Endotracheal Tube Preparation

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About this medical skill
Parent skills Airway Management
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The EndoTracheal Tube (or ET tube) is an airway adjunct that provides both a protected opening into the airway as well as a degree of aspiration protection. Placement of an ET tube (called endotracheal intubation) is outside of the scope of practice for EMTs, but you may be called upon in the field to prepare the ET tube and an intubation kit for a Paramedic, and as such should be familiar with the components and assembly.

To assemble the ET Tube:

  1. Select the requested size of ET tube. For pediatric patients this will likely range from 3.0/3.5 Fr for neonates up to 7.0/7.5 Fr in older children, and somewhere between 6.5 to 8.5 Fr for adults. The size should be listed on the package
  2. Don gloves, and open the package with aseptic technique and lay out with a 10 cc syringe on a clean (preferably sterile) surface
  3. Insert the stylet to, but not past, the side opening at the tip of the ET tube which is known as "Murphy's Eye" and bend the back end of the stylet to ensure it does not advance further during use. Some ET tubes come preassembled with the stylet, but verify that the tip of the stylet is not past Murphy's Eye.
  4. Test the cuff. Fill a 10 cc Luer lock syringe with air, and attach to the cuff inflation port at the proximal end of the ET tube. Inflate the cuff with 10 cc of air and confirm that the cuff inflates and the external bladder indicating inflation also inflates.
  5. Deflate the cuff, and lay out the tube for the Paramedic with their intubation kit.

The Intubation kit should include:

  • An appropriate size laryngoscope blade MAC, Miller, or combination blade, with a functioning light source
  • Age appropriate BVM with a reservoir and needed attachments to ventilate the patient before and after the procedure
  • Suction equipment to clear vomitus, secretions, or foreign bodies
  • Tape or commercially available "tube holders" to maintain appropriate ET position
  • Gloves, mask, and goggles as personal protective equipment

Ventilating the Intubated Patient

You will also be called upon to ventilate patients who have been intubated. The connector that sits outside the patient's mouth is the same standard diameter as the mask portion of the Bag Valve Mask, so may be directly connected to the Bag Valve. To ventilate:

  1. Stabilize. It is essential that the ET tube not be pulled out or pushed further in to the airway, and as such, in addition to any applied tape or tube stabilizers, the tube should be stabilized manually while attaching the bag valve or providing breaths.
  2. Ventilate. Ventilation with the BVM on an ET tube is delivered every 6 to 8 seconds (note this is slower than the rate with the external mask). It is particularly important to ventilate smoothly as forceful ventilations can more easily cause overinflation injuries.
  3. Monitor. Note the insertion depth of the ET tube from the markings on the side, and ensure this does not change. Check for adequate and symmetric chest rise, listen for bilateral breath sounds. Recognizing the signs of a dislodged or misplaced tube is a lifesaving skill.