating room, Mort calculated the
increased relative risk for more than two intubation
attempts for hypoxemia, regurgitation of gastric contents,
aspiration of gastric contents, bradycardia, and cardiac
arrest and showed a significant increase in these compli-
cations with repeated laryngoscopic attempts.
The indications for endotracheal intubation often
relate to clinical urgency. If the patient is in cardiorespira-
tory arrest, for example, or near arrest with absent muscle
tone and loss of protective airway reflexes, endotracheal
intubation in the ED becomes an emergency. In this situ-
ation, immediate direct laryngoscopy and oral intubation
with a cuffed ETT, without adjunct drugs, is indicated.
Urgent endotracheal intubation is indicated for a range
of situations involving the trauma patient, when the
342      PART 4  The Airway Techniques
airway may be at immediate or potential risk, or the
patient’s medical condition requires urgent airway man-
agement. These patients may be managed with a rapid
sequence induction (RSI) and endotracheal intubation.
RSI with preoxygenation followed by induction of anes-
thesia with a potent anesthetic agent (etomidate, propo-
fol, ketamine, or thiopentone) and a rapid- and short-acting
muscle relaxant (succinylcholine) is the gold standard
technique for oral endotracheal intubation in the ER. RSI
has a high success rate and is the main back-up procedure
when other oral or nasal intubation techniques fail and
require rescue, which occurs in up to 2.7% of emergency
intubations.28 The use of cricoid pressure for RSI is debat-
able and may compromise airway management.29,30
Urgency may be assessed clinically from signs of respira-
tory distress and impending fatigue (Box 16-2).
Other medical conditions may justify a more conserva-
tive approach to airway management, depending on the
progress of medical treatment, including anaphylaxis,
burns, asthma, laryngotracheobronchitis, or acute epiglot-
tis. These patients may require endotracheal intubation if
the clinical situation deteriorates or if the progress of the
condition is likely to deteriorate. Airway management for
unconscious patients with drug overdose is often managed
without endotracheal intubation.
RSI is contraindicated if the patient has a mouth
opening that is impossible or severely limited and in
patients with intrinsic pathology of the larynx, trachea,
or distal airway. This includes patients presenting with
stridor after a penetrating neck injury and patients in
respiratory distress with a mediastinal mass. Restricted
mouth opening can result from angioedema, Ludwig’s
angina, an immobile mandible, cervical spine pathology,
a wired jaw, or airway distortion.31 These patients may
require alternative intubation techniques and may benefit
from a collaborative multidisciplinary approach to airway
management.32
Awake intubation with a flexible fiberoptic broncho-
scope is promoted for cooperative, stable patients with a
known or suspected difficult airway.33 This technique is
inappropriate in the ED for the rapidly deteriorating
patient, especially when performed by inexperienced
practitioners. Endotracheal intubation may also be war-
ranted for the unstable emergency patient requiring a
secure and safe airway during transfer for computed
tomography or magnetic resonance imaging in the radiol-
ogy department or to the intensive care unit (ICU).
BOX 16-2  Signs of Respiratory Distress and
Impending Fatigue
1. Look of anxiety (frowning)
2. Signs of sympathetic overactivity (dilated pupils,
forehead sweat)
3. Dyspnea (decreased talking)
4. Use of accessory muscles (holds head off pillow)
5. Mouth opens during inspiration (licking of dry lips)
6. Self-PEEP (pursed lips, expiratory grunting, groaning)
7. Cyanosed lips
8. Restlessness and fidgeting (apathy and coma)
PEEP, Positive end-expiratory pressure.
Data from references 61 to 64.
V.  ENDOTRACHEAL INTUBATION FOR
INTENSIVE CARE
The most common indications for endotracheal intuba-
tion in the ICU are acute respiratory failure, shock, and
neurologic disorders.34 Endotracheal intubation is indi-
cated for controlled ventilation of a patient with refrac-
tory hypoxemia, often in the presence of multiple organ
failure. Predictors of hypoxemic respiratory failure appear
in Box 16-3.
