CHAPTER 222

Tracheal Intubation
Dan F. Casey

Airway emergencies can be some of the most daunting situations
a practitioner encounters. Radical advances in airway management
have been made and are reviewed in this chapter.
Indications
• Hypoxia
• Respiratory distress
• Protection of the airway
• Cardiopulmonary arrest
• Need to maintain hyperventilation (e.g., with traumatic brain
injury) 
Contraindications
N
•  eed for emergent surgical airway
• Severe facial or neck trauma (consider needle or surgical crico-
thyroidotomy; see Chapter 223, Cricothyroid Catheter Insertion,
Cricothyroidotomy, and Tracheostomy)
• Intact tracheostomy or stoma (replace tracheostomy tube)
• Cervical spine injury (may use video and optical laryngoscopes,
fiberoptic laryngoscope, or digital [tactile] technique)
• Cervical spine severely immobilized due to arthritis (may use vid-
eo and optical laryngoscopes, fiberoptic laryngoscope, or digital
[tactile] technique)
• Expanding neck hematoma (relative, must use caution but may
require surgical airway)
• Uncontrolled oropharyngeal hemorrhage (relative, may require
surgical airway)
C
•  ombative patient (consider rapid-sequence intubation [RSI])
• Trismus (consider RSI or nasotracheal intubation)
• When a less invasive technique may be adequate in a patient
whose medical conditions are likely to respond quickly to medi-
cal interventions (e.g., cardiogenic pulmonary edema or pneu-
monitis may respond to diuresis and continuous positive airway
pressure [CPAP] or bilateral positive airways pressure [BIPAP] if
they have a normal mental status and are breathing spontane-
ously) 
Equipment
See Fig. 222.1.
• Laryngoscope (and fresh batteries)
• Laryngoscope blades (at least two different types)
• Size 1 for infants age 1 month to 2 years, size 2 for children 3
to 6 years, size 2 or 3 for children between 6 and 12 years, size
3 for adolescents, women, and average-sized males, size 4 for
large males. To estimate size, place base of blade, excluding
the insertion block, at the level of the patient’s upper incisor
teeth. The tip of blade should be 1 cm proximal or distal to
angle of mandible.
• Endotracheal tubes
• Adult men sizes 7 to 9
• Adult women sizes 6 to 8
• Nasotracheal intubation sizes 5 to7

Straight blades Stylet

Laryngoscope

Endotracheal
tubes
Oxygen setup

Batteries
Tape

Suction Scissors
setup Anesthesia and
bag valve masks

Fig. 222.1  Suggested intubation equipment.

1477
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1478 HOSPITALIST

• P ediatrics—Consult Broselow tape or use the size equal to the

width of the fingernail of the little finger. Use uncuffed tubes
in infants and small children up to 8 years of age.
• Stylet (optional, but most useful when bent to 35 degrees in
hockey stick configuration) or esophageal bougienage (bougie
with coudé tip, which has hockey stick configuration)
• Water-soluble lubricant
• 10-mL syringe
• Umbilical tape or endotracheal tube holding device
• Scissors
• Bag-valve-mask device (Ambu-bag) with 100% oxygen delivery
system
• Suction system with dental or Yankauer tip
• Stethoscope
• Pulse oximeter
• Capnograph, carbon dioxide detector, esophageal detector, or
other device to confirm tube placement
• Cardiac monitor and defibrillator
• Blood pressure monitor Fig. 222.2  Sellick maneuver. Either the practitioner or assistant uses the
• Gloves thumb and index and middle fingers pinched into a double “V” or tripod. Pos-
• Face mask, goggles, or eye shield, and any other equipment nec- terior pressure is then applied to the cricoid to avoid aspiration and bring the
essary to follow universal blood and body fluid precautions larynx into view. Note the upward and forward direction of forces applied in
• Intravenous line (if possible) a nonfulcrum manner by the laryngoscope.
• Ventilator
• Cricothyroidotomy kit
• Sedative medication to use for chemical restraint (e.g., Propofol,
benzodiazepines)
• For rapid sequence intubation, paralytic agent (e.g., succinylcho-
line, rocuronium, vecuronium, atracurium, mivacurium), seda-
tive agent (e.g., etomidate, ketamine, midazolam, thiopental),
and adjuncts (e.g., lidocaine, atropine)
• Glidescope or equivalent for video-assisted intubation (see Fig.
222.9)
  
