Step-by-Step Guide to Intubation

Learn the procedures, steps, risks, and requirements for performing intubation.

Intubation can mean the difference between life and death. Doctors, respiratory therapists, and some nurses perform this procedure on patients who cannot breathe on their own. Patients may need to be intubated when anesthetized during surgery or because of a severe illness that affects their respiratory system.

This article focuses on the art and science of intubation, one of the most vital procedures for nurses and other medical staff. Healthcare professionals who master this skill can help save more lives and contribute to higher rates of patient satisfaction.

(Click here to see our full list of the most common nursing duties and responsibilities).

Intubation is an essential step for surgeries and other lifesaving measures. This important skill can be exciting yet daunting for new healthcare professionals. It’s especially important for Advance Practice Registered Nurses (APRNs), like Nurse Anesthetists, to learn the proper method for intubation in a healthcare environment.

Intubation Definition

What Is Intubation?

Upon entering the medical field, most aspiring nurses and healthcare professionals quickly learn the importance of proper airway management and, more specifically, the role of intubation in that process. Intubation is a valuable skill that some aspiring nurses should consider learning for their career. It’s also practiced in the field of emergency medical services (EMS).

Endotracheal intubation is the process of inserting a tube through the patient’s mouth and into their airway. This is done for patients who need to be placed on a ventilator during anesthesia, sedation, or severe illness.

Nasogastric intubation is the insertion of a plastic tube (nasogastric tube or NG tube) through the nose, past the throat, and into the stomach.

Nasotracheal intubation is the passing of an endotracheal tube through the naris into the nasopharynx and the trachea.

Orogastric intubation is the insertion of a plastic tube (orogastric tube) through the mouth.

Orotracheal intubation is a specific type of tracheal tube that is usually inserted through the mouth (orotracheal) or nose (nasotracheal).

Fiberoptic intubation is a technique in which a flexible endoscope with a tracheal tube loaded along its length is passed through the glottis.

Intubation vs. Tracheostomy

Some people confuse the terms “intubation” and “tracheostomy.” However, these two concepts are different.

Intubation is the process of inserting a tube through the mouth and then into the airway. This procedure is done to support a patient’s breathing when placed on a ventilator.

Tracheostomy is a medical procedure in which healthcare professionals will create an opening in their patient’s neck to place a tube into their patient’s windpipe. This allows air to enter the lungs.

When a trach is placed, the patient may be able to breathe without the aid of a ventilator. Typically, a patient is intubated for the sole purpose of providing oxygen through a machine (i.e. for surgery, sedation, or illness).

What Is the Purpose of Intubation?

Intubation is a relatively common procedure that’s performed on patients who can’t maintain their airway, patients who can’t breathe without assistance, or a combination of both.

Common reasons for intubation:

1. The patient will undergo general anesthesia.
2. The patient suffers from respiratory failure. There are various reasons why a patient may be too ill to breathe on their own:
   • They may have suffered an injury to their lungs.
   • They might have severe pneumonia.
   • They may have a breathing problem, like chronic obstructive pulmonary disease (COPD).

How Long Does It Take to Perform Intubation?

In most cases, intubation can be performed in as little as 30 seconds.

If there aren’t any complications, the entire process (from prep to completion) shouldn’t take more than five minutes. Once it’s complete, an overseeing physician will typically check the tube’s placement, listen to the patient’s breathing, monitor their CO2 levels, or take a chest X-ray.

Who Performs Intubation?

Intubation can be performed by various healthcare professionals, such as physicians, respiratory therapists, anesthesiologists, Nurse Anesthetists, and other Advance Practice Registered Nurses (APRNs).

(Click here to learn how to become a Nurse Anesthetist).

Some EMTs and paramedics may also perform intubation, and in veterinary medicine, the procedure is usually performed by veterinarians or veterinary technicians.

Although intubation is not typically performed by most RNs, some states, like Nevada, allow Registered Nurses to intubate patients if they have completed special training (i.e. advanced cardiac life support training). In addition, nurses who work in emergency medicine or air-and-surface transport may also be allowed to intubate patients.