The decision to intubate is usually made on clinical
grounds and based on the expected prognosis of the
patient’s condition. Clinical signs (see Box 16-2) or evolv-
ing deterioration in objective criteria (Table 16-1) may
support this decision.
Urgent intubation in the ICU may be required imme-
diately for apnea, airway obstruction, reintubation, or
cardiopulmonary arrest. If the patient is unconscious,
without airway reflexes, or paralyzed, endotracheal intu-
bation can proceed without pharmacologic support.
RSI, commonly used in the ED, may not be as appli-
cable for the unstable ICU patient. Preoxygenation of the
patient with limited respiratory reserve is compromised
by decreased functional residual capacity (FRC) and
increased dead space.35 Commonly used induction agents
can adversely affect the unstable patient. In these situa-
tions, a non-RSI technique with sedation and local anes-
thetic may be used.
Noninvasive ventilation techniques have become
increasingly popular over the past 20 years, with develop-
ment of clear indications and a range of masks and inter-
faces. Indications include patients with cardiogenic
pulmonary edema and exacerbations of chronic obstruc-
tive pulmonary disease (COPD). Noninvasive ventilation
is contraindicated for respiratory arrest or patients who
are unable to be mask ventilated.36 Relative contraindica-
tions for noninvasive ventilation that favor endotracheal
intubation are listed in Box 16-4.
The incidence of airway mishaps in the ICU involving
endotracheal intubation is relatively low. In a study of
5046 intubated ICU patients, the airway accident rate
was 0.7%. Accidents were less common with ETTs than
with tracheostomies.37 Self-extubation is the most
common ETT accident, with rates of up to 16%. With
strict clinical monitoring and in-service education, this
rate can be reduced to 0.3%. After unplanned extubation,
reintubation rates range from 14% to 65%.38
BOX 16-3  Predictors of Hypoxemic Respiratory
Failure
1. No or minimal rise in the ratio of PaO2 to FIO2 after 1 to 2
hours
2. Patients older than 40 years
3. High acuity illness at admission (simplified acute
physiology score > 35)65
4. Presence of acute respiratory distress syndrome (ARDS)
5. Community acquired pneumonia with or without sepsis
6. Multiorgan failure
Adapted from Nava S, Hill N: Non-invasive ventilation in acute
respiratory failure. Lancet 374:250–259, 2009.
 CHAPTER 16  Indications for Endotracheal Intubation      343

TABLE 16-1 
Objective Quantitative Criteria for Endotracheal Intubation
RESPIRATORY FUNCTION
Acceptable Possible Intubation, Chest PT, Possible Intubation, Probable
Category Variable Range Oxygen, Drugs, Close Monitoring Intubation, and Ventilation
Mechanics Vital capacity (mL/kg) 67-75 65-15 <15
Inspiratory force (cm H2O) 75-100 50-25 <25
Oxygenation PAO2 − PaO2 (mm Hg) room air <38 38-55 >55
FIO2 = 1.0 <100 100-450 >450
PaO2 (mm Hg) room air <72 72-55 <55
FIO2 = 1.0 >400 400-200 <200
Ventilation Respiratory rate (breaths/min) 10-25 25-40 or <8 >40 or <6
PaCO2 (mm Hg) 35-45 45-60 <60
PAO2 − PaO2, Alveolar-arterial partial pressure of oxygen difference; PaCO2, arterial partial pressure of carbon dioxide; PaO2, arterial partial pressure of
oxygen; FIO2, inspired concentration of oxygen; PT, physical therapy.
Adapted from Pontpoppidan H, Geffin B, Lowenstein E: Acute respiratory failure in the adult: 2. N Engl J Med 287:743–752, 1972.

In addition to mechanical ventilation, endotracheal VI.  ENDOTRACHEAL INTUBATION  

intubation facilitates other types of respiratory therapy.
