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Endotracheal tube (ETT) insertion (intubation)

How to insert an endotracheal tube (intubation) for doctors and medical students


What is an endotracheal tube?

  • A fexible plastic tube with cuff on end which sits inside the trachea (fully secures airway – the gold standard of airway management)
  • Attached to ventilation bag/machine
  • Use:
    • Ventilation during anaesthetic for surgery (if muscle relaxant is required, long case, abdominal surgery, or head positing may be required)
    • Patient can’t protect their airway (e.g. if GCS <8, high aspiration risk or given muscle relaxation)
    • Potential airway obstruction (airway burns, epiglottitis, neck haematoma)
    • Inadequate ventilation/oxygenation (e.g. COPD, head injury, ARDS)
  • Rapid sequence induction (RSI) intubation
    • Procedural variation using rapid anaesthetisation with cricoid pressure to prevent aspiration while airway is quickly secured
    • Used for patients at risk of aspiration e.g. non-fasted patients
  • Size: 8mm diameter for men, 7mm diameter for women


How to insert an endotracheal tube (ETT)

  • Equipment required for ET tube insertion
    • Laryngoscope (check size – the blade should reach between the lips and larynx – size 3 for most patients), turn on light
    • Cuffed endotracheal tube
    • Syringe for cuff inflation
    • Monitoring: end-tidal CO2 monitor, pulse oximeter, cardiac monitor, blood pressure
    • Tape
    • Suction
    • Ventilation bag
    • Face mask
    • Oxygen supply
    • Medications in awake patient: hypnotic, analgesia, short-acting muscle relaxant (to aid intubation)


Video on how to insert an endotracheal tube


  • Laryngoscope technique
    • Give medications if required
    • Pre-oxygenate patient with high concentration oxygen for 3-5mins
    • Position patient
      • Neck flexed to 15˚, head extended on neck (i.e. chin anteriorly), no lateral deviation
    • Stand behind the head of the patient
    • Open mouth and inspect: remove any dentures/debris, suction any secretions
    • Holding laryngoscope in left hand, insert it looking down its length
    • Passing the tongue
      • Slide down right side of mouth until the tonsils are seen
      • Now move it to the left to push the tongue centrally until the uvula is seen
    • Advance over the base of the tongue until the epiglottis is seen
  • Insertion technique
    • Apply traction to the long axis of the laryngoscope handle (this lifts the epiglottis so that the V-shaped glottis can be seen)
    • Insert the tube in the groove of the laryngoscope so that the cuff passes the vocal cords
    • Remove laryngoscope and inflate the cuff of the tube with ̴ 15ml air from a 20ml syringe
    • Attach ventilation bag/machine and ventilate (~10 breaths/min) with high concentration oxygen and observe chest expansion and auscultate to confirm correct positioning
    • Consider applying CO2 detector or end-tidal CO2 monitor to confirm placement
    • Secure the endotracheal tube with tape
      • if it takes more than 30 seconds, remove all equipment and ventilate patient with a bag and mask until ready to retry intubation


Other airway pages

How to insert a nasopharyngeal airway (NPA)

How to insert a supraglottic airway

How to insert an oropharyngeal airway

What is a tracheostomy?