Training Requirements for Intubation

Intubation requirements can vary and likely depend on your location as well as your profession. It’s important to consult your employer and state governing board.

When it comes to intubation training, most licensed professionals such as anesthesiologists, Nurse Anesthetists, and other Advance Practice Registered Nurses (APRNs) will typically learn how to perform intubation through their advanced nursing and medical training within their respective fields of study.

Aspiring APRNs can start this journey by pursing their BSN degree, followed by their master’s degree in nursing.

Intubation Procedure

A Detailed Guide to Intubation

By reviewing the following steps, you can begin to learn more about the process of intubation. Like any other skill, intubation requires a lot of time and practice to get it right. While in school, try not to feel disheartened if you don’t get it right the first time. And don’t hesitate to ask for help.

Intubation Prep

Preparation can greatly vary from one situation to the next. If you’re facing a difficult airway, you will likely perform an “awake intubation.” This is because a detailed airway examination is time-consuming and often not feasible during an emergency. Using a simple 1-2-3 rule for airway examination will allow you to detect potential airway difficulty in a minute or less.

When possible, however, psychological preparation is always best for the patient. Do your best to explain the procedure in basic terms. Sedatives can also be used to provide comfort without compromising airway patency. According to NCBI, other types of preparation may include “anaesthetizing the airway through topical application of local anesthetics and appropriate nerve blocks.”

Intubation Steps

Here are some of the general guidelines you should follow when intubating a patient in a controlled setting:

1. Before intubation, the patient is usually sedated or not conscious, allowing their mouth and airway to relax. They often lie on their back, while the healthcare professional stands near the top of the bed, facing the patient’s feet.
2. The patient’s mouth is gently opened. Using an instrument to flatten the tongue and illuminate the throat, the tube is steered into the throat and advanced into the airway.
3. A small balloon around the tube is inflated to keep the tube in place and prevent air from escaping. Once this balloon is inflated, the tube must be tied or taped in place at the mouth.
4. Successful placement is checked by listening to the lungs with a stethoscope and can be further verified through a chest X-ray.
   • If faced with a problematic airway, call for the difficult airway cart and ask experienced colleagues to help.
   • Note: Preoxygenation and monitoring during awake intubation is important.
5. The tube is much easier to remove than to place. First, remove the ties or tape that hold it in place. Then, deflate the balloon so that the tube can be carefully pulled out.

Nasal Intubation

In some cases, the breathing tube is placed in the nose rather than the mouth. This is called nasal intubation. It’s performed if the mouth or throat has been injured or requires an operation. During this procedure, the nasotracheal tube (NT) goes into the nose, down the back of the throat, and into the upper airway.

This type of intubation is far less common, though, as it’s easier to intubate using the larger mouth opening. It also isn’t necessary in most scenarios.

Pediatric Intubation

While the size of the equipment is smaller, the actual process of intubation is often the same for adults and older children. However, it’s important to remember that a child requires a smaller tube than an adult. The procedure will also require a higher degree of precision since their airway is also smaller.

Nasal intubation is preferred for neonates and infants. In addition, there are different steps to follow in order to prepare a child for surgery.

Intubation Recovery

Healthcare professionals will remove the tube when their patient no longer has trouble breathing on their own. After the procedure, the patient may have a mild sore throat or experience some difficulty swallowing, but this side effect should dissipate quickly.

Necessary Equipment for Intubation

The suggested supplies for endotracheal intubation include the following:

• Laryngoscope: A metal or plastic device with a handle and curved blade attached to a light. It’s inserted into the top of the throat to visualize the epiglottis.
• Endotracheal tube: A thin, flexible tube outfitted with an inflatable balloon (cuff) that is placed inside the airway.
• Stylet: A slender and pliable rod or wire that is placed inside the tube to make insertion easier.
• Syringe: This instrument is used to inflate the balloon within the tube.
• Suction catheter: A tube to suction out secretions and prevent aspiration.
• Carbon dioxide detector: A device that’s used to check the position of the tracheal tube by measuring exhaled carbon dioxide.
• Oral airway: A device that conforms to the shape of the tongue and is placed inside the mouth to maintain a clear airway.
• Nasal airway: A device that keeps the nasopharyngeal airway clear.
• Bag-valve-mask: A mask used for preoxygenation, which is the administration of oxygen to a patient prior to intubation. This is done to extend ‘the safe apnoea time.’
• Nasal cannula: A tube with two prongs that fit into the nostrils, which provides additional oxygen.