Patients with moderate to severe carbon monoxide poi-
soning benefit from 100% oxygen. This concentration of
oxygen in normobaric conditions is most reliably achieved
through an ETT. Other therapy through an ETT includes
synthetic surfactant for premature newborns with estab-
lished respiratory distress syndrome (RDS). Nitric oxide
is administered to adults, infants, and neonates receiving
mechanical ventilation to treat acute lung injury, acute
respiratory distress syndrome (ARDS), and RDS. Heliox
is a blend of oxygen and helium gas used to improve gas
flow to patients with airway narrowing such as in asthma.
Use of the ETT as a route for emergency drug administra-
tion during CPR is no longer recommended due to
unpredictable plasma concentrations and the reliability
of the intraosseous route.2
Clearing secretions by suctioning through the ETT is
important to maintain ventilation by avoiding atelectasis
and consolidation. Suctioning is associated with a number
of complications such as hypoxemia, cardiovascular insta-
bility, elevated intracranial pressure, atelectasis, infection,
and trauma to the airway. Evidence-based recommenda-
tions for endotracheal suctioning of adult intubated
intensive care patients are provided in Box 16-5.39
FOR ANESTHESIA
Significant improvements to the design of the ETT have
been historically precipitated by evolving surgical tech-
niques. Upper airway surgery performed in the early 19th
century led to an increase in postoperative pneumonia
cases caused by aspiration of surgical debris. In 1878,
William Macewen first used an ETT in anesthesia for a
patient with a tumor of the base of the tongue.40 Macewen
was also concerned with preventing aspiration, and in
1880, he developed a metal ETT with a sponge collar
that he introduced blindly through the mouth for endo-
tracheal intubation. In 1888, O’Dwyer designed a curved
metal cannula with a conical end to provide a laryngeal
seal. This device helped raise intratracheal pressure to
avoid pulmonary collapse during thoracic surgery. In
1895, Alfred Kirstein performed awake direct laryngos-
copy with the autoscope.41 This primitive instrument was
the precursor of other laryngoscopes developed by
Jackson and others, aiding application of the ETT. World
War I precipitated a demand for plastic surgery of the
head and neck, which led to oral and nasal ETT designs
with pharyngeal or tracheal cuffs by Rowbotham and
Magill. Anesthetic management for thoracic surgery

BOX 16-4  Relative Contraindications to BOX 16-5  Recommendations for Endotracheal

Noninvasive Ventilation and Suctioning of Intubated Adult Patients
Indications for Endotracheal in Intensive Care
Intubation
1. Suction no longer than 15 seconds.
1. Medically unstable 2. Perform continuous rather than intermittent suctioning.
2. Agitated and uncooperative 3. Avoid saline lavage.
3. Unable to protect the airway 4. Provide hyperoxygenation before and after suctioning.
4 Swallow is impaired 5. Provide hyperinflation combined with hyperoxygenation
5. Excessive secretions that are not being adequately routinely.
managed 6. Always use an aseptic technique.
6. Multiple organ failure (two or more organs) 7. Use closed or open suction systems.
7. Recent upper airway or upper gastrointestinal surgery
8. Failed noninvasive ventilation Adapted from Pedersen CM, Rosendahl-Nielsen M, Hjermind J,
et al: Review. Endotracheal suctioning of the adult intubated
Adapted from Nava S, Hill N: Non-invasive ventilation in acute patient—What is the evidence? Intensive Crit Care Nurs
respiratory failure. Lancet 374:250–259, 2009. 25:21–30, 2009.
344      PART 4  The Airway Techniques
led to the next advance in ETT design with the intro­
duction of the first endobronchial tubes in 1932 by
Gale and Waters.1 By this time, the technique of
endotracheal intubation was established, prompting the
statement by Macintosh that “the ability to pass an ETT
under direct vision was the hallmark of a successful
anesthesiology.”42
Endotracheal intubation is used extensively in modern
anesthesia for elective and emergency indications as a
primary and a rescue airway. Patient characteristics and
surgical indications often dictate the appropriateness of
an ETT. Elective endotracheal intubation is indicated for
patients requiring anesthesia for major surgery when con-
trolled ventilation, resuscitation, airway access, patient
positioning, and duration of surgery are factors in the
overall airway plan. Specialized ventilation tubes are used
for specific indications. Examples include thoracic surgery
requiring lung isolation, laryngeal surgery requiring
microlaryngoscopy or laser treatment, and nasal intuba-
tion for limited mouth opening, oral surgery, and maxil-
lofacial surgery.
