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Views: 0 Author: Site Editor Publish Time: 2025-09-09 Origin: Site
In the critical moments of an emergency, when airway obstruction or sudden respiratory failure occurs, the interruption of oxygen supply leaves life hanging by a thread. Every second calls for urgent intervention, and the endotracheal tube becomes a core lifesaving measure. It can immediately restore the ventilation pathway, making the difference between life and death. This intervention not only rescues patients on the edge of emergency situations but also extends to anesthetic support in surgical operations, airway management in intensive care units, and routine procedures in emergency departments. In clinical practice, it plays a fundamental and indispensable role.
However, the complexity of endotracheal tube placement cannot be overlooked. It requires highly skilled technical competence, and operational risks loom like shadows. Any mistake—including misplacement—can trigger bleeding, tissue injury, or even catastrophic respiratory failure. This guide was created to provide healthcare professionals with a systematically integrated map of knowledge: analyzing when to initiate intubation, how to properly execute the insertion procedure, how to verify the placement accurately, and how to identify errors early from clinical data, thereby offering reliable guidance for subsequent practice in this field.
When a patient is facing an airway crisis that directly threatens life, endotracheal tube placement becomes an urgent medical decision.
The primary indication points to acute respiratory failure—when the body cannot independently maintain effective gas exchange, oxygenation rapidly declines, or carbon dioxide retention continues to rise. In such cases, intubation becomes the core method of reestablishing the breathing pathway. Likewise, any severe airway obstruction caused by foreign body aspiration, laryngeal edema, or bronchospasm—if unresponsive to standard interventions—requires immediate establishment of an artificial airway.
When consciousness is profoundly impaired, with coughing and swallowing reflexes significantly weakened or absent, the ability to clear secretions or prevent aspiration is lost, and airway protection is critically compromised. For patients with persistently low Glasgow Coma Scale scores or in a comatose state, endotracheal tube placement is not just a treatment but a vital defense line for survival.
In the field of surgical anesthesia, endotracheal tube placement is an indispensable routine step. It provides a stable pathway for mechanical ventilation and inhaled anesthetics, ensuring safe respiratory management during long and complex operations.
Furthermore, in extreme emergency scenarios such as massive trauma with hemorrhage, severe polytrauma with shock, or asphyxial respiratory arrest, early intubation is often the cornerstone for stabilizing vital signs and buying time for subsequent rescue measures. Clinicians must base their decisions on accurate assessment of the pathological process and make timely, effective judgments before the patient’s condition deteriorates rapidly.
Before beginning the procedure, meticulous preparation is the foundation of safety. The first task is a systematic check of all equipment: ensuring the laryngoscope light source is bright, the endotracheal tube cuff has no leakage, appropriate stylets and obturators are available, and laryngoscope blades are matched in size. Effective suction equipment must be ready as well.
Next, adjust the patient’s position precisely: place the head on a pillow to achieve slight neck flexion with full atlanto-occipital extension—known as the “sniffing position”—to optimally align the oral, pharyngeal, and laryngeal axes. Prior to intubation, provide several minutes of high-flow preoxygenation or bag-mask ventilation, raising oxygen saturation to its peak or near-peak levels, thereby extending the safe apnea window for subsequent manipulation.
Smooth passage through the glottis is the technical core. The operator holds the laryngoscope in the left hand, sliding it gently along the right edge of the tongue into the oropharynx under direct vision. Upon reaching the base of the tongue, upward vertical traction is applied—not levering on the teeth—to lift the tongue and epiglottis, fully exposing the glottic opening.
With the right hand, the operator introduces the well-lubricated endotracheal tube into the midline visual field, advancing it steadily along the natural curve of the airway until the cuff passes completely beyond the vocal cords. Throughout this step, visual focus must remain on the glottis to ensure that the tube enters along the intended trajectory without deviation.
Immediately after the tube enters the airway, multiple verifications are required:
· Observe whether both sides of the chest rise symmetrically.
· Connect an end-tidal CO₂ monitor to obtain continuous, regular capnography waveforms.
· Auscultate both axillary lung fields for clear breath sounds and auscultate the epigastrium to rule out esophageal misplacement.
Once the correct placement is confirmed, remove the stylet and inflate the cuff to achieve a proper sealing pressure, avoiding overinflation that can damage mucosa. Finally, secure the tube at the oral commissure using dedicated fixation devices or adhesive tape with a double-locking method, preventing accidental displacement or dislodgement. Connect the ventilator tubing, initiate assisted ventilation with preset parameters, and continuously monitor dynamic changes in vital signs.
