Videos

Tracheal intubation animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Equipment needed

  • Personal protective equipment, including gloves

  • Laryngoscope (ensure light is working)

  • Cuffed tracheal tube; an average size adult will require a size 7 or 8 cuffed tracheal tube, which corresponds to a 7 or 8 mm internal diameter. (Paediatric intubation is done with uncuffed tubes and should be carried out by an experienced clinician.)

  • Syringe for inflating and deflating cuff (ensure cuff inflates and deflates before intubation)

  • Bag-valve apparatus, including mask for pre-oxygenation

  • Suction

  • Oxygen

  • End-tidal CO₂ monitor (if available)

  • Cotton tape to secure the tube

  • Ventilator

  • Magills forceps (in case of foreign material in the oropharynx)

  • Gum elastic bougie (to use as guide wire in case of difficult intubation)

Contraindications

Lack of skilled, experienced personnel is a contraindication; tracheal intubation should be used only when trained personnel are available to carry out the procedure, with a high level of skill and confidence.

Note: Laryngospasm due to anaphylaxis, an inhalation burn, near drowning, or a foreign body will not improve significantly with simple airway manoeuvres, and occasionally tracheal intubation may not even be possible. In this case, the patient may need an advanced airway procedure such as cricothyroidotomy.

The tracheal tube has generally been considered the optimal method of managing the airway during cardiac arrest, and is indicated in an ongoing resuscitation event. It enables delivery of continuous chest compressions, without pausing during ventilation. Most patients with return of spontaneous circulation remain comatose and require tracheal intubation and mechanical ventilation.[102] 

Tracheal intubation is also used for airway management during general anaesthesia.

Complications

In inexperienced hands, attempts at tracheal intubation can have negative consequences for the patient. The incidence of incorrect intubation varies with experience, some studies showing that rates of inadvertent oesophageal intubation can be as high as 50% in inexperienced hands.[103] Harm from unrecognised oesophageal intubation can be avoided by reducing the rate of oesophageal intubation, together with prompt detection and immediate action when it occurs.[104] The detection of sustained exhaled carbon dioxide using waveform capnography is the primary diagnostic test used to exclude oesophageal placement of an intended tracheal tube.[104]

Complications of tracheal intubation include:

  • Failed intubation

  • Spinal cord and vertebral column injury

  • Occlusion of central artery of the retina and blindness

  • Corneal abrasion

  • Trauma to lips, teeth, tongue, and nose

  • Hypertension, tachycardia, bradycardia, and arrhythmia

  • Raised intracranial and intraocular tension

  • Laryngospasm

  • Bronchospasm

  • Aspiration

  • Laryngeal trauma

  • Cord avulsions, fractures, and dislocation of arytenoids

  • Airway perforation

  • Nasal, retropharyngeal, pharyngeal, uvular, laryngeal, tracheal, oesophageal, and bronchial trauma

  • Oesophageal intubation

  • Bronchial intubation.

Aftercare

If the tube is not correctly positioned, the stomach or the right lung only may be ventilated. Deflate the cuff and re-position the tube and again auscultate to check position.

Continue to resuscitate the patient in keeping with life support guidelines using ABCDE principles.