Endotracheal intubation may occur when the primary
surgical plan changes. An example is conversion of a
diagnostic procedure such as bronchoscopy to a lung
resection. Occasionally, complications arise during simple
anesthesia that necessitate endotracheal intubation during
resuscitation, such as major hemorrhage, anaphylaxis, or
malignant hyperthermia.
SLAs rival the oral ETT for routine airway manage-
ment in the fasted elective patient. Limitations of the
SLA include the inability to provide a nasal airway, the
volume of the SLA in the oral cavity, and inadequate PPV
due to a disrupted airway, low lung compliance, or high
airway resistance. These are important considerations
when choosing a suitable airway device. Second genera-
tion laryngeal masks with improved cuff seal and gastric
drainage tubes have extended the application of the
SLA.43 Procedures that previously were only considered
suitable for endotracheal intubation such as laparoscopic
surgery,44 prone position,45,46 surgery in obese patients,47,48
prolonged surgery,49 tonsillectomy,50 and craniotomy in
sedated patients can now be managed with an SLA in
experienced hands with close monitoring of airway
quality.51 Selection of an SLA as a ventilation device
should be based on case selection with careful individual
patient assessment.
Safe airway management should always include a
plan B for failed mask or SLA ventilation. Conversion
of the airway to endotracheal intubation may occur as
plan B after inadequate mask or SLA ventilation.
Impossible mask ventilation during anesthesia has an
incidence of 0.15% and is associated with neck changes
from irradiation, male gender, sleep apnea, a Mallam-
pati III or IV score, and the presence of a beard.52 In a
study by Kheterpal of 53,041 operations that included
an attempt at mask ventilation, 77 patients proved
impossible to ventilate (0.15%). Of those 77 patients,
19 (25%) were also difficult to intubate, but 15 of the
patients were intubated. Ultimately, 74 of the 77
impossible mask ventilation cases were intubated,52
reinforcing the value of endotracheal intubation for
failed ventilation.
The American Society of Anesthesiologists (ASA)
Practice Guidelines for Management of the Difficult Airway
recommend awake intubation for the patient with a
known difficult airway.33 This usually involves endotra-
cheal intubation with a flexible fiberoptic bronchoscope,
but other techniques have been described, including ret-
rograde awake intubation,53 submental awake intuba-
tion,54 awake intubating LMA,55 and awake lightwand
intubation.56 The outcome of each technique is a secure
airway with an ETT.
Endotracheal intubation is regarded as the gold stan-
dard for protection against aspiration of gastric contents
in anesthetized patients.57 However, evaluation of the
cuff seal is important because of the risk of fluid draining
past the cuff. This particularly applies to high-pressure,
low-volume cuffs.58 Evidence evaluating the relative risk
of an ETT or SLA for pulmonary aspiration is limited.
An analysis of the relative risk in 65,712 procedures
found that the use of an LMA was not associated with
an increased risk of pulmonary aspiration compared with
an ETT.59
VII.  CONCLUSIONS
The benefits of endotracheal intubation apply to patients
in many clinical situations. Although recent develop-
ments of SLAs have provided a useful alternative, par-
ticularly for day surgery procedures or for inexperienced
practitioners in emergency situations, endotracheal intu-
bation remains the first choice in many situations. The
limiting factors for the safe application of this important
technique are the skill of the practitioner, the use of
patient monitoring, and an understanding of the indica-
tions for endotracheal intubation. The ability to safely
perform endotracheal intubation remains one of the most
important skills for airway specialists.
