Virtual Disaster Medicine

Training Center (VDMTC)

Module 1

Basic Review of Endotracheal Intubation

for Providers at a Mass Casualty

Confirmation of Endotracheal Tube Placement

Squeeze the ventilation bag several times to confirm placement of the endotracheal tube in the trachea.

Confirm the presence of CO₂ with a chemical detector.  Alternatively, use a suction device to confirm placement in a large gas containing space.

Watch for the chest rising symmetrically with each delivered breath.

Listen for bilateral and equal breath sounds over the chest.

If you hear breath sounds only over the right side, but not over the left, then the endotracheal tube is probably located in the right mainstem bronchus and needs to be pulled back a little until breath sounds are heard over the left side as well.

Listen over the stomach for evidence of unintentional esophageal intubation.

Further steps after intubation

If you do not hear breath sounds over the chest, or if the patient is difficult to ventilate, or if you hear bubbling over the stomach with each delivered breath, then the endotracheal tube is in the esophagus and must be removed immediately.

Replace the mask and ventilate the patient by mask for 3 to 4 breaths before maneuvers such as changing to a more optimal blade or repositioning the patient are accomplished and a second attempt at endotracheal intubation is done.

If the second attempt fails, try to have a more experienced laryngoscopist attempt the intubation.  This should be done because even though you may be able to ventilate the patient by mask, continued intubation attempts may cause you to loose the ability to mask ventilate due to airway trauma causing edema and/or bleeding.  This concept will be reviewed in detail under our advanced airway management section.

A CO₂ monitor attached to the airway circuit will demonstrate a waveform to confirm successful intubation.  It is necessary to check.  Note – It is possible to insufflate CO₂ into the stomach and get a CO₂ waveform with esophageal intubation, but this waveform will rapidly dissipate (decrease in size over 2-3 breaths) and should be detected by auscultation over the stomach and chest.

If correct placement of the endotracheal tube is confirmed by auscultation and CO₂ measurement, secure the endotracheal tube to the patient with tape, noting the position of the tube in the patient’s mouth (typically 19-21 cm markings at the teeth.)