Editor’s note: The ET tube and cuff should be examined for
defects before use. No matter which hand is dominant for the physi-
cian, laryngoscopes are designed to be used in the left hand. The two Fig. 222.3  Jaw thrust. Rotate mandible forward with index fingers. Arrow
basic laryngoscope blades are the Macintosh (curved; the tip fits into indicates motion to bring soft tissues forward to relieve airway obstruction.
the vallecula) and the Miller (straight; the tip fits directly under the
epiglottis to lift it), with the Macintosh being the most commonly that applying pressure to the thyroid cartilage was helpful in 88% of
used. Blade size is very important; correct size allows for approxi- cases, while applying pressure on cricoid cartilage was only helpful in
mately 90% of first attempt intubations to be successful versus 57% 11% (Benumof and Cooper, 1996). Once the best position is found,
if the blade is too small.  an assistant assumes control of the larynx by applying similar pres-
sure in the same location and direction. 
Cricoid Pressure (Sellick Maneuver)
Providing or performing cricoid pressure may help protect against
Airway Assessment
regurgitation of gastric contents; it also increases visibility by mov- Begin with the patient on 100% nonrebreather mask if sponta-
ing the trachea into the visual field of the person intubating. To neously breathing. Remember that 5 minutes of preoxygenation
perform cricoid pressure (Sellick maneuver), first find the thyroid provides 5 minutes of protection. The jaw thrust maneuver can be
cartilage (Adam’s apple), and then the small indentation beneath it used to keep the airway open (Fig. 222.3), or begin bag-valve-mask
(cricothyroid membrane). The cartilage beneath this small indenta- breathing with a second assistant providing cricoid pressure (Sell-
tion is the cricoid bone. Cricoid pressure is performed by pinching ick maneuver). Nasopharyngeal oxygen insufflation, even during
the extended thumb, index, and middle finger together into a double apnea, has been found to be beneficial. Morbidly obese patients are
“V,” or tripod. This is then placed on the cricoid bone and pressed best preoxygenated in a 25-degree head up position. The practitio-
down with enough pressure to occlude the esophagus (Fig. 222.2). ner should be familiar with the anatomic landmarks (Fig. 222.4).
The pressure should be applied toward the patient’s back and the Many airway management failures can be traced to lack of airway
head somewhat. Cricoid pressure should not be released until intu- assessment. Patients can be classified into three groups (shades)
bation is completed and confirmed and the cuff inflated. based on two criteria: anticipated difficulty in intubation and abil-
ity to maintain oxygen saturation greater than 90% by bag-valve-
Note: The effectiveness of the Sellick maneuver has been ques- mask ventilation. Airway assessment is critical. An experienced
tioned. Because of the wide variation in pressure applied by opera- person can assess an airway in less than 4 seconds, and an inexperi-
tors, cricoid pressure should be removed if there is difficulty in enced person should be able to do so in less than 8 seconds.
visualizing the airway. Another technique known as optimal exter- The mnemonic for assessing difficulty in intubation is 332-NUTS:
nal laryngeal manipulation (OLEM) can be tried. For OLEM, the   
intubator uses their right hand to manipulate the larynx into opti- • 3—fingerbreadths, mouth opening
mal position while simultaneously viewing the patient’s airway and • 3—fingerbreadths, mentum (distance from the tip of the chin to
controlling the laryngoscope with their left hand. One study found the anterior soft tissue of the neck)

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Laryngeal opening
Nares
Hypopharynx
Oral
pharynx
Uvula
Vocal cords
Esophagus
Fig. 222.4  Anatomic landmarks of the head and neck.
• 2—fingerbreadths, thyromental distance (distance from the top
of the thyroid cartilage to the upper soft tissue angle of the neck)
• N—normal neck flexion
• U—uvula visible when opening the mouth
• T—no tension pneumothorax
• S—no “soup” (foreign body in the airway)
  
