How to Use Endotracheal Tube: Essential Techniques for Successful Insertion

An endotracheal tube (ETT) is a flexible plastic tube inserted through the mouth (or sometimes the nose) into the trachea (windpipe) to establish and maintain an open airway. It is a crucial medical device used in various settings, including hospitals, during surgeries, and in emergency medical situations. The primary purposes of an endotracheal tube are to facilitate mechanical ventilation, deliver oxygen to the lungs, and protect the airway in patients who cannot breathe adequately on their own. The tube is connected to a ventilator or other respiratory device, allowing healthcare providers to control the patient's breathing and administer necessary gases. The size and type of endotracheal tube used depend on factors such as the patient's age, size, and medical condition. 


How to Use Endotracheal Tube?

Endotracheal intubation is a crucial skill within Basic Life Support (BLS), especially in emergency situations where maintaining a patent airway is vital. This step-by-step guide provides a comprehensive overview for BLS providers, ensuring a clear understanding of the procedure.


1. Preparation and Assessment

Before initiating endotracheal intubation, thorough preparation is key. This involves:

  • Ensure a proper environment for the procedure with adequate lighting.
  • Confirm the need for intubation based on the patient's condition, focusing on indications such as respiratory distress, unconsciousness, or cardiac arrest.
  • Assemble all necessary equipment, including endotracheal tubes, laryngoscope, stylet, bag-valve-mask (BVM), and end-tidal CO2 monitoring device.


2. Positioning

Proper patient positioning significantly influences the success of endotracheal intubation. Placing the patient in the "sniffing position" involves extending the neck and aligning the oral, pharyngeal, and tracheal axes for improved visualization. It's crucial to ensure the patient's mouth is open wide, removing any visible obstructions. This step creates an optimal anatomical alignment for a successful intubation procedure.


3. Preoxygenation

Administering high-flow oxygen via a Bag-Valve-Mask (BVM) is a critical component of the preoxygenation phase. This step helps maximize the patient's oxygen reserves, reducing the risk of hypoxia during the brief ventilation interruption that occurs during intubation. Adequate preoxygenation is essential for maintaining oxygenation levels and preventing complications.


4. Laryngoscope Insertion

Proper laryngoscope insertion is fundamental for obtaining a clear view of the airway anatomy.

  • Hold the laryngoscope in the left hand (right-handed providers) and insert it into the patient's mouth, avoiding dental trauma.
  • Lift the tongue to visualize the vocal cords by gently sweeping the laryngoscope blade to the left.


5. Vocal Cord Visualization

Identifying the vocal cords and epiglottis is crucial for successful intubation. Lifting the epiglottis with the laryngoscope blade exposes the glottic opening, providing a clear visual of the structures. This step ensures accurate endotracheal tube placement through the vocal cords, optimizing the procedure's success.


6. Endotracheal Tube Insertion

With the vocal cords visible, the provider carefully inserts the endotracheal tube through the cords. Using a style to maintain the tube's shape and assist in airway navigation enhances precision. Proper insertion ensures that the tube reaches the trachea, securing a patent airway.


7. Cuff Inflation and Securement

After successfully placing the tube in the trachea, inflating the cuff with the appropriate air volume is essential to establish a proper seal. Securing the tube at the patient's lips and maintaining the correct depth prevent dislodgement and ensure effective ventilation. Proper cuff inflation is crucial for preventing complications and optimizing ventilation.


8. Confirmation of Tube Placement

Confirming the correct placement of the endotracheal tube is paramount to avoid complications. Employing multiple methods, including auscultation, observation of chest rise, and end-tidal CO2 monitoring, enhance the provider's confidence in accurate tube positioning. This step is crucial for ensuring effective respiratory support.


9. Securing the Tube

Stabilizing the endotracheal tube in place using tape or commercial securing devices is the final step in the procedure. Confirming that the securing mechanism is not too tight is crucial, allowing for adequate ventilation while preventing accidental extubation. Proper securing ensures the stability of the airway and ongoing respiratory support.


10. Post-Intubation Care

After successful intubation, continuous monitoring of the patient's vital signs and oxygenation is crucial. Securing the endotracheal tube in place and ensuring it remains correctly positioned are essential components of post-intubation care. This phase involves ongoing vigilance and adjustment to provide optimal respiratory support.


This step-by-step guide provides a structured approach to endotracheal intubation within the BLS framework. Regular practice and ongoing education are essential for BLS providers to maintain proficiency in this critical life-saving skill.

What are the components of the Endotracheal Tube?

