Learning intubation technique can be challenging. Fall is the time of year when new students commonly begin to learn how to intubate. My first intubation was one of the first times I literally held someone’s life in my hands. I was nervous. The anesthesiologist teaching me tried to not look too anxious as I awkwardly grabbed my laryngoscope blade, fumbled while opening the patient’s mouth, and cautiously maneuvered the endotracheal tube into the trachea. It felt like time stopped until the tube was in place, after which the three of us (me, my teacher and my patient) all took a deep breath. Since then, over the last almost 37 years, I’ve intubated thousands of people in the U.S. and, as an international volunteer, eight countries.
So I thought it would be helpful at this time of year to discuss a step-by-step approach to intubation with the commonly used curved blade. Intubation, like a dance, is composed of steps that flow naturally from one to the next. The trick to a smooth intubation is to allow each step to blend seamlessly into the next. The text and illustrations below are excerpted from my book Anyone Can Intubate, as well as from my upcoming book on pediatric intubation, which I’m busy writing.
Oral Intubation Technique
Intubation Alternates Hands
The act of intubation alternates hands. One hand positions the patient for the next action by the other hand. With practice, coordinating the alternating hand movements becomes natural. Once the head is optimally positioned, tilt the head into extension with your right hand to bring all the axes into alignment. This provides you with as straight a path as possible to see the larynx and pass the tube.
Anchor it there momentarily using your left hand .
Anchoring the head frees your right hand. Open the mouth with your right hand by placing your thumb on the lower jaw and your middle finger on the upper jaw. The position is similar to snapping your fingers. By using a pushing rather than a spreading motion, you can open the mouth wider and more forcefully. Make sure that you place your fingers as far to the right side of the mouth as you can in order to keep your fingers out of the way of the blade. Your right hand now does double duty. It holds the mouth open as wide as possible. Pulling toward you also places the head in extension.
Your right hand opening the mouth now also holds the head in extension.
You can now use your left hand to pick up the blade. Hold it with the blade away from you. Because my hands are small, I place my hand lower down on the handle. By positioning the heel of my hand on the junction between blade and handle, I can fine tune the angle of the blade. You will need to see what feels correct for you.Notice how easily you can change the angle of the blade by tilting your wrist. You must control this motion carefully to avoid tooth damage.
Inserting The Blade: Protect Those Lips and Teeth
Insertion of the blade should be delicate and deliberate. Hold the handle in your left hand, blade down, pointing away from you. Grasp it firmly but don’t clench your fist because this decreases control and causes early fatigue.
With the mouth open, insert the blade, slightly to the right of the tongue. Don’t hit the teeth as you insert. If necessary, you can tilt the top of the handle slightly to insert the blade into the mouth, then rotate the blade back, scooping it around the right side of the tongue as you do so.
Avoid catching the lips between the blade and the teeth. I use my right index finger to sweep the lips out of the way of the blade as I insert it. You may need to angle a curved blade slightly to pass the teeth and then return the blade to a more neutral position once it has entered the mouth.
Look For The Tip Of The Epiglottis Before The Final Lift
Slowly advance the blade with your left hand until you see the tip of the epiglottis, a very important landmark. Simultaneously sweep the tongue to the left as you advance . Once you see the epiglottis you can start to transfer the weight of the patient’s head onto the blade as you lift. Leave your blade toward the left side of the mouth with the tongue pushed out of the way.
How You Lift Matters
Good intubation technique depends on optimal mechanical advantage. Lift upward with the left arm held fairly rigid. Keep you elbows in. Lift on a line connecting the patient’s head with the intersection of the opposite ceiling and the wall . It won’t be straight, but keeping your arm straighter and fairly rigid it gives you the strength of your shoulders to lift the head. It prevents you from using the teeth as a fulcrum — dangerous for the teeth. And it allows you to use binocular vision for depth perception.
The typical beginners often use bad intubation technique. They mistakenly hunch close to the patient, bend the elbow completely, and place the right eye practically in the patient’s mouth. They then can’t understand why he or she has no leverage or control.