Meeting all these criteria indicates a low-risk intubation; con-
versely, the fewer the criteria present, the higher the risk. Although
the last two categories, tension pneumothorax and foreign body, do
not strictly determine the anatomic difficulty of intubation, estab-
lishing their absence is a vital part of early airway assessment. The
Mallampati system has previously been used to assess the uvular por-
tion of the mnemonic; however, it is important to note that this
classification was designed to assess a patient sitting upright with
voluntary mouth opening—a condition rarely encountered in clini-
cal practice outside anesthesiology. A simpler method is to open the
mouth with the thumb while standing to either side of the patient’s
head. (Standing at the head of the patient changes the angle of view
and may produce a false result.) If any portion of the uvula can be
seen, then intubation will likely be unimpeded by this factor. The
three risk groups (shades) are as follows:
  
• Pink—Able to keep the oxygen saturation greater than 90%; an-
ticipate easy intubation and use standard technique.
• Purple—Able to keep the oxygen saturation greater than 90%
but anticipate difficult intubation. Attempt awake laryngoscopy.
If successful, perform an assisted intubation with a gum elastic
bougie, lighted stylet, intubating, fiberoptic or video laryngo-
scope, or similar device. If not, use an intermediate airway (laryn-
geal mask airway [LMA] or King LTS-D) if possible, and obtain
expert assistance for further management.
• Blue—Unable to keep the oxygen saturation greater than 90%.
If possible, perform a single attempt at an intermediate airway
(LMA or King LTS-D). If successful and easy intubation is an-
ticipated, attempt assisted intubation as in the purple patient.
If difficulty is anticipated, obtain expert assistance for further
management if time permits. If not, needle or surgical cricothy-
roidotomy may be needed.  of the bed in most care settings compound this problem. Unfor-
Standard Orotracheal Intubation
Preparation
Lack of proper preparation is another common reason for failure to
intubate. If the airway risk is purple or blue, auxiliary techniques
should be strongly considered. However, if the patient is classified
in the pink group, attempt standard orotracheal intubation. Prepare
for intubation using the mnemonic “airway START.” The airway
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222 –––– TRACHEAL INTUBATION 1479
Trachea
Cricoid cartilage
Tongue
Epiglottis
Vallecula
Route to
trachea Arytenoid cartilage
Visualization
of cords
via pharynx
prefix distinguishes it from a similar mnemonic used for triage in
mass disasters.
  
• S—shade (classify the patient as pink, purple, or blue and select
the proper technique)
• T—technicians (respiratory technician and cricoid pressure
technician)
• A—assemble (ensure all the equipment and drugs are prepared)
• R—respiration (preoxygenate with at least eight vital capacity
breaths. If time permits, and the patient is breathing spontane-
ously, 5 minutes of preoxygenation provides 5 minutes of protec-
tion.)
• T—tilt (ensure both the patient and the practitioner are prop-
erly positioned) 
Technique
The cricoid pressure technician should initiate cricoid pressure using
the Sellick maneuver as soon as the respiratory therapist begins bag-
ging. This will reduce stomach insufflation and the risk for vomiting.
The cricoid pressure technician also watches the oxygen saturation
of the patient and announces saturations below 90% to the practi-
tioner. In addition, this technician holds the endotracheal tube and
passes it to the practitioner so the practitioner can focus uninter-
rupted on the intubating view.
“Tilt” or position of the patient and the practitioner is often
overlooked, but this is probably the most critical component of suc-
cessful intubation. If the patient is not suspected of having neck
problems that could be worsened by movement, place the patient in
the “sniffing” position with the neck flexed and the head extended
backward (Fig. 222.5). The neck may be flexed by raising the head
several inches using a folded towel or firm pillow. It is important to
remember that the padding should be placed under the head and not
between the shoulders (see Fig. 222.4).
The position of the practitioner is even more important. The
most common problem is having an angle of view that is too high
to visualize the anatomy, which is caused by being both too close
to and too high above the patient. Crowded conditions at the head
tunately, the practitioner usually reacts by bending forward at the
waist, which serves only to worsen the angle of view. Raise the bed
and move it a full 2 feet or more forward if possible. If a lower angle
of view is needed, the practitioner should bend at the knees and not
at the waist.
Intubation
The paraglossal technique has supplanted older methods of intu-
bation. It is easier to learn, has a higher success rate, and uses the
same technique regardless of whether a curved or straight blade is
1480 HOSPITALIST
B
Fig. 222.5  Proper head position is important for successful endotracheal
intubation. Axes of the mouth, pharynx, and larynx need to be aligned. (A)
Divergent axes. (B) Axes in line, or “sniffing position.”
used. Dr. Scott Savage, a previous author, nicknamed the method
the “Diamond Technique,” based on the four “Ds” of the steps used
to intubate:
  
