Setting Up for a Successful Intubation

*Editor’s Note: This is a post by Dr. Karen Chung, PGY4, about how she goes about preparing for her intubations. The articles is best for our junior learners who are getting started intubating for the first time. Like most procedures, there is a lot of variability in how people prepare for intubation. Below Dr. Chung’s method to prepare, you’ll see how Dr. Arman Hussain, PGY4, prepares. Note how both authors end up with the same ultimate outcome, but prepare a little bit differently.

Karen

Imagine you have a patient you suddenly need to intubate – perhaps a patient having a seizure who is not protecting their airway, or a patient who suffers a cardiac arrest while in the emergency department. Whatever the situation, you don’t have time to prepare and leisurely take your time collecting your airway equipment. How do you make sure you don’t forget anything? 

In our shop, we gather our own materials. In other hospitals, a respiratory therapist may bring everything to you. Even in those places, it is good to double check what you have, because the last thing you want in a critical scenario is to be scrambling around because you are missing something. When you do have the luxury of time to prepare, having a standard checklist also helps provide structure for a time out with your team so that everyone is ready. As with any other procedure, preparation is (at least) half the battle. 

There are many mnemonics out to help you remember what you’ll need for intubation; the one I like is SOAP ME¹: 

S – suction

O – oxygen

A – airway and adjuncts

P – positioning 

M – monitor and medications

E – end-tidal CO2 and other equipment

Suction: Have your suction connected to your suction canister and turned on (in our shop, we use the Yankauer). Make sure it works! I like to tuck the Yankauer under the stretcher mattress on the right side so that I can easily grab it.

Oxygen: This includes pre-oxygenating the patient, as well as having a bag-valve mask hooked up to oxygen and ready to use. I like to pre-oxygenate using a non-rebreather with the oxygen turned up to maximum (that means turning the oxygen up to and past 15 L/min). You can also have a nasal cannula under the non-rebreather, so that the patient is still getting some oxygen once you remove the non-rebreather to intubate. 

*Editor’s note: Preoxygenation is a huge topic by itself and won’t be in full covered here. There are lots of references to what safe apneic time is depending on pre-oxygenation, whether you can/should use non-invasive ventilation to pre-oxygenate, etc. In most cases when intubating in the ED, we tend to pre-oxygenate with a bag valve mask with an optional nasal canula²³.

Airway and adjuncts: Prepare your ET tube with the stylet. Test the balloon and leave the syringe attached. I like to place this next to the suction under the mattress as well so that I know where it is and don’t have to fumble for it once I have my view of the vocal cords. If you are using a video laryngoscope, place it in a location where you can easily see the screen. Additionally, have airway adjuncts and backups ready in case you encounter a difficult airway – nasopharyngeal (NPA) or oropharyngeal (OPA) airways, bougie, or laryngeal mask airways (LMAs) . You don’t need your cricothyrotomy kit right next to you but you should know where it is. 

Positioning: Make sure the stretcher is at the right height for you. If possible, extend the patient’s neck to place them in the sniffing position. Prop a rolled towel under their shoulders if needed. 

Monitor and medications: Ensure the patient is connected to the monitor, with the blood pressure cycling at least every five minutes. Designate someone to keep an eye on the patient’s vitals while you are intubating. Ask your nursing team to draw up the rapid sequence intubation (RSI) medications (which we won’t cover here), and have your post-intubation sedation medications ready as well. Check that the patient has at least two well functioning IVs to deliver these medications. 

End-tidal CO2 and other equipment: Your color change capnography device, or whatever you use to verify successful intubation, should be close at hand. Other equipment to have nearby include the tube securement device and ventilator, and maybe a code cart, just in case. I also like to have a backup direct laryngoscope in case my video laryngoscope stops working.

Arman

I have a hard time using mnemonics for my procedures and am definitely more of a visual person. When I prepare for intubations, I like to do two things: 1. I visualize myself successfully performing the procedure and 2. Try and think of everything that could possibly go wrong at each step (disaster thinking). This is a much longer process than Karen’s method, but gets faster with repetition. This isn’t to say I don’t use checklists though – I have a fear that one day I’ll get so comfortable with intubation that I’ll forget something simple like attaching a syringe to the endotracheal tube. My method is to work through the procedure and asking what could go wrong at each stage:

Pre-intubation

• What if I can’t open the patient’s mouth? Make sure I have two working IVs to push induction drugs in the other IV
• What if the video laryngoscope runs out of battery/doesn’t work? Keep a backup direct laryngoscope in my pocket, plug all the video laryngoscopes in the department in and nearby
• What if my patient is hypotensive? Start fluids or pressors prior to pushing induction agents

Peri-intubation

• What if I can no longer oxygenate or ventilate the patient, and cannot intubate? I keep a scalpel in my pocket or at least know where it is
• What if I can’t intubate on the first try and the patient’s oxygen saturation is plummeting? I make sure to pre-oxygenate the patient beforehand as best as possible
• What if I my tube just isn’t going where I want it? I keep a bougie in my pocket while intubating or wear it as a good luck necklace
• What if my tube is getting stuck on the arytenoids/nearby soft tissue structures? The tip of my ETT is lubricated with jelly
• What if I my tube is stuck on the rigid stylet and isn’t advancing off? Test my stylet to make sure it won’t stick before inserting into the mouth
• What if I can’t identify my landmarks? I know where the LMA is, I position the patient with blankets/sheets/etc, I have a phone to call for a difficult airway alert if needed
• What if the mouth is full of vomit/blood/schmutz? Have suction nearby and on

Post-intubation

• What if the patient isn’t appropriately sedated after I intubate? I order post-intubation sedation beforehand or have already discussed it with the nurse
• What if the tube is in the wrong place? I order the post-intubation chest x ray beforehand or have already discussed it with the nurse/x-ray tech, and have my end tidal CO2 monitor/colorimeter to confirm
• What if the balloon isn’t inflated? I test the balloon beforehand
• What if the vent is alarming? I keep the bag valve mask nearby, leave my set up the way it is until the tube is confirmed with x-ray
• What if my patient loses a pulse during/after intubation? I ask everyone in the room to “humor” me, and put a finger on the femoral pulse prior to intubation and confirm pulse afterwards, I also ensure a good waveform on the pulse oximeter if possible prior to intubation

As you can see – this is a lot. When first learning how to intubate, I definitely recommend using Karen’s SOAP ME mnemonic, but after a little while, the “what if” scenarios help me keep calm when something goes wrong because I’ve already prepared for it.

Cite this post: Karen Chung, MD, Arman Hussain, MD. “Setting Up for a Successful Intubation”. GW EM Blog. October 24, 2024. Available at: https://gwemblog.com/setting-up-for-a-successful-intubation/.

Related Posts:

References

1. Nickson, C. (2024, July 1). Rapid sequence intubation (RSI). Life in the Fast Lane • LITFL. https://litfl.com/rapid-sequence-intubation-rsi/
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2. Rezaie, S. (2019, March 13). Preoxygenation and Apneic Oxygenation. REBEL EM – Emergency Medicine Blog. https://rebelem.com/preoxygenation-apneic-oxygenation/
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3. Rezaie, S. (2024, July 24). The PREOXI trial: Pre-oxygenation with NIV vs Facemask. REBEL EM – Emergency Medicine Blog. https://rebelem.com/the-preoxi-trial-pre-oxygenation-with-niv-vs-facemask/
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