Advanced Airways and Intubation
Key Points
- Intubation is indicated for upper airway obstruction, airway protection, mechanical ventilation need, or tracheal suctioning need.
- Mallampati class helps predict difficulty; class 1 is usually easier, while class 4 may be difficult.
- Correct tube depth and placement verification are safety-critical after intubation.
- Exhaled CO2 detection, bilateral breath sounds, chest rise, and X-ray confirmation are core verification steps.
Pathophysiology
When ventilation or airway protection fails, hypoxemia and respiratory decompensation progress rapidly. Advanced airways maintain a patent route for ventilation, oxygen delivery, secretion management, and aspiration risk reduction while underlying pathology is treated.
Endotracheal intubation bypasses upper airway instability by positioning a cuffed tube in the trachea. Incorrect placement or migration can cause ineffective ventilation, unilateral ventilation, or critical hypoxia, so structured confirmation and reassessment are required.
Classification
- Supraglottic rescue devices: laryngeal-mask-airway, King LT, and Combitube options when standard intubation is not feasible.
- Definitive tracheal airway: Oral or nasal endotracheal intubation with cuff inflation and securement.
- Visualization modality: Direct laryngoscopy (Macintosh/Miller) or video-laryngoscopy for indirect visualization.
Nursing Assessment
NCLEX Focus
Priority items test difficult-airway prediction and immediate verification of tracheal tube position after insertion.
- Assess airway difficulty risk using oral cavity view and Mallampati context.
- Identify high-risk features for difficult intubation, such as obesity with short neck, reduced cervical motion, large upper teeth, small mouth, or small mandible.
- Monitor for adequate chest rise, bilateral lung sounds, and CO2 evidence after airway placement.
- Track documented tube depth and compare serial checks for migration.
Nursing Interventions
- Prepare ETT by cuff test with 10 mL air, lubrication, and stylet placement before insertion.
- Assist laryngoscopy and tube passage past vocal cords, then align depth marker and adult depth target at about 20-25 cm at mouth corner.
- Remove stylet, inflate cuff with 10 mL air, apply oxygen, and confirm effective ventilation.
- Verify placement with colorimetric/CO2 detector, bilateral breath sounds, chest movement, and follow-up X-ray.
- Secure tube, document insertion depth landmark at lips/teeth, and reassess cuff pressure over time.
Misplacement and Migration Risk
Failure to verify and document tube position can delay detection of esophageal placement or later tube movement.
Pharmacology
| Drug Class | Examples | Key Nursing Considerations |
|---|---|---|
| oxygen-therapy | Supplemental oxygen post-intubation | Apply immediately after placement and reassess oxygenation and ventilation response. |
| sedative-hypnotics | Sedation context | Ongoing ventilated patient care may require sedation planning and close respiratory/hemodynamic monitoring. |
Clinical Judgment Application
Clinical Scenario
A critically ill patient with worsening respiratory-failure cannot maintain oxygenation despite basic airway support. Team proceeds to endotracheal intubation.
Recognize Cues: Persistent instability and inadequate response to basic support indicate airway escalation need. Analyze Cues: Definitive tracheal airway is needed to secure ventilation and protect airway. Prioritize Hypotheses: Immediate priority is correct ETT placement and verification. Generate Solutions: Use structured intubation preparation, depth targeting, CO2 confirmation, and bilateral auscultation. Take Action: Assist insertion, cuff inflation, oxygen application, securement, and post-placement imaging workflow. Evaluate Outcomes: Stable chest rise, bilateral sounds, CO2 confirmation, and maintained documented tube depth.
Related Concepts
- airway-adjuncts - Adjunct devices may bridge or rescue before definitive intubation.
- laryngeal-mask-airway - Common supraglottic alternative when direct intubation is difficult.
- bag-valve-mask-manual-ventilation - Essential pre-intubation and peri-intubation ventilatory support.
- respiratory-failure - Primary clinical context driving airway escalation.
- airway-adjunct-insertion - Foundational airway skills before advanced intervention.
Self-Check
- Which immediate findings best confirm that an ETT is in the trachea rather than the esophagus?
- Why is depth documentation at lips or teeth required after successful placement?
- How does difficult-airway assessment change preparation before intubation?