• Dental—Always hold the laryngoscope in the left hand. Place
the flange of the blade against the right molars with no tongue
intervening.
• Deep—Sweep the tongue centrally and insert the blade to the
hilt or until resistance is met in the esophagus. If the patient is in
the sniffing position, this is usually easy. If the patient cannot be
moved safely into the sniffing position, follow the contour of the
base of the tongue to reach the esophagus. Place the blade deeply
and in the esophagus on purpose. In this position, the location
of the tip of the blade is known and, more important, so is the
location of the airway: shallow and superior to the blade tip.
• Direct—Once the blade is in the esophagus, lift the handle up-
ward and forward (see Fig. 222.2), using the same technique as in
the older methods of intubation.
• Depart—From this position, withdraw the blade while monitor-
ing the view. Most of the time, there will be a slight sensation of
“give” when the blade clears the esophagus, and a good intubat-
ing view is obtained.
  
From this position, the practitioner requests the tube from the
cricoid pressure technician. Once received, the practitioner inserts
it with the right hand guiding the tip down against the right buc-
cal mucosa to avoid obstructing the intubating view (Fig. 222.6). A
common mistake is to try to slide the tube straight down the center.
This obstructs the view and increases the probability of accidental
esophageal intubation. The endotracheal tube is advanced until the
tip is at least 2 to 3 cm beyond the vocal cords.
Rarely, the tip of the epiglottis is encountered. If this is the case, lift
the epiglottis with the blade tip. Using the right hand, after handing
the tube back to the technician, replace the pressure on the cricoid
cartilage that is being applied by the pressure technician. Consider
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B
Fig. 222.6  Insertion of tube with laryngoscope in place. (A) Insert the
tube with the tip initially against the right buccal mucosa so that a clear view
of the vocal cords can be maintained at all times. As it advances, watch the
tube pass through the cords. (B) The tube is correctly placed when the tip is
2 to 3 cm beyond the vocal cords.
OLEM to manipulate the trachea to obtain a good view (commonly,
the cricoid pressure technician will use too much pressure). When a
good view is obtained, have the cricoid pressure technician replace
the same amount of pressure to maintain a constant view. The tech-
nician then hands the endotracheal tube back to the practitioner,
who intubates the trachea as described previously. The tip and cuff
of the ET tube must be visualized passing through the vocal cords to
ensure proper placement. The tube insertion depth can be approxi-
mated by the Chula formula: 4 cm + (patient height in inches/4). In
most patients, this will be between 21 and 23 cm. Inflate the balloon
according to manufacturer directions. Most balloons take 10 mL of air. 
Confirm Placement
Listen at the stomach to assess for an esophageal intubation, and
then listen in each axilla to assess for equal breath sounds. Listening
over the anterior chest is not as accurate as listening in the axil-
lae for determining proper tube placement (Fig. 222.7). Asymmetric
breath sounds suggest that the mainstem bronchus was intubated—
typically, the right mainstem bronchus because it is more vertical
than the left mainstem bronchus.
Next, use a secondary device to ensure proper placement. The
devices available include bulb-type and syringe-type esophageal
detector devices or carbon dioxide colorimetric devices. These
devices are attached to the endotracheal tube after intubation. The
bulb device is squeezed shut before being placed on the tube. If the
bulb reinflates, the tube is in the proper location. One way to remem-
ber this is “reinflate means you’re great.” If a syringe device is used,