Seeing The Larynx
When you lift the jaw upward you should have an unobstructed view of the larynx. Pressure from the tip of a curved blade in the vallecula pulls the epiglottis forward. The straight blade lifts the epiglottis itself. Placement of the blade is critical. If you place the blade in the center of the tongue, it will mound up blocking your view. You must sweep the tongue to the left or you will see nothing.
In this photo you can clearly see the arytenoids below the glottic opening.
Ask For Cricoid Pressure If You Can’t See The Larynx
Cricoid pressure is one of the most valuable intubation techniques to help you during intubation. We often use it to improve visualization of the so-called anterior airway, where the view of the larynx is hidden behind the back of the tongue. Often used during difficult intubation, cricoid pressure can also help with the routine intubation if the patient’s positioning is not optimal or if the blade you have chosen is not providing the best view.
Cricoid pressure can also be used to protect against aspiration, as this action pinches off the upper esophageal sphincter in patient’s with full stomachs or a history of gastric reflux.
To apply cricoid pressure, place your assistant places their thumb on one side of the cricoid ring and their index or ring finger on the other. Pushing down firmly to force the cricoid also forces the vocal cords downward and often into the field of view.
Pass The Tube
The head is now suspended from the blade held in your left hand, freeing your right hand to place the tube. Use a 6.5-8.5 for a woman and a 7.5-9.0 for a man. The larger the tube, the less resistance to breathing there will be. Hold the preselected tube in your right hand like a pencil, curve forward.
Pass the tube into the larynx through the cords in one smooth motion. If the patient is breathing, time the forward thrust for inspiration when the cords are fully open. During expiration, the tube may bounce off the closing cords into the esophagus.
Pass the tube to the right of the blade, past the right side of the tongue. You can understand why the blade should optimally be as far to the left side of the mouth as possible.
Watch The Tube Enter The Trachea
Try to watch the tube pass through the cords into the trachea. Although there may be a blind spot impairing your view at the moment of intubation, you can often see the arytenoid cartilages behind the tube after proper placement. Don’t relax and pull the blade out without trying to be sure of success with your own eyes. Get into the habit of seeing the tube between the cords and you will be less likely to intubate the esophagus. Stop advancing the tube when you see the cuff completely pass the cords,usually 21-22 cm at the front teeth in an adult. Carefully hold the tube where it exits the right side of the mouth and remove the blade with your left hand.
Remove The Stylet
If you’ve used a stylet, remove it before you fully advance the tube down the trachea. Make sure you have a strong grip on the tube where it exits the mouth because the force needed to remove the stylet will sometimes threaten to pull the tube out with it.
To inflate the cuff, slowly inject air through the pilot tube until the pilot balloon just starts to get tense. Don’t overfill. You don’t want the pilot balloon to feel hard when you squeeze it or it may apply excessive pressure to the tracheal mucosa. Later, after verifying tracheal placement you can go back to check the minimal sealing pressure of the cuff. To check minimal seal, suction the airway free of secretions. Apply constant airway pressure of about 20 mmHg. Remove some air until you hear a leak and then refill the cuff until the tracheal leak just disappears. Excessive cuff inflation can damage mucosa by impairing its blood supply.
Always Verify Placement, Assume Nothing!
Before doing anything else, be sure that the tube is in the trachea. Listen for the presence and equality of breath sounds over both lung fields and for the absence of gurgling sounds over the stomach. Never assume that the tube is in the trachea until you have checked it yourself.
Ventilation Is More Important Than Intubation
In the event you can’t intubate easily, stop after 30 – 60 seconds. Ventilate the patient briefly before your next attempt in order to maintain oxygenation. As long as you can ventilate the patient you have time. Time to alter your technique, change the position of the head, or use a different type of laryngoscope blade. Keep your suction handy and use it. Don’t be afraid to ask for help.
Follow this link to a video showing an entire intubation sequence using both the Macintosh and straight Miller blade.
This link takes you to a discussion on how a straight blade intubation differs from using the curved MacIntosh blade.