An endotracheal tube is a medical device with several components designed to secure a patient's airway during mechanical ventilation or other respiratory interventions. The main parts of an endotracheal tube include:

  1. Tube Body: The main, flexible tube portion inserted through the mouth (or nose) into the trachea to facilitate air passage.
  2. Cuff: A balloon-like inflatable cuff near the tube's distal end. The cuff is inflated once the tube is in the trachea to create a seal, preventing air leakage and reducing the risk of aspiration.
  3. Inflating Port: A small port or valve outside the tube that connects to the cuff. This port allows healthcare providers to inflate or deflate the cuff using a syringe, regulating the pressure inside the cuff.
  4. Murphy's Eye: A side opening or aperture near the distal tip of the tube. The Murphy's eye ensures a secondary passage for airflow in case the main opening becomes obstructed.
  5. Connector: The proximal end of the tube has a standard connector designed to attach to a ventilator or other respiratory equipment.
  6. Pilot Balloon: A small, inflatable balloon attached to the cuff via a tube. It serves as a visual indicator of cuff inflation, allowing healthcare providers to monitor cuff pressure.
  7. Cuff Pilot Tube: A narrow tube connecting the pilot balloon to the cuff, enabling the inflation and deflation of the cuff.
  8. Depth Markings: Graduations or markings on the tube that help healthcare providers estimate the depth of tube insertion and position it appropriately in the trachea.
  9. Radiopaque Line: A line or stripe made of radiopaque material along the length of the tube. This feature allows for visualization of the tube's position on X-rays or other imaging studies.
  10. High-Volume, Low-Pressure Cuff: Some endotracheal tubes come with cuffs designed to minimize pressure on the tracheal wall, reducing the risk of complications.


It's important to note that variations exist among endotracheal tubes, and the specific design and features varies based on factors such as patient age, intended use, and manufacturer specifications.


How does endotracheal tube size selection vary for different age groups, particularly pediatrics vs. adults?

Endotracheal tube size selection varies significantly between pediatric and adult populations. In pediatrics, age-based formulas and weight-based criteria are commonly used, with a preference for uncuffed tubes in very young children. Pediatric tubes are more flexible and range in size from 2.0 to 6.0 mm for neonates and infants.

In adults, size selection is based on gender and height, and cuffed tubes are commonly used for a better seal. Adult tubes are less flexible, with sizes typically ranging from 7.0 to 9.0 mm. Continuous monitoring and confirmation of tube placement are crucial in both age groups for optimal airway management.


What is the potential complication of low pressure in the endotracheal tube cuff?

One potential complication of low pressure in the endotracheal tube cuff is the risk of inadequate sealing around the trachea. The cuff's primary purpose is to create a seal, preventing air leakage or secretions and minimizing the risk of aspiration. When the cuff pressure is too low, it fails to maintain an effective seal, allowing air to escape. This leads to a decrease in the efficacy of mechanical ventilation, compromising respiratory support for the patient.

Additionally, inadequate cuff pressure increases the likelihood of microaspiration, which is the aspiration of small amounts of secretions or contaminants past the cuff into the lower airways. This microaspiration contributes to developing ventilator-associated pneumonia (VAP) and other respiratory complications. Therefore, maintaining appropriate cuff pressure is crucial for ensuring the safety and effectiveness of endotracheal tube management. Regular monitoring and cuff pressure adjustment are essential components of airway management protocols in clinical settings.


What is a reinforced endotracheal tube?

A reinforced endotracheal tube is a specialized type of endotracheal tube designed with additional layers of material to enhance its structural integrity and prevent kinking or collapse. These tubes are commonly used when a standard endotracheal tube might be at risk of deformation, especially during procedures or patient movements. The reinforcement is typically achieved by incorporating layers of wire or other materials into the tube wall, providing added strength and resistance to compression. Key features and considerations of reinforced endotracheal tubes include:

  1. Structure: The tube's construction includes a layer of reinforcement, often made of wire, embedded within the wall of the tube. This reinforcement helps maintain the tube's shape and patency.
  2. Applications: Reinforced endotracheal tubes are frequently used in surgeries or medical procedures where the patient's head and neck might be manipulated, increasing the risk of tube deformation.
  3. Flexibility: Despite the added reinforcement, these tubes are designed to remain flexible enough for proper insertion and positioning in the trachea.
  4. Sizes: Like standard endotracheal tubes, reinforced versions come in various sizes to accommodate different patient populations, from neonates to adults.
  5. Use in Specialized Procedures: They are often employed in situations such as head and neck surgeries, dental procedures, and other scenarios where the risk of kinking or compression is elevated.
  6. Radiolucency: Some reinforced tubes are designed to be radiolucent, allowing for imaging procedures without interference.
  7. Cuff Options: Reinforced endotracheal tubes comes with high-volume, low-pressure cuffs to effectively seal the trachea while minimizing the risk of pressure-related complications.