Fig. 222.7  Auscultation points for confirmation of placement are over the
stomach (should be lack of sound) and the axillae. The same locations should
be used to auscultate in the adult.
Fig. 222.8  Secure the tube to minimize patient discomfort while main-
taining correct positioning. Consider a bite block.
aspiration of more than 30 mL of air indicates proper tube placement.
Colorimetric devices, which change from yellow to purple with an
elevated carbon dioxide level, are also useful. These end-tidal car-
bon dioxide detectors are placed between the tube and the bag-valve
device after intubation: the detectors will change from purple to yel-
low if the tube is in the proper location. An easy way to remember
the colors is “yellow, yellow in the bellow.” Carbon dioxide capno-
graphic devices should show adequate respiratory waveforms. These
forms are characterized by three phases: baseline, rapid upstroke, and
long alveolar plateau, similar to a small “r” written in longhand.  The tip of the blade can be inserted gently into the vallecula, if needed.
Secure
Secure the tube with umbilical tape or a commercial device made
for that purpose (Fig. 222.8). Avoid using tape or tincture of benzoin
on the face because facial irritation can cause at least temporary skin
changes. Consider inserting a bite block if the patient might bite the
tube. Insert a nasogastric or orogastric tube. Use chemical restraints
with appropriate monitoring to prevent tube removal. Finally, take
a chest radiograph to ensure proper depth and placement. The ideal
location is to have the tube 2 to 3 cm above the carina. 
Video-assisted Intubation (GlideScope)
Video-assisted intubation is indicated for both routine and difficult
intubations and is very useful in the patient with an immobilized
cervical spine. The GlideScope was the first to market of the newer
generation video-assisted laryngoscopes (Fig. 222.9); it is likely the
most studied. In the patient with tongue edema, GlideScope has
been shown to have an advantage over the Macintosh blade. It can
be used in pediatric patients that weigh as little as 1.8 kg. There are
no contraindications for using this device.
Preparation
Attach the GlideScope blade to the monitor using the video cable.
If a single-use STAT blade is to be used, insert the baton into the
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222 –––– TRACHEAL INTUBATION 1481
Fig. 222.9  Video-assisted laryngoscope (GlideScope). (Courtesy Verathon
Inc.)
STAT blade. A click will be heard when the baton is in place. Turn
on the device, and it is ready to use. Next, prepare the ET tube by
inserting the GlideRite malleable stylet. The curve or angle of the
stylet should somewhat match the hockey stick shape of the GlideS-
cope blade, usually about 35 degrees. While use of a stylet generally
facilitates manipulation of the ET tube, it is not required. 
Technique
Similar to traditional intubation, open the patient’s mouth and insert
the blade into the midline of the oral cavity. Avoid any sweeping of the
tongue; instead insert under direct visualization down the midline of the
tongue, and finally over the tongue at the base. Next, turn your atten-
tion to the monitor and observe while advancing the blade through the
pharynx. Continue to advance until the epiglottis is observed. Lift the
blade, if necessary, to elevate the epiglottis and observe the vocal cords.
If the glottis is not well visualized, tilt the handle back slightly.
Next, advance the ET tube under direct visualization, past the
tip of the GlideScope and toward the vocal cords. Before inserting
the ET tube through the vocal cords, withdraw the GlideRite stylet
approximately 2 cm. Turn your attention back to the monitor and
advance the ET tube through the vocal cords. Advance until the
marker line reaches the glottis. Inflate the ET tube cuff and finish
withdrawing the stylet. Confirm proper placement of the ET tube
using the previously described methods.
Editor’s note: Novice operators should probably practice use of the
GlideScope on mannequin models and for routine intubations before
having to use it as a rescue device for a difficult intubation. Otherwise, the
time to intubation may actually be longer than with direct laryngoscopy. 
Bougienage-assisted (Bougie) Intubation
Many critical care clinicians carry a bougie with them in their coat
pocket in case there is need for emergency intubation in a difficult air-
way. Similar to traditional intubation, open the patient’s mouth and
insert the laryngoscope blade into the midline of the oral cavity. Using
the laryngoscope in the usual manner, attempt to find the epiglottis.
If you can find the epiglottis, you will be able to intubate the patient.
Find the best view of epiglottis possible and insert the bougie with the
distal coudé tip (hockey stick configuration) turned upward against
the epiglottis. Riding the epiglottis inward (bougie tip pressed upward
1482 HOSPITALIST
against undersurface of epiglottis), the distal tip will enter the glottis
and then the trachea. Confirmation of placement in the trachea is
made by feeling the tracheal rings. If unable to feel the tracheal rings,
when you continue to advance the tip, at some point it will meet
resistance or stop. This happens when the tip reaches the carina or a
bronchial branch. Conversely, if in the esophagus, the bougie will not
meet resistance; instead, it will continue to advance.
Next, the endotracheal tube must be advanced over the bougie.
Having an assistant available is very helpful for this step. Make sure
there is adequate lubrication on the outside of the endotracheal
tube; have the assistant get the endotracheal tube started down the
bougie and advance it until you can take it further. While continu-
ing to hold the laryngoscope in place with your left hand, advance
the endotracheal tube down the remainder of the bougie and into
the trachea. The assistant should be holding the other end of the
bougie steady and prevent it moving while you advance the endotra-
cheal tube. Occasionally, the endotracheal tube will get held up on
cartilage when advancing; gently rotating it counterclockwise up to
90 degrees will usually ease it into place. It may need to be counter-
rotated gently several times as you advance the tube into its final
position. When the tube is in the correct position, withdraw the
bougie, remove the laryngoscope, and confirm proper placement.
Rapid-Sequence Intubation
RSI is an important technique to assist intubation in patients who
are combative. It prevents laryngospasm and can have other thera-
peutic benefits. The prime candidate has been the “can’t intubate,
can’t ventilate patient,” but in actual practice this is rare. Airway
assessment before the procedure should detect patients at risk for
this problem, and often alternative methods can be used. Rarely,
this may occur without warning, so an intermediate airway, such as
an LMA or Combitube, as well as a cricothyroidotomy kit, needs
to be readily available. There are many medications from which to
choose, and the topic can be complex. Here, only the most common
technique is explained, and this will be suitable for patients without
suspected bronchospasm or increased intracranial pressure.
  
