The laryngoscopy is rarely what kills the patient. The peri-intubation physiology is: hypoxemia, hypotension, and acidosis punish the unprepared during the one minute the patient isn't breathing. Resuscitate before you intubate.
This page covers technique and preparation. RSI drug selection, dosing, and sedation protocols are institutional-reference territory and are deliberately not covered.
Suction on and under the pillow. Video and direct laryngoscope. Tube (7.0–7.5 women, 7.5–8.0 men) with stylet or bougie, plus one size down. BVM, OPA/NPA, rescue supraglottic, surgical airway kit locatable in seconds.
Ramp the patient until the external auditory meatus is level with the sternal notch — in the obese patient this takes real blankets. Bed at your umbilicus height.
High-flow non-rebreather at flush rate, or NIV for the shunted lung, for at least 3 minutes. Nasal cannula stays on under the mask for apneic oxygenation during the attempt.
Roles · failure plan · the numbers that abort the attempt
Say the plan out loud: who pushes meds (per your institutional RSI protocol), who hands equipment, who watches the monitor. Name plan B and C — bougie, supraglottic, surgical — before you need them, and the saturation at which you stop and bag.
Right of the tongue · sweep left · advance in steps: tongue, epiglottis, vallecula
Insert the blade along the right side of the tongue and sweep it left out of your view. Advance deliberately, identifying structures as they appear — uvula, epiglottis, then seat the tip in the vallecula and lift along the handle's axis. Don't rock back on the teeth. With hyperangulated video blades, resist burying the blade: a slightly worse view gives an easier tube delivery.
From the right corner of the mouth · watch the cuff pass the cords
Bring the tube in from the corner of your mouth view, not down your line of sight. Pass the cuff just beyond the cords — typical depth at the teeth is about three times the tube size (21–23 cm in most adults). A bougie first, feeling for tracheal rings and hold-up, converts many marginal views into easy tubes.
Continuous waveform capnography · bilateral breath sounds · then the tube holder
Sustained waveform ETCO2 over multiple breaths is the confirmation; everything else — misting, chest rise, auscultation — only supports it. Inflate the cuff to minimal seal, secure the tube, note the depth at the teeth, and get the chest x-ray for position (tip mid-trachea, a few cm above the carina).
Sedation · blood pressure · vent settings · gastric tube
The intubation isn't over when the tube passes. Start post-intubation sedation and analgesia promptly (per institutional protocol), watch the pressure — the catecholamine drop plus positive pressure drops preload — set lung-protective ventilation, and recheck the patient anytime the vent alarms rather than silencing it.
| Check | Standard | Notes |
|---|---|---|
| Waveform ETCO2 | sustained | The gold standard. Colorimetric devices can mislead in arrest and after bagged breaths. |
| Depth at teeth | ~3 × tube size | 21–23 cm typical adult; right mainstem is the commonest malposition — breath sounds louder on the right |
| Chest x-ray | tip above carina | Confirms depth, not tracheal placement — ETCO2 already did that |
| D — Displaced | recheck ETCO2 | Sudden deterioration: is the tube still in? Waveform answers instantly |
| O — Obstructed | pass suction | Kinked, bitten, or plugged — a suction catheter that won't pass is diagnostic |
| P / E | pneumothorax / equipment | Ultrasound or needle the chest if crashing; disconnect and hand-bag to take the circuit out of the equation |
Ear-to-sternal-notch alignment converts more difficult airways than any blade upgrade. In the obese patient, if you didn't build a ramp, you haven't started yet.
Used first-line on marginal views, the bougie raises first-pass success. Feel for the clicks of tracheal rings and distal hold-up; a bougie that slides forever is in the esophagus.
Repeated attempts at a failing plan while the saturation falls is the classic airway death. Two attempts, then change something meaningful — operator, device, or to the supraglottic that buys time.
Induction agents plus positive pressure in a hypovolemic, acidotic patient produces the peri-intubation arrest. The pressure you didn't fix before the tube becomes the code you run after it.
A paralyzed, intubated, awake patient is a catastrophic and invisible failure — the long-acting paralytic outlasts the induction agent. Sedation starts when the tube is secured, not when someone remembers.
A shared mental model — "sat is 94 and falling, we bag at 90" — recruits the whole room's judgment. Quiet cockpits crash; verbalized ones get rescued by the nurse who saw it first.
A starting template for the procedure note. Text in brackets [ ] and pick-lists in { } are fields to complete. Save it as a SmartPhrase, then edit every field to match the actual procedure.
PROCEDURE: ENDOTRACHEAL INTUBATION
Indication: [***]
Consent: {emergent, implied : discussed with patient/family}
Timeout performed. Operator: @ME@
Supervising/assisting: [***]
Preoxygenation: {NRB flush rate : BiPAP : BVM} for *** min,
apneic oxygenation via nasal cannula {yes : no}.
Medications: RSI per institutional protocol [see MAR ***]
Device: {video laryngoscope *** : direct, Mac *** : Miller ***}
Grade of view: Cormack-Lehane {I : II : III : IV}
Adjuncts: {bougie : stylet : external laryngeal manipulation}
Tube: ***.* ETT, cuffed, secured at *** cm at the teeth.
Attempts: *** Lowest SpO2 during attempt: ***%
Confirmation: sustained waveform ETCO2, {bilateral breath
sounds : ***}, CXR ordered for depth.
Complications: {none : hypoxemia : hypotension : ***}
Post-intubation: sedation/analgesia initiated per protocol;
lung-protective ventilation ordered; OG/NG placed {yes : no}.
Electronically signed: @ME@ @TD@ @NOW@
Sample template only — not a validated institutional SmartPhrase. Verify wording, consent, and attestation requirements against your department's documentation, coding, and compliance policies before clinical use.