VIII.  CLINICAL PEARLS
• The best airway technique for resuscitation depends on
the patient’s needs and clinical circumstances, the
availability of appropriate equipment, and the skill of
the rescuer.2,5
• Prehospital endotracheal intubation improves outcome
for all patients with a GCS score of 8 or less, with early
treatment of hypoxia, normoventilation, and preven-
tion of aspiration, and it is recommended by the inter-
national Brain Trauma Foundation guidelines.10
• The increased mortality associated with prehospital
intubation may be caused by suboptimal intubation
performance and hyperventilation.18
• Elective endotracheal intubation is indicated for
patients requiring anesthesia for major surgery when
controlled ventilation, resuscitation, airway access,
patient positioning, and duration of surgery are factors
in the overall airway plan.
• SLAs rival the oral ETT for routine airway manage-
ment in the fasted elective patient, but limitations of
the SLA include inadequate PPV (particularly in the
presence of a disrupted airway, low lung compliance,
 CHAPTER 16  Indications for Endotracheal Intubation      345
or high airway resistance), the volume of the SLA in
the oral cavity, and the inability to provide a nasal
airway.
• Endotracheal intubation protects against aspiration of
gastric contents in anesthetized patients57; however, the
use of a LMA is not associated with an increased risk
of pulmonary aspiration compared with an ETT.59
• Endotracheal intubation facilitates various types of
respiratory therapy, including mechanical ventilation,
100% O2 for carbon monoxide poisoning, nitric oxide,
surfactant, Heliox, and suctioning.
• Risks of endotracheal intubation are heightened when
airway management is required away from the operat-
ing room and when multiple endotracheal intubation
attempts are made.26,27,60
• The limiting factors for the safe application of endo-
tracheal intubation are the skill of the practitioner, the
use of patient monitoring, and an understanding of the
indications for endotracheal intubation. The ability to
safely perform endotracheal intubation remains one of
the most important skills for the airway specialist.
SELECTED REFERENCES
All references can be found online at expertconsult.com.
1. White GM: Evolution of endotracheal and endobronchial intuba-
tion. Br J Anaesth 32:235–246, 1960.
4. Timmermann A, Russo SG, Eich C, et al: The out-of-hospital esoph-
ageal and endobronchial intubations performed by emergency phy-
sicians. Anesth Analg 104:619–623, 2007.
10. Winchell RJ, Hoyt DB: Endotracheal intubation in the field
improves survival in patients with severe head injury. Trauma
Research and Education Foundation of San Diego. Arch Surg
132:592–597, 1997.
15. Franschman G, Peerdeman SM, Greuters S, et al: Prehospital endo-
tracheal intubation in patients with severe traumatic brain injury:
Guidelines versus reality. Resuscitation 80:1147–1151, 2009.
25. Schwartz DE, Matthay MA, Cohen NH: Death and other complica-
tions of emergency airway management in critically ill adults. A
prospective investigation of 297 tracheal intubations. Anesthesiology
82:367–376, 1995.
34. Jaber S, Amraoui J, Lefrant JY, et al: Clinical practice and risk factors
for immediate complications of endotracheal intubation in the
intensive care unit: A prospective, multiple-center study. Crit Care
Med 34:2355–2361, 2006.
36. Nava S, Hill N: Non-invasive ventilation in acute respiratory failure.
Lancet 374:250–259, 2009.
39. Pedersen CM, Rosendahl-Nielsen M, Hjermind J, et al. Endotra-
cheal suctioning of the adult intubated patient—What is the evi-
dence? Intensive Crit Care Nurs 25:21–30, 2009.
52. Kheterpal S, Martin L, Shanks AM, et al: Prediction and outcomes
of impossible mask ventilation: A review of 50,000 anesthetics.
Anesthesiology 110:891–897, 2009.
59. Bernardini A, Natalini G: Risk of pulmonary aspiration with laryn-
geal mask airway and tracheal tube: Analysis on 65,712 procedures
with positive pressure ventilation. Anaesthesia 64:1289–1294,
2009.
 CHAPTER 16  Indications for Endotracheal Intubation      345.e1
REFERENCES
1. White GM: Evolution of endotracheal and endobronchial intuba-
tion. Br J Anaesth 32:235–246, 1960.
2. Deakin CD, Nolan JP, Soar J, et al: European Resuscitation Council
guidelines for resuscitation 2010: Section 4. Adult advanced life
support. Resuscitation 81:1305–1352, 2010.
