ETCO2 & Other Equipment

Airway Confirmation Equipment (ETCO2)

- Minimum: Visualization of the tube through the cords and auscultation of breath bilateral sounds
- Better: Colorimetric capnography
- Best: Continuous end-tidal carbon dioxide (ETCO2)

Regardless of how an endotracheal tube is placed, a verification of correct tube placement must be performed every time as incorrect tube placement may be fatal. The right mainstem and hypopharynx are the most common locations of incorrect placement of ETT. Visualization of the tube passing through the vocal cords (in the case of endotracheal intubation) should be assured. Esophageal intubation is also common. Auscultate, if possible, to verify bilateral breath sounds and absence of gurgling in the epigastric region. When performing a cricothyroidotomy subcutaneous placement of the tube may occur. For both oral and surgical airways colorimetric capnography and endotracheal detection devices should be considered to verify correct tube placement as tube misplacement can be fatal. Continuous ETCO2/wave capnography is the gold standard for initial detection of and monitoring for appropriate tube placement. (See Appendix G: Waveform Capnography & Pulse Oximetry Interpretation for a detailed description)

Other Equipment

Supraglottic airways are most commonly placed blindly. They are also not considered definitive airways in that they do not provide an inflated cuff in the trachea. Without an inflated cuff in the trachea, the airway is not protected against aspiration. Nonetheless, supraglottic airways can provide a conduit for oxygenation and ventilation. If definitive airway is required, an endotracheal tube may be placed through the supraglottic airway or a bougie may be threaded to allow for endotracheal exchange. (See Appendix D: Supraglottic Airway Placement for a detailed description.)

Repeated attempts at endotracheal intubation are associated with worse outcomes. Visualization of the vocal cords is vital for endotracheal intubation. Direct laryngoscopy traditionally has been used for endotracheal intubation. Although there are shortcomings described regarding the use of video laryngoscopy, including fogging especially in airways with heavy secretions, video laryngoscopy is associated with a higher first attempt intubation rate and should be considered the best option especially in those with limited experience. Nonetheless, given its limitations, airway providers must maintain competency with both techniques.

An important adjunct to passing an endotracheal tube whether trans orally or through a cricothyroidotomy, is the use of a bougie (sometimes also referred to as an Eschmann Stylet). This device is simple, rugged and can be used to guide tube placement. The bougie is placed in the trachea before the endotracheal tube and may be used first to confirm proper positioning. The bougie will provide tactile feedback against the tracheal rings confirming proper placement, or by encountering a hard stop when abutted against a distal bronchus. An endotracheal tube is then introduced over the bougie into the trachea, while the laryngoscope is maintained in place to lift the laryngeal structures. Lastly, the bougie is removed. A bougie may also be used to change tubes in the case of a tube malfunction. This may be accomplished by placing a bougie in a tube or SGA that is currently positioned, remove the tube over the bougie (ensuring the bougie remains in the proper position within the airway lumen), and replacing a new tube over that bougie. Remove the bougie, leaving the new tube in place.

Placement of a nasogastric or orogastric tube should be considered following intubation of a patient in order to reduce the risk of pulmonary aspiration and prevent gastric distention. If only supraglottic airway access is available, consider using a supraglottic device that incorporates an orogastric tube port. Always measure the distance from nose to stomach and note the distance prior to insertion, then verify epigastric sounds. Always reassess tube position prior to putting anything into stomach to ensure proper gastric placement.