• Choose the paralytic agent. Succinylcholine 1.5 mg/kg is the first
choice unless contraindicated. The vagal stimulatory effects of
succinylcholine can cause bradycardia, hypotension, and other
muscarinic effects. Contraindications are conditions in which
hyperkalemia may be worsened, where there is concern that in-
creased intracranial pressure or intraocular pressure may worsen
the patient’s condition, or there is a risk of malignant hyperther-
mia such as the following:
• End-stage renal disease with missed dialysis
• Rhabdomyolysis (e.g., patients found down for a long time)
• Muscular dystrophy of any type
• History of spinal cord injuries
• Open globe injury (of controversial significance)
• Conditions under which there may be increased intracranial
pressure
• History of a recent cerebrovascular accident
• Burns of greater than 10% body surface area more than 24
hours old but incompletely healed
• Patients with crush injuries more than 24 hours old
• Family history of an anesthetic reaction
• If succinylcholine is indicated, then a standard dose is 2 mg/kg intra-
venously. It should not be given until other preparations are made.
• If succinylcholine is contraindicated, rocuronium 0.6 to 1 mg/kg
is considered by many to be the best alternative. It has a rapid on-
set of action, but paralysis lasts an average of 50 minutes (possibly
longer in geriatric patients), placing it second to succinylcholine.
Vecuronium and atracurium are intermediate-acting agents with
an onset of action of approximately 3 minutes and a duration of
action of 30 minutes. Mivacurium has an onset of action of 2 to 3
minutes and a duration of action of 15 to 20 minutes. Fortunate-
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ly, these drugs have minimal cardiovascular effects and, with the
exception of mivacuronium, cause minimal release of histamines.
• Choose the sedative agent. Etomidate (0.3 mg/kg intravenous
perfusion) is the most common choice because of its lack of car-
diovascular depression and versatility. Other agents include keta-
mine 1 to 2 mg/kg in bronchospasm, midazolam 0.2 mg/kg, or
thiopental 3 mg/kg in increased intracranial pressure. Each has
its benefits and drawbacks, which should be studied before use.
• Choose the adjuncts. Although not indicated in all cases, lido-
caine 1.5 mg/kg is considered useful in patients with bronchos-
pasm or concerns for increased intracranial pressure. Atropine
should be administered to children younger than 10 years at
0.02 mg/kg (minimum 0.1 mg, maximum 1 mg) to inhibit reflex
bradycardia before the use of succinylcholine. Atropine should
be considered for any adult who is receiving either ketamine or a
second dose of succinylcholine during the intubation or reintu-
bation procedure to reduce complications.
• Three minutes before intubation, give adjuncts.
• Two minutes before intubation, give a priming dose (10% of the
dose drawn up in the syringe) of succinylcholine (if this medica-
tion is to be used for paralysis).
• One minute before intubation, give the paralytic agent (succi-
nylcholine or rocuronium), followed immediately by the sedative
(etomidate, midazolam, or thiopental). Begin giving the patient
eight vital capacity breaths.
• Assess for adequate paralysis by gently stroking the eyelashes. If
there is no response, proceed with intubation as described in pre-
vious sections. 
Nasotracheal Intubation
Nasotracheal intubation generally requires the patient to be breath-
ing spontaneously and has the complications of nasal bleeding and
sinusitis. It is of limited usefulness, except in cases where awake intu-
bation is required. This technique is relatively contraindicated in
the combative patient and in those patients with a coagulopathy or
bleeding diathesis. It is important to examine the facial anatomy and
nares for distortion, trauma, or other contraindications. If no contra-
indications are noted, use the side with the larger passage. If they are
equal, use the right side because this helps reduce trauma from the
tube bevel. Use a 6.5-mm tube or smaller, if anatomically indicated.
Preparation
Most nasotracheal intubation failures are the result of inadequate
preparation.
  