3. Kramer-Johansen J, Wik L, Steen PA: Advanced cardiac life support
before and after tracheal intubation—Direct measurements of
quality. Resuscitation 68:61–69, 2006.
4. Timmermann A, Russo SG, Eich C, et al: The out-of-hospital esoph-
ageal and endobronchial intubations performed by emergency phy-
sicians. Anesth Analg 104:619–623, 2007.
5. Timmermann A, Russo SG: Which airway should I use? Curr Opin
Anaesthesiol 20:595–599, 2007.
6. Richmond S, Wyllie J: European Resuscitation Council guidelines
for resuscitation 2010: Section 7. Resuscitation of babies at birth.
Resuscitation 81:1389–1399, 2010.
7. Wiswell TE, Gannon CM, Jacob J, et al: Delivery room management
of the apparently vigorous meconium-stained neonate: Results of
the multicenter, international collaborative trial. Pediatrics 105:1–7,
2000.
8. Soar J, Perkins GD, Abbas G, et al: European Resuscitation Council
guidelines for resuscitation 2010: Section 8. Cardiac arrest in
special circumstances: Electrolyte abnormalities, poisoning, drown-
ing, accidental hypothermia, hyperthermia, asthma, anaphylaxis,
cardiac surgery, trauma, pregnancy, electrocution. Resuscitation
81:1400–1433, 2010.
9. Garner A, Rashford S, Lee A, et al: Addition of physicians to para-
medic helicopter services decreases blunt trauma mortality. Aust N
Z J Surg 69:97–701, 1999.
10. Winchell RJ, Hoyt DB: Endotracheal intubation in the field
improves survival in patients with severe head injury. Trauma
Research and Education Foundation of San Diego. Arch Surg
132:592–597, 1997.
11. Davis DP, Peay J, Sise MJ, et al: Prehospital airway and ventilation
management: A trauma score and injury severity score-based analy-
sis. J Trauma 69:294–301, 2010.
12. Gausche M, Lewis RJ, Stratton SJ, et al: Effect of out-of-hospital
pediatric endotracheal intubation on survival and neurological
outcome: a controlled clinical trial. JAMA 283:783–790, 2000.
13. Gerritse BM, Draaisma JM, Schalkwijk A, et al: Should EMS-
paramedics perform paediatric tracheal intubation in the field?
Resuscitation 79:225–229, 2008.
14. Guidelines for the management of severe traumatic brain injury.
J Neurotrauma 24(Suppl 1):S1–S106, 2007.
15. Franschman G, Peerdeman SM, Greuters S, et al: Prehospital endo-
tracheal intubation in patients with severe traumatic brain injury:
Guidelines versus reality. Resuscitation 80:1147–1151, 2009.
16. Hesdorffer DC, Ghajar J: Marked improvement in adherence to
traumatic brain injury guidelines in United States trauma centers.
J Trauma 63:841–847: discussion 847–848, 2007.
17. Eckstein M, Chan L, Schneir A, et al: Effect of prehospital advanced
life support on outcomes of major trauma patients. J Trauma
48:643–648, 2000.
18. Davis DP: Early ventilation in traumatic brain injury. Resuscitation
76:333–340, 2008.
19. Timmermann A, Eich C, Russo SG, et al: Prehospital airway man-
agement: A prospective evaluation of anaesthesia trained emer-
gency physicians. Resuscitation 70:179–185, 2006.
20. Benumof JL: Management of the difficult adult airway. With special
emphasis on awake tracheal intubation. Anesthesiology 75:1087–
1110, 1991.
21. Timmermann A, Russo SG, Crozier TA, et al: Novices ventilate and
intubate quicker and safer via intubating laryngeal mask than by
conventional bag-mask ventilation and laryngoscopy. Anesthesiology
107:570–576, 2007.
22. Helm M, Hauke J, Lampl L: A prospective study of the quality of
pre-hospital emergency ventilation in patients with severe head
injury. Br J Anaesth 88:345–349, 2002.