Potential Risks or Complications of Intubation

While this is typically a low-risk procedure, serious intubation risks or complications can include some of the following conditions:

• Trauma to the teeth, mouth, tongue, and/or larynx
• Accidental intubation in the esophagus (food tube) instead of the trachea (air tube)
• Trauma to the trachea
• Bleeding
• Inability to be weaned from the ventilator, requiring a tracheostomy
• Aspirating vomit, saliva or other fluids while intubated
• Pneumonia, if aspiration occurs
• Sore throat
• Hoarseness
• Erosion of soft tissue with prolonged intubation

However, the most common reaction to intubation is a mild sore throat or (temporary) minor difficulty when swallowing.

You can avoid many of these issues by following the appropriate steps. What they say is true: practice makes perfect.

For more professional tips, just keep reading!

Pro Tips for Mastering the Art of Intubation

Many of our pro intubation tips involve technique, knowing your instruments, and handling difficult-to-intubate cases. Here are a few pro intubation tips that may assist you in the future.

• Your initial goal is to find the epiglottis. If you insert the blade extremely slowly into the mouth (about 1 cm at a time), the progression will be tongue, tongue, tongue, tongue, tongue, tip of the epiglottis. This intentionally slow blade insertion technique gives you the best opportunity to slip the blade into the vallecula.
• If you only see pink mush, that’s not the tongue and you need to pull back. Everyone knows what the tongue looks like, and the epiglottis is obviously the epiglottis. So, the only mushy thing in there is the esophagus (and technically the posterior pharynx).
• If you pass the epiglottis, you’re either looking at the trachea, or you’ve snuck the tip of the blade into the esophagus. Keep in mind that, once you lift the esophagus, it opens up as big as the trachea and looks similar to a trachea without vocal cords.
• When using a Miller (i.e. straight) blade, if the tongue is moving in your view, shift the blade slightly to the right of the tongue’s midline. This will pop the tongue over to your left and keep it out of the way.
• With the Macintosh blade, get the mouth to open wide and insert the blade on the far-right side of the mouth. Then, turn the handle of the blade 90 degrees so that the handle is nearly pointing toward the left ear. Advance to just about the depth of the epiglottis and rotate back to the normal position (perpendicular to the teeth and pointing toward the far corner of the room).
• How to confirm you’re in the trachea during emergencies or loud environments: The solution lies with capnography. As soon as you place a tube in the trachea, carbon dioxide will stream from the tube with every exhalation. If you have a quantitative capnometer, you’ll promptly receive a CO2 level in the 30s or 40s. If you have a qualitative capnometer, it will switch from purple to yellow the instant you’re in the trachea, but be extremely careful.
• The key to ventilating is to use the c-clamp technique you’ve seen in class, but make sure you pull the chin up and into the mask. Don’t press the mask down on the face. Hook the chin with one of your fingers and squeeze it up into the mask. Try to put your pinkie on the angle of their jaw and pull up.
• If you perform each of these tips and still can’t see the vocal cords, your patient is likely a “hard tube.” You need to ask someone else to intubate them or try another rescue airway.

Why Should Nurses Learn Intubation?

In an emergency, it is critical that the patient has adequate oxygen in their blood. The primary goal is to prevent brain damage and sustain life. When the patient is unable to breathe, intubation may be necessary to save their life. Some states allow Registered Nurses to intubate patients for emergency purposes or to administer anesthesia.

On the other hand, Advance Practice Registered Nurses have an expanded scope of practice. For instance, intubation is generally included in the scope of practice for a Nurse Anesthetist. Nurse Practitioners are usually permitted to intubate as well.

In the nursing field, you never know when you may encounter life-or-death situations. Reflect on your goals and which specialization is best for you. Ensure that you live in a state that suits your needs. And, of course, make sure you pick the right school.

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