While reinforced endotracheal tubes offer advantages in specific clinical scenarios, their use is typically dictated by the nature of the procedure or patient condition. Healthcare providers assess the potential risks and benefits to determine the most suitable type of endotracheal tube for a given situation.


What are the considerations for endotracheal intubation in patients with specific conditions like asthma, COPD, or neck injuries?

Endotracheal intubation in patients with specific conditions, such as asthma, chronic obstructive pulmonary disease (COPD), or neck injuries, requires careful consideration to minimize complications and ensure successful airway management. Here are the key considerations for each condition:



During intubation, administer bronchodilators like albuterol for asthmatic patients to mitigate bronchoconstriction risk. Choose sedation carefully, favoring short-acting agents to avoid respiratory depression. Continuously monitor respiratory parameters, including peak flow, and consider rapid sequence intubation (RSI) for reduced aspiration risk and shorter apnea duration.


Chronic Obstructive Pulmonary Disease (COPD)

During intubation in COPD patients, prioritize strategies to address hypoxemia, including thorough preoxygenation and administering bronchodilators. Adopt a slower ventilation rate and higher PEEP levels to prevent complications. Exercise caution with sedation, titrating medications carefully, and opting for agents with shorter durations of action to avoid respiratory depression. 


Neck Injuries

In neck injury cases, ensure cervical spine protection using manual in-line stabilization (MILS) during intubation to maintain alignment and minimize neck movement. Consider video laryngoscopy or fiberoptic intubation to reduce motion. Rapid Sequence Intubation (RSI) is often preferred to minimize apnea time and aspiration risk. In high-risk situations, explore alternative airway techniques, like awake fiberoptic intubation, to mitigate the risk of exacerbating spinal cord injuries.


How does an endotracheal tube use differ in emergencies compared to planned surgical procedures?

In emergency situations, endotracheal intubation is performed urgently with limited preoxygenation, often using Rapid Sequence Intubation (RSI) due to the immediate life-threatening nature. There are constraints in equipment and patient stability.

In planned surgical procedures, there is more time for thorough preparation, careful medication selection, and consideration of surgical factors. The controlled environment allows for optimal airway management with routine use of neuromuscular blockade and the availability of backup plans.


What are the specific challenges and solutions for prolonged endotracheal intubation in critical care?

Prolonged endotracheal intubation in critical care settings presents challenges requiring careful management. Here are some challenges and corresponding solutions:

  1. Ventilator-Associated Complications: Prolonged intubation increases the risk of ventilator-associated complications, including ventilator-associated pneumonia (VAP) and ventilator-associated lung injury.
  2. Airway Complications: Extended intubation leads to airway-related issues such as mucosal damage, ulcerations, and the development of granulation tissue.
  3. Communication Barriers: Patients experiences difficulty communicating, leading to frustration and psychological distress.
  4. Risk of Tracheostomy: Prolonged intubation necessitates tracheostomy placement, introducing additional risks and complexities.



Here are the solutions to address these challenges:

  • Implement regular assessments for extubation readiness to minimize the duration of intubation and reduce complications.
  • Enforce comprehensive oral care protocols to mitigate the risk of ventilator-associated pneumonia and airway-related complications.
  • Employ alternative communication methods, such as communication boards or assistive devices, to address challenges in verbal communication.
  • Introduce early mobility and rehabilitation programs to prevent deconditioning associated with prolonged immobility.
  • Provide psychosocial support to alleviate the emotional and psychological impact of prolonged intubation.
  • Consider tracheostomy when prolonged intubation is anticipated, facilitating weaning and improving patient comfort.
  • Maintain vigilant monitoring through a multidisciplinary approach to detect and address complications promptly.


How does patient positioning affect endotracheal intubation and tube management?

Patient positioning, whether supine or prone, affects endotracheal intubation and tube management. In the supine position, direct laryngoscopy is standard, and cervical spine alignment is crucial. Ventilation challenges and the risk of gastric aspiration should be considered.

In the prone position, airway access is challenging, and alternative techniques like video laryngoscopy is preferred. Cervical spine alignment is still important. Tube fixation, confirmation of placement, and awareness of pressure points are critical in both positions. Careful consideration of clinical context and patient factors is necessary for optimal airway management.


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Laryngeal Tube vs Endotracheal Tube

The laryngeal tube is a supraglottic airway device inserted blindly through the mouth, creating a seal above the glottis. It is commonly used in emergency situations where rapid airway management is needed, and it requires less training compared to endotracheal intubation.

On the other hand, the endotracheal tube is a flexible tube inserted directly into the trachea through visualization using laryngoscopy. It provides controlled ventilation and is commonly employed in surgical procedures and intensive care settings. T

he choice between the two depends on the clinical scenario, patient condition, and the specific requirements of airway management in a given situation, with laryngeal tubes favored in quick-response scenarios and endotracheal tubes in situations requiring precise control over ventilation.