• Get an assistant.
• Explain the procedure to the patient. This is the most important
step.
• Place the patient in the standard “sniffing” position, as described
previously.
• Determine if nasal vasoconstriction is safe. If the patient appears
to be at risk for limited perfusion to the nasal area from either
local or systemic disease, avoid the use of a vasoconstrictor.
• Prepare the nasopharyngeal path. Place 15 mL of 2% lidocaine
with epinephrine (or plain lidocaine, if vasoconstriction is con-
traindicated) in a Toomey syringe.
• Have one assistant keep the syringe upright to prevent spillage
and connect the Toomey syringe to a small Foley catheter. A red
Robinson catheter is preferred.
• While an assistant continues to hold the catheter upright, lubri-
cate the distal catheter with a water-soluble lubricant.
• With the free hand, apply cricoid pressure. This facilitates entry
of the catheter into the airway. Insert the catheter through the
nose to the level of the vocal cords. This is approximately twice
the distance from the front of the lips to the tragus of the ear.
Ideally, the patient will cough, indicating vocal cord stimulation.
 222 –––– TRACHEAL INTUBATION 1483

• C
 heck the patient and the respiratory setup frequently. Carbon
dioxide detectors and whistles can be used to confirm expiratory
efforts. 
Assistant’s hand
Complications
• S  hort-term laryngeal edema: Sore throat occurs in almost every
patient after extubation (repeated attempts at intubation by un-
skilled personnel may cause enough edema to preclude intuba-
Magill tion by highly skilled clinicians).
forceps • Trauma
• Broken teeth
Do not • Oral lacerations or ulcerations (lip, tongue, pharynx, esopha-
grasp cuff gus, or trachea)
with forceps • Bleeding, hematoma, or abscess formation as a result of trau-
ma
• Avulsion of arytenoid cartilage
• Hypoxia resulting from
• Long duration of procedure
• Esophageal intubation (most commonly results from not visu-
alizing the vocal cords)
• Intubation of a bronchus
Fig. 222.10  Nasotracheal intubation using a laryngoscope and Magill for- • Failure to recognize esophageal or bronchial intubation
ceps. The forceps are not used to pull the tube; rather, they serve to guide • Pneumothorax
the tip of the tube through the vocal cords while an assistant advances the • Failure to secure the placement
tube. The cuff is frequently damaged if it is grasped. • Failure to recognize misplacement of the tube
• Aspiration of vomited material, especially in unconscious or
• H  ave the assistant turn the syringe upright and administer about semiconscious patient
5 mL of the solution while the patient coughs, which helps dis- • Laryngospasm
perse the solution. • Hypertension/hypotension
• Withdraw the catheter, administering another 5 mL of the solu- • Bradycardia
tion as the catheter is removed. • Tachycardia with or without arrhythmias
• Administer the last 5 mL at the Kiesselbach plexus in the anteri- • Sequelae of long-term endotracheal tube placement
or nasal passage of the septum. Allow the solution to work while • Nosocomial infection
lubricating the endotracheal tube and checking the balloon.  • Pneumothorax
• Corneal abrasions
• Epistaxis
Two-Handed Nasotracheal Intubation Technique • Sinusitis
