Chapter 27

### Introduction

Endotracheal intubation is the definitive way to secure an airway in a patient with respiratory insufficiency, cardiopulmonary insufficiency, or neurological compromise. This chapter will discuss oral and nasal endotracheal intubation.

### Definitions and Terms

• ▪  Airway: Conduit through which gas passes between the atmosphere and the lungs, including the oropharynx, nasopharynx, hypopharynx, trachea, or an artificial airway such as an endotracheal tube (ETT).
• ▪  ETT: An artificial airway usually inserted through the mouth or nose into the trachea (Figure 27-1). While a variety of variants are available for specialty uses, the typical ETT has the following features:
• —Made of flexible, clear plastic material.
• —Equipped with a standard-sized (universal) 15 mm connector at the proximal end, which ensures compatibility with all ventilator circuits and ventilation bags (Figure 27-2).
• —Having an opaque stripe along the length of the tubing to facilitate tube location on chest x-ray.
• —Beveled tip to facilitate passage through vocal cords.
• —Length markers to assist in correct placement of ETT.
• —ETTs may or may not be equipped with an inflatable cuff just proximal to the distal tip of the tube which can be inflated to sequester the trachea from the hypopharynx—pediatric ETTs are typically uncuffed to maximize the available diameter of the tube for gas passage, whereas adult tubes are typically cuffed.
• —Cuffed ETTs are often equipped with a “Murphy eye,” which is a side vent just proximal to the distal end of the tube, designed to allow an alternative air passage in the event that the distal tip was occluded by contact with the tracheal wall or a plug (Figure 27-3).
• ▪  Laryngoscope (Figure 27-4): One of a variety of tools designed to allow an operator to open and align the oral pharynx and hypopharynx, and illuminate the vocal cords, thereby permitting insertion of an oral ETT under direct visualization.
• ▪  Direct laryngoscopy: The act of using a laryngoscope to visualize the airway—as compared with indirect laryngoscopy using either a mirror or fiberoptic laryngoscopy. The latter procedures are typically performed for diagnostic reasons.
• ▪  Oral entotracheal intubation: Placement of the distal tip of an ETT in the trachea, typically using direct laryngoscopy, although the procedure can be performed using a fiberoptic bronchoscope to locate the airway and subsequently threading the ETT over the bronchoscope into the trachea.
• ▪  Nasal endotracheal intubation: Placement of the distal tip of an ETT into the trachea after passage of the ETT through the nose, nasopharynx and hypopharynx. The ETT can be passed blindly using breath sounds as a locator or alternatively threaded over a bronchoscope.

###### Figure 27-1.

A standard ETT with a syringe attached to the “pilot balloon” for cuff inflation, as well as a malleable stylet to form the tube during insertion and an end-tidal C2 detector.

###### Figure 27-2.

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