This link takes you to a discussion on how we can make intubation much more difficult, even in a patient who should be easy to intubation.
Although intubation technique requires practice to master, if you understand how the steps fit together to bring the larynx into view, and are gentle and purposeful in your actions, you too will soon be safely performing this life saving skill.
22 thoughts on “Intubation: Step By Step”
is a good and raith step
Thank you! Very helpful and well written!
It’s not the cricoid pressure. It’s pressure on thyroid, posterior and cephalad. Cricoid pressure was used during rapid induction when suspected of full stomach, a controversial issue during recent times.
thank you, simple steps. Donna Vincent.
No patient should EVER be intubated by a medical student. By a resident ( with vigilant and ever-present supervision ) – yes, but definitely not by a medical student. The army of patients intubated by medical students left with damaged vocal cords, damaged teeth and other endless ( not necessarily life threatening ) complications is large enough. Also, patients are NEVER told about the prospect of being intubated by medical students. This is being deliberately hidden behind the consent ( definitely not informed one ) given to the “ ACT – anesthesia care team “. ACT means you will most likely be intubated by CRNA and/or medical student, if things get complicated you will be intubated by anesthesiology resident and when things go really wrong an attending anesthesiologist will be called and he/she will step in to do damage control. The exceptions are highly specialized operations or pediatrics. The public is not educated about it. Also, none of the people involved in academia pay their malpractice insurance out of their pockets. So they put the educational needs of students and academic institutions before the needs of their patients. Ask any anesthesiologist in private practice if they would ever allow a medical student to intubate their patient.
While I agree that the instructor must be vigilant, I disagree that a medical student should never learn to intubate. A medical student on their first day of rotation has the same intubation experience as a resident on their first day of rotation. Respiratory therapists, midwives, and paramedics can learn to intubate, a medical student with more training can surely do so. My hospital requires that students identify themselves and the patient has the option, as well as the right, to refuse their participation.
I disagree as well. In fact, I have known CRNAs and medics, especially flight medics or military special operations medics who are far more experienced and proficient than any resident. They started off doing intubation on live patients fairly early so I wouldn’t put the same limitations on med school students. It is not that complicated for the majority of patients.
If your point is that there should be more training on models before transitioning to live patients, that’s different. But no model replicated doing it for real IMO.
I have a question if someone might answer. The inflation of the cuff must be done after the tube s placement has been checked right?
The cuff must be inflated as soon as the ETT is placed for several very important reasons. First, if the cuff is not inflated then when you give that first breath to test placement the air will exit the trachea around the tube, not inflate the lungs. In other words you won’t be able to tell the tube is in the trachea. Second, in the presence of concerns about infectious disease such as COVID, inflation before ventilation prevents the escape of aerosols that might contaminate the intubation team. Third, the longer the cuff remains uninflected, the longer the patient is at risk of aspirating around the tube because the tube will wick any secretions in the mouth into the trachea. However, once you have verified ETT placement it’s important to check that the ETT cuff is not overinflated so that it will not damage the tracheal mucosa.
“By using a pushing rather than a spreading motion, you can open the mouth wider and more forcefully.”
Could you explain this more? I’m not getting it :/
Love this article, so detailed and the pictures are so clear
Thanks for your question. Sorry that’s not clear. By spreading I mean placing your thumb on the upper teeth and middle finger on the lower teeth to spread the upper and lower jaw apart. This is making an open V out of your fingers, not a very strong motion at all. By pushing I mean using your thumb on the LOWER teeth and your middle finger on the upper teeth. You are essentially making the same motion your would use to snap your fingers, but in these positions you are pushing the lower and upper jaw apart. By pushing you have much more fine control and strength. Hope that helps.
Dr. Whitten, thank you for this excellent tutorial. I am an internal medicine resident and found this extremely helpful. Thank you for taking the considerable time, talent and expertise to create this manual.
Thank you for this!
What are your thoughts on commonly intubating patients 180 degrees away from the anesthesia machine as long as there are 2 providers present?
Very well explained in a step by step way