- Patient meets clinical indications for oral intubation.
- Three attempts at oral tracheal intubation (follow Airway Protocol). Age less than 8 or endotracheal tube size less than 6.5 mm.
- Prepare position and oxygenate the patient with 100% Oxygen.
- Select proper endotracheal tube (ETT) without stylet, test cuff and prepare suction.
- Lubricate the distal end and cuff of the ETT and the distal 1/2 of the endotracheal tube introducer (Bougie®) (note: failure to lubricate the Bougie® and the ETT may result in being unable to pass the ETT.
- Using laryngoscopic techniques, visualize the vocal cords if possible using Sellick’s/BURP as needed.
- Introduce the Bougie® with curved tip anteriorly and visualize the tip passing the vocal cords or above the arytenoids if the cords cannot be visualized.
- Once inserted, gently advance the Bougie® until you meet resistance or “hold-up” (if you do not meet resistance you have a probable esophageal intubation and insertion should be reattempted or the Airway Protocol implemented as indicated).
- Withdraw the Bougie® ONLY to a depth sufficient to allow loading of the ETT while maintaining proximal control of the Bougie®.
- Gently advance the Bougie® and loaded ETT until you have hold-up again, thereby assuring tracheal placement and minimizing the risk of accidental displacement of the Bougie®.
- While maintaining a firm grasp on the proximal Bougie®, introduce the ETT over the Bougie® passing the tube to its appropriate depth.
- If you are unable to advance the ETT into the trachea and the Bougie® and ETT are adequately lubricated, withdraw the ETT slightly and rotate the ETT 90⁰ COUNTER clockwise to turn the bevel of the ETT posteriorly. If this technique fails to facilitate passing of the ETT you may attempt direct laryngoscopy while advancing the ETT (this will require an assistant to maintain the position of the Bougie® and, if so desired, advance the ETT).
- Once the ETT is correctly placed, hold the ETT securely and remove the Bougie®.
- Inflate the cuff with 3 to 10 mL of air, auscultate for equal breath sounds, and reposition accordingly.
- Confirm and document tracheal placement using end-tidal CO2 monitoring or an esophageal bulb device.
- When final position is determined, secure the ETT, reassess breath sounds, and monitor readings to assure continued tracheal intubation.