23. Belpomme V, Ricard-Hibon A, Devoir C, et al: Correlation of arte-
rial PCO2 and PETCO2 in prehospital controlled ventilation. Am J
Emerg Med 23:852–859, 2005.
24. Levitan RM, Everett WW, Ochroch EA: Limitations of difficult
airway prediction in patients intubated in the emergency depart-
ment. Ann Emerg Med 44:307–313, 2004.
25. Schwartz DE, Matthay MA, Cohen NH: Death and other complica-
tions of emergency airway management in critically ill adults. A
prospective investigation of 297 tracheal intubations. Anesthesiology
82:367–376, 1995.
26. Mort TC: Complications of emergency tracheal intubation: imme-
diate airway-related consequences: Part II. J Intensive Care Med
22:208–215, 2007.
27. Mort TC: Complications of emergency tracheal intubation: hemo-
dynamic alterations: Part I. J Intensive Care Med 22:157–165, 2007.
28. Bair AE, Filbin MR, Kulkarni RG, et al: The failed intubation
attempt in the emergency department: analysis of prevalence,
rescue techniques, and personnel. J Emerg Med 23:131–140, 2002.
29. Brimacombe JR, Berry AM: Cricoid pressure. Can J Anaesth
44:414–425, 1997.
30. Ovassapian A, Salem MR: Sellick’s maneuver: To do or not do.
Anesth Analg 109:1360–1362, 2009.
31. Levitan RM: Patient safety in emergency airway management and
rapid sequence intubation: Metaphorical lessons from skydiving.
Ann Emerg Med 42:81–87, 2003.
32. Mort TC: Anesthesia practice in the emergency department: over-
view, with a focus on airway management. Curr Opin Anaesthesiol
20:373–378, 2007.
33. American Society of Anesthesiologists: Practise guidelines for man-
agement of the difficult airway: An updated report by the American
Society of Anesthesiologists Task Force on Management of the
Difficult Airway. Anesthesiology 98:1269–1277, 2003.
34. Jaber S, Amraoui J, Lefrant JY, et al: Clinical practice and risk factors
for immediate complications of endotracheal intubation in the
intensive care unit: A prospective, multiple-center study. Crit Care
Med 34:2355–2361, 2006.
35. Mort TC, Waberski BH, Clive J: Extending the preoxygenation
period from 4 to 8 mins in critically ill patients undergoing emer-
gency intubation. Crit Care Med 37:68–71, 2009.
36. Nava S, Hill N: Non-invasive ventilation in acute respiratory failure.
Lancet 374:250–259, 2009.
37. Kapadia FN, Bajan KB, Raje KV: Airway accidents in intubated
intensive care unit patients: An epidemiological study. Crit Care
Med 28:659–664, 2000.
38. Lucas da Silva PS, de Carvalho WB: Unplanned extubation in pedi-
atric critically ill patients: A systematic review and best practice
recommendations. Pediatr Crit Care Med 11:287–294, 2010.
39. Pedersen CM, Rosendahl-Nielsen M, Hjermind J, et al. Endotra-
cheal suctioning of the adult intubated patient—What is the evi-
dence? Intensive Crit Care Nurs 25:21–30, 2009.
40. Macewen W: Clinical observations on the introduction of tracheal
tubes by the mouth, instead of performing tracheotomy or laryn-
gotomy. Br Med J 2:163–165, 1880.
41. Kirstein A: Autoskopie des larynx un der trachea, Berlin, 1895,
Klinische Wochenschrift, pp 476–478.
42. Jephcott A: The Macintosh laryngoscope. A historical note on its
clinical and commercial development. Anaesthesia 39:474–479,
1984.
43. Cook TM, Lee G, Nolan JP: The ProSeal laryngeal mask airway: A
review of the literature. Can J Anaesth 52:739–760, 2005.
44. Maltby JR, Beriault MT, Watson NC, et al: LMA-Classic and LMA-
ProSeal are effective alternatives to endotracheal intubation for
gynecologic laparoscopy. Can J Anaesth 50:71–77, 2003.