This entire process emphasizes coordination, precision of placement, and a closed-loop system of risk management.
The ideal position of the endotracheal tube requires precise anatomical placement. The tip of the tube should rest within the tracheal lumen, approximately 2–3 cm below the vocal cords. More specifically, the distal end should be located about 2–4 cm above the carina. This ensures effective airway sealing while avoiding direct contact with critical nearby structures.
Excessive advancement may lead the tube into one main bronchus (usually the right), causing complete interruption of ventilation to the contralateral lung, resulting in catastrophic single-lung ventilation, hypoxemia, and barotrauma.
If the tube tip remains at the glottic level, the cuff cannot seal the trachea effectively. Ventilation will fail, and persistent pressure on the vocal cords may cause edema, injury, or dislocation. In this case, the tube is prone to accidental extubation with coughing or changes in body position, requiring urgent repositioning.
Thus, immediate verification and ongoing monitoring are critical after intubation. Regardless of initial accuracy, tube displacement may occur with neck flexion, extension, coughing, or during patient transfer. After every intervention or movement, the tube depth and function must be reconfirmed to ensure safe ventilation.
Ensuring precise placement of the endotracheal tube requires a multidimensional verification strategy, applied throughout the procedure and repeated dynamically.
Continuous clear visualization during intubation is the most direct evidence of correct placement. Observing the tube tip pass through the vocal cords under laryngoscopy confirms accuracy. The operator must ensure that the tube is aligned with the anatomical midline and inserted to a depth that allows the cuff to be entirely below the vocal cords.
Immediately after placement, auscultation must be performed. Using a stethoscope, compare both lung fields at the midaxillary line to confirm equal and symmetric breath sounds without delay. Also auscultate the epigastric region to ensure absence of gastric insufflation sounds, ruling out esophageal misplacement.
Capnography provides objective evidence. Continuous rectangular ETCO₂ waveforms for 4–6 breaths (ETCO₂ > 10 mmHg) confirm alveolar gas exchange. Loss of waveform or irregular flat tracings warn of esophageal misplacement or tube dislodgement.
Observe chest wall symmetry and rhythm of expansion, and monitor SpO₂ recovery from dangerous thresholds. Physiological improvements must complement instrument-based verification, forming a dual safeguard.
Immediate verification is required if any of the following clinical signs appear:
Complete or markedly diminished breath sounds on one side (commonly the left) indicate bronchial intubation, often due to excessive depth in the right main bronchus, resulting in absent ventilation to the contralateral lung.
Critical signs include:
· Persistent absence of waveform or ETCO₂ near zero.
· Sudden disappearance after initial presence.
· Small, irregular sawtooth waveforms.
· These findings strongly indicate esophageal intubation or total airway dislodgement.
SpO₂ drops steeply (>15% below baseline or persistently <90%) without explanation from the underlying disease, particularly after ventilator malfunction is excluded, suggesting loss of effective ventilation.
· Ventilator high-pressure alarms, caused by deep intubation blocking a bronchus or secretion obstruction.
· Low tidal volume alarms, suggesting leakage from inadequate cuff sealing or tube displacement.
Visible chest wall asymmetry—expansion only on one side or paradoxical suprasternal retraction—indicates single-lung ventilation or airway obstruction.
Audible gurgling beneath the xiphoid or progressive upper abdominal distension confirms air entry into the gastrointestinal tract, a direct sign of esophageal intubation.
In conscious patients, sudden severe coughing, agitation, cyanosis, or patient-ventilator dyssynchrony after spontaneous breathing recovery suggests tube tip irritation of the carina or vocal cords.
Any single sign warrants immediate emergency management: discontinue ventilation, disconnect from the ventilator, provide bag-mask oxygen, and perform visual repositioning (laryngoscopy or bronchoscopy) rather than blind adjustments to avoid further injury. Final confirmation must return to multiparametric assessment: ETCO₂ waveform, bilateral breath sound symmetry, and chest X-ray verification are all essential.
The safety and effectiveness of endotracheal tube placement fundamentally depend on rigorous adherence to standard procedures and continuous vigilance in monitoring. Each intubation is not the endpoint but the beginning of meticulous airway management.
A single verification is never enough. Variations in vital signs and subtle changes in respiratory mechanics are silent alarms. Only by maintaining continuous monitoring throughout the airway management process can the risks of deep placement (single-lung ventilation), shallow placement (extubation), or esophageal misplacement be avoided.
The foundation of every successful ventilation is obsessive compliance with standards and extreme sensitivity to changes in data. On the vital pathway of maintaining oxygenation, safety allows no margin for error.