• S  tanding at the side of the patient, insert the tube so the leading • Vocal cord damage or paralysis (left cord more frequently in-
edge of the bevel is away from the septum. If the left nostril is volved than right)
used, the tube will be initially inserted with most of it positioned • Tracheomalacia and stenosis (occur more frequently in men;
above the face and scalp, and then rotated 180 degrees once the are more common with older tubes that use higher cuff pres-
turbinates are passed. sures)
• Once the tube is about halfway in, apply cricoid pressure with the • Tracheoesophageal fistula
nondominant hand. Remember that unlike in training models, • Innominate artery erosion by endotracheal cuff
  
the trachea is a mobile structure. Use this advantage to move the
Note: Rarely are teeth broken with nasotracheal intubation.
trachea to assist placing the tube.
However, acute epistaxis and nasal trauma can result. Pulmonary
• Lean forward and listen for breath sounds through the end of the
infection can also be caused by nasal flora introduced through the
tube, adjusting both the tube and the trachea to create maximum
nasotracheal tube. 
breath sounds. Once resistance is felt at the vocal cord opening,
await inspiration and then guide the tube past the vocal cords. CPT/Billing Codes
This is often easily felt with the hand manipulating the trachea.
• Pass the tube 26 to 28 cm in an adult, depending on the size of 31500 Intubation, endotracheal, emergency procedure
the patient.
• Check and secure the tube in the standard fashion (see Fig. 222.8).  ICD-10-CM Diagnostic Codes
• Direct visualization can also be used for nasotracheal intubation. E87.2 Acidosis
With the patient supine, use the laryngoscope in the same man- E87.3 Alkalosis
ner as for standard intubation. While visualizing the cords, use E87.4 Acid-base mixed disorder
the Magill forceps to grasp the tube already inserted through the I46.9 Cardiac or cardiorespiratory arrest unspecified
nasopharynx and pass it through the cords (Fig. 222.10). Avoid I50.1 Pulmonary edema (left heart failure)
tearing the cuff when grasping the tube with forceps.  J44.9 Chronic obstructive bronchitis, unspecified
J44.1 Chronic obstructive bronchitis, with (acute)
Postprocedure Patient Care exacerbation
J43.9 Emphysema, not otherwise specified
O
•  rder daily chest radiographs to verify tube placement. J45.22 Asthma, extrinsic with status asthmaticus
• The respiratory services department of the hospital usually sup- J45.902 Asthma, unspecified with status asthmaticus
plies the ventilator, tape, and other equipment as well as provid- J95.2 Pulmonary insufficiency following nonthoracic
ing care; however, the clinician is ultimately responsible. surgery

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1484 HOSPITALIST

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RECOMMENDED READING
Ambrosio A, Pfannenstiel T, Bach K, Cornelissen C, Gaconnet C, Brigger
MT. Difficult airway management for novice physicians. A randomized
trial comparing direct and video-assisted laryngoscopy. Otolaryngol Head
Neck Surg. 2014;150(5):775–778.

Descargado para YESSENIA KATHERIN ARBAYZA AVALOS (yarbayzaa1@upao.edu.pe) en Antenor Orrego Private University de ClinicalKey.es por Elsevier en mayo 30, 2020.
Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.