45. Abrishami A, Zilberman P, Chung F: Brief review: Airway rescue
with insertion of laryngeal mask airway devices with patients in the
prone position. Can J Anaesth 57:1014–1020, 2010.
46. Sharma V, Verghese C, McKenna PJ: Prospective audit on the use
of the LMA-Supreme for airway management of adult patients
undergoing elective orthopaedic surgery in prone position. Br J
Anaesth 105:228–232, 2010.
47. Doyle DJ, Zura A, Ramachandran M, et al: Airway management in
a 980-lb patient: Use of the Aintree intubation catheter. J Clin
Anesth 19:367–369, 2007.
48. Zoremba M, Aust H, Eberhart L, et al: Comparison between intu-
bation and the laryngeal mask airway in moderately obese adults.
Acta Anaesthesiol Scand 53:436–442, 2009.
49. Fabregat-Lopez J, Garcia-Rojo B, Sanchez-Ferragut E, et al: Use of
a ProSeal laryngeal mask airway for eight hours of unplanned
abdominal surgery. Can J Anaesth 56:625–626, 2009.
50. Hatcher IS, Stack CG: Postal survey of the anaesthetic techniques
used for paediatric tonsillectomy surgery. Paediatr Anaesth 9:311–
315, 1999.
345.e2      PART 4  The Airway Techniques
51. Hagberg CA, Gollas A, Berry JM: The laryngeal mask airway for
awake craniotomy in the pediatric patient: report of three cases.
J Clin Anesth 16:43–47, 2004.
52. Kheterpal S, Martin L, Shanks AM, et al: Prediction and outcomes
of impossible mask ventilation: A review of 50,000 anesthetics.
Anesthesiology 110:891–897, 2009.
53. Dhara SS: Retrograde tracheal intubation. Anaesthesia 64:1094–
1104, 2009.
54. Ramsey CA, Dhaliwal SS: Retrograde and submental intubation.
Atlas Oral Maxillofac Surg Clin North Am 18:61–68, 2010.
55. Ferson DZ, Rosenblatt WH, Johansen MJ, et al: Use of the intubat-
ing LMA-Fastrach in 254 patients with difficult-to-manage airways.
Anesthesiology 95:1175–1181, 2001.
56. Xue FS, Yang QY, Liao X: Topical anaesthesia of the airway using
Trachlight and MADgic atomizer in patients with predicted diffi-
cult tracheal intubation. Br J Anaesth 99:920–921, 2007.
57. Ng A, Smith G: Gastroesophageal reflux and aspiration of gastric
contents in anesthetic practice. Anesth Analg 93:494–513,
2001.
58. Young PJ, Ridley SA: Ventilator-associated pneumonia. Diagnosis,
pathogenesis and prevention. Anaesthesia 54:1183–1197, 1999.
59. Bernardini A, Natalini G: Risk of pulmonary aspiration with laryn-
geal mask airway and tracheal tube: Analysis on 65,712 procedures
with positive pressure ventilation. Anaesthesia 64:1289–1294,
2009.
60. Mort TC: Emergency tracheal intubation: complications associated
with repeated laryngoscopic attempts. Anesth Analg 99:607–613,
2004.
61. Cohen BM: The interrelationship of the respiratory functions of the
nasal and lower airways. Bull Physiopathol Respir (Nancy) 7:895–
911, 1971.
62. Knelson JH, Howatt WF, DeMuth GR: The physiologic significance
of grunting respiration. Pediatrics 44:393–400, 1969.
63. Mueller RE, Petty TL, Filley GF: Ventilation and arterial blood gas
changes induced by pursed lips breathing. J Appl Physiol 28:784–
789, 1970.
64. Schmidt RW, Wasserman K, Lillington GA: The effect of air flow
and oral pressure on the mechanics of breathing in patients with
asthma and emphysema. Am Rev Respir Dis 90:564–571, 1964.
65. Le Gall JR, Lemeshow S, Saulnier F: A new Simplified Acute Physi-
ology Score (SAPS II) based on a European/North American mul-
ticenter study. JAMA 270:2957–2963, 1993.