Lab NO 4 Endotracheal Intubation

ENDOTRACHEAL INTUBATION
OBJECTIVE
The student will be able to demonstrate proper intubation technique to include
selection of appropriately sized equipment in a laboratory and clinical setting. This
will be done following aseptic guidelines and in a competent manner as determined
by lab and clinical instructors. It is assumed that the student is either anticipating a
required intubation (such as with an expected premature delivery) or that the patient is
being manually ventilated while the student obtains equipment and washes his or her
hands.
TASK A: State Indications.
It is important to understand and commit to memory the indications for intubation.
The four indications are (1) prolonged PPV is required; (2) ineffective bag/mask
ventilation; (3) tracheal suctioning is necessary (short or long term); and (4) the
patient has a suspected diaphragmatic hernia.
TASK B: Obtain and Prepare Equipment.
When it is determined that the patient needs intubation, gather the necessary
equipment. First, select an appropriately sized endotracheal tube (ETT) as shown in
the following table:
After selecting an appropriate Weight Endotracheal tube size
ETT, obtain a wire stylet. The <l,000 g 2.5 ETT
stylet is inserted into the ETT to 1,000-2,000 g 3.0 ETT
make it rigid, facilitating 2,000-3,000 g 3.5 ETT
intubation. >3,000 g 4.0 ETT

Be certain that the tip of the stylet does not extend beyond the tip of the ETT because
it may cause trauma. Now gather the appropriate suction equipment and assemble as
necessary. Obtain a laryngoscope and an appropriately sized blade. Use a size 0 blade
for premature neonates and a size I blade for term neonates. Attach the blade to the
laryngoscope to assure proper function of the light. Next, a shoulder roll should be
obtained to help hyperextend the neck. Obtain a roll of 1/2 -3/4 inch tape or some
other device to secure the ETT. A pair of scissors is invaluable and should be found at
this time.
A properly functioning resuscitation bag and mask must be set up and ready for use at
the bedside. For this intubation, eye protection and exam gloves should be obtained.

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Lab NO 4 Endotracheal Intubation

Finally, solicit the help of another person who will monitor the patient and assist as
required during the procedure.
TASK C: Wash Hands.
Washing hands before performing an intubation will greatly reduce the risk of
contaminating the endotracheal tube and introducing organisms to the trachea.
TASK D: Place Gloves and Eye Protection.
Because of the invasive nature of tracheal intubation, eye protection and gloves are
required. Put them on at this time.
TASK E: Position the Patient.
Place the patient in the supine position, the head straight, and the neck extended
slightly. Placing the shoulder roll under the shoulders helps to maintain the desired
head extension.
TASK F: Hyperoxygenate the Patient.
Hyperoxygenate the patient with 1.0 FiO2 using a manual resuscitation bag, Just
before performing the intubation.

TASK G: Perform the Procedure.

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Lab NO 4 Endotracheal Intubation

You are now ready to intubate the patient. The laryngoscope is picked up in the left
hand and the blade locked in place so that the light illuminates. The blade is inserted
into the mouth until the tip of the blade reaches the approximate level of the base of
the tongue. At this point, the blade is lifted, exposing the area of the pharynx above
the epiglottis. Secretions should be suctioned out at this point to improve visibility.
The epiglottis is visualized and the tip of the laryngoscope blade is placed in the
vallecula, which is the pouch between the base of the tongue and the epiglottis. Gentle
lifting of the laryngoscope raises the epiglottis and exposes the vocal cords and the
trachea. When lifting the laryngoscope to visualize the trachea, lift up and away from
the roof of the mouth. Never use the upper gums as a fulcrum to pry the laryngoscope
handle downward while raising the blade tip.
Using the right hand, the endotracheal tube is inserted into the trachea, the tip going
just beyond the vocal cords. The endotracheal tube is now held in place with the right
hand, and the laryngoscope blade is gently removed. The stylet is then removed from
the ETT. The tube must be securely held while removing the stylet to prevent
accidental extubation.

TASK H: Hyperoxygenate and Auscultate.

PPV is immediately initiated and the lungs auscultated for breath sounds. Good
aeration in both lungs with adequate chest excursion indicates good tube position.
Auscultation above the stomach will also help to rule out an esophageal intubation.
The practitioner must be cautious, however, because breath sounds may be
transmitted and heard over the stomach.
TASK I: Secure the Tube.
Before securing the tube, the centimeter marking on the tube that is at the level of the
lips should be noted for future reference. When the chest x-ray is returned, this
information facilitates any necessary movement of the tube to achieve proper
placement. The tube is then appropriately secured to the patient.

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Lab NO 4 Endotracheal Intubation

TASK J: Obtain Chest X-Ray.

A chest x-ray is then obtained to verify proper placement of the ETT above the carina.
Ideally, the tip of the tube should be midway between the carina and the clavicles.
TASK K: Record Results.
Following completion of the intubation, the procedure is documented in the patient
chart. Charting should include the size of endotracheal tube, tube placement on chest
x-ray, tube marking at patient lip, oxygenation status, breath sounds, pulse rate, and
patient toleration of procedure.
TASK L: Monitoring.
The appropriate timing and method of monitoring the equipment and the patient
should be determined. This is based on any orders, written department standards, and
patient condition.

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Lab NO 4 Endotracheal Intubation

PERFORMANCE EVALUATION
INTUBATION

Student Name __________________ Date: Lab ___________________

Lab: Pass______ Fail______ Clinical: Pass______ Fail______

Instructors Name _______________

PASSING CRITERIA:
Obtain 90 percent or better on the procedure. Tasks indicated by a dot (●)
must receive at least 1 point or the evaluation is terminated. The procedure must be
performed within the designated time or the performance receives a failing grade.

SCORING:
2 Points – Task performed satisfactorily without prompting.
1 Point – Task performed satisfactorily with self- initiated correction.
0 Point – Task performed incorrectly or with prompting re1quired.
NA – Task not applicable to the patient care situation.

TASKS:

• A. State indications for intubation

B. Obtain equipment
• Appropriately sized endotracheal tubes and stylet.
• suction equipment
• laryngoscope and appropriately sized blade;
check for proper function
• shoulder roll
• tape or other securing device
• scissors
• resuscitation bag and mask attached to 100% oxygen source
• eye protection gloves
• another person to monitor vital signs and assist
• C. Wash hands
• D. Put on eye protection and gloves
• E. Position the patient
• F. Hyperoxygenate the patient
G. perform the procedure
• insert blade into mouth with laryngoscope in left hand
• insert blade to base of tongue

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Lab NO 4 Endotracheal Intubation

• lift the blade up and away from the roof of mouth

suction as needed
• visualize epiglottis and place tip of blade into the vallecula
• gently lift epiglottis and insert ETT into trachea to proper depth
• secure tube and remove blade and stylet

• H. Hyperoxygenate and auscultate

• I. Secure the tube with tape or device
• J. Obtain chest x-ray for tube placement
• K. Record results and observations
• L. Monitor appropriately

SCORE:
Lab: ________ points out of _________ (52) _________%

Time: _______ out of possible 15 minutes.

STUDENT SIGNATURES INSTRUCTOR SIGNATURE

_______________________ ________________________