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Endotracheal intubation is an essential resuscitative procedure in the emergency setting. Direct and video laryngoscopy are the two most common approaches utilized for endotracheal intubation. Endotracheal intubation indications include altered mental status, poor ventilation, and poor oxygenation. This activity describes the technique of endotracheal intubation and highlights the role of the interprofessional team in managing patients who undergo this procedure. Objectives: Identify the indications for endotracheal tube intubation techniques. Describe the equipment, personnel, preparation, and technique necessary for endotracheal tube intubation. Outline appropriate evaluation of the potential complications and clinical significance of endotracheal tube intubation techniques. Summarize interprofessional team strategies for improving care coordination and communication to advance endotracheal tube intubation techniques and improve outcomes. Access free multiple choice questions on this topic.

Endotracheal intubation is an essential skill performed by multiple medical specialists to secure a patient’s airway as well as provide oxygenation and ventilation. There are multiple techniques available, including the visualization of the vocal cords with a laryngoscope or video laryngoscope, direct placement of the endotracheal tube into the trachea via cricothyrotomy, and fiberoptic visualization of the vocal cords via the nasal or oral route. This section will focus on intubations in the emergency department using direct and video laryngoscopy.

Assessment for intubation should take into consideration potential complications. Hypoxemia is a feared complication of intubation that may be precipitated by multiple attempts with poor oxygenation between attempts, misplaced endotracheal tubes, and failed intubation. Oxygenation can be optimized by pre-oxygenation and apneic oxygenation. To avoid an unrecognized misplaced endotracheal tube, immediate confirmation of the tube position should take place. In cases of anticipated difficult airways, physicians should consider if RSI, DSI, or awake intubation using direct, video, or fiberoptic laryngoscopy is most appropriate for the patient. Cardiovascular complications can arise as a result of direct pharyngeal manipulation as well as induction medications. Bradycardia can result from vagal stimulation during direct laryngoscopy. Some sedative medications can cause hypotension that can lead to hemodynamic compromise and cardiac arrest during the intubation of critically ill patients. Appropriate resuscitation before intubation can mitigate some of these risks. Patients should also have large-bore and reliable intravenous or intraosseous access to administer intubation and resuscitation medications if required. Other complications include laceration to the oropharynx from direct manipulation, trauma to the teeth, and aspiration of vomit or objects from the oropharynx, such as dentures. Complications after intubation include uvular and mucosal necrosis from the pressure of the endotracheal tube against these anatomical structures. Tracheal rupture is extremely rare but can result from tracheal necrosis from cuff overinflation or direct trauma from the tube or stylet. Using manometry to inflate the cuff to a goal of 20-30cm water can prevent some of these complications.[16]