Are there any advancements in endotracheal tube technology for better patient outcomes?

Yes, there are continuous advancements in endotracheal tube technology aimed at improving patient outcomes. Some notable trends and advancements include:

  • Subglottic Suctioning: Endotracheal tubes with subglottic suction ports help reduce the incidence of ventilator-associated pneumonia (VAP) by enabling the removal of secretions above the cuff.
  • Cuffed Tubes with Pressure Monitoring: Cuffed endotracheal tubes equipped with pressure monitoring systems provide real-time feedback on cuff pressure. Maintaining optimal cuff pressure helps prevent complications such as tracheal injury and aspiration.
  • Tapered Cuff Designs: These designs aim to improve the cuff and tracheal wall seal, reducing the risk of microaspiration and enhancing ventilation.
  • Antimicrobial Coatings: Some endotracheal tubes incorporate antimicrobial coatings to mitigate the risk of infections associated with prolonged intubation.
  • Endotracheal Tubes with Camera Systems: Video-assisted intubation systems integrated into endotracheal tubes provide improved visualization during intubation, potentially reducing the difficulty of the procedure.
  • Shape-Memory Tubes: Shape-memory endotracheal tubes designed to conform to the patient's airway anatomy aim to enhance ease of intubation and reduce the risk of complications.
  • Ultrasound-Guided Intubation: Integrating ultrasound technology into the intubation process allows for real-time visualization of the airway structures, aiding in difficult airway management.
  • Wireless Communication and Monitoring: Advancements in connectivity enable wireless communication and monitoring of endotracheal tube parameters, providing healthcare providers with continuous data on cuff pressure, temperature, and other relevant metrics.
  • Reduced Cuff Pressures: Innovations in cuff design and materials aim to provide a better seal at lower cuff pressures, reducing the risk of complications associated with high pressures.
  • Improved Materials: The use of novel materials, such as polyurethane and silicone, in endotracheal tube construction, contributes to enhanced flexibility, biocompatibility, and patient comfort.
  • Customizable Tube Lengths: Endotracheal tubes with customizable lengths cater to variations in patient anatomy, allowing for a more tailored and comfortable fit.


It's important to note that adopting these advancements varies across healthcare institutions, and the choice of endotracheal tube technology depends on factors such as patient characteristics, clinical requirements, and institutional preferences. Healthcare providers should stay informed about the latest developments and evidence-based practices in airway management for improved patient outcomes.


What are the protocols for weaning and extubation of an endotracheal tube?

Weaning and extubation protocols aim to safely remove an endotracheal tube while minimizing the risk of complications and ensuring adequate respiratory function. The specific protocols varies among healthcare institutions, but here are general considerations and steps often included in weaning and extubation processes:


Endotracheal Tube Weaning Protocols

  1. Assessment for Readiness: Regularly assess the patient's readiness for weaning from mechanical ventilation. Criteria includes improvement in the underlying condition, stable hemodynamics, and satisfactory oxygenation.
  2. Sedation Vacation: Conduct sedation vacations to assess the patient's level of consciousness and spontaneous breathing ability. This helps determine the readiness for weaning.
  3. Spontaneous Breathing Trials (SBT): Initiate spontaneous breathing trials, typically by transitioning the patient to a T-piece or a low-level pressure support ventilation. Monitor the patient's respiratory parameters and tolerance during the trial.
  4. Weaning Parameters: Evaluate parameters such as respiratory rate, tidal volume, and rapid shallow breathing index during spontaneous breathing trials. Use established weaning criteria to assess the patient's ability to sustain unassisted breathing.
  5. Monitoring Blood Gases: Monitor arterial blood gases during SBTs to ensure adequate oxygenation and ventilation.
  6. Cardiorespiratory Stability: Ensure cardiovascular stability during weaning by monitoring heart rate, blood pressure, and other relevant parameters.


Endotracheal Tube Extubation Protocols:

  1. Successful SBT: Completing spontaneous breathing trials is a prerequisite for extubation.
  2. Adequate Secretion Management: Ensure adequate secretion management to prevent post-extubation complications. Suction the airway as needed.
  3. Gag Reflex Assessment: Assess the patient's ability to protect the airway by checking for the return of the gag reflex.
  4. Cuff Deflation: Gradually deflate the endotracheal tube cuff and assess for any signs of airway obstruction or stridor.
  5. Confirmation of Readiness: Confirm the patient's readiness for extubation based on clinical criteria, such as improved mental status, stable respiratory status, and appropriate cough reflex.
  6. Preoxygenation: Administer preoxygenation to optimize oxygen reserves before extubation.
  7. Elevation of Head: Elevate the patient's head to reduce the risk of aspiration.
  8. Coordination with Breathing: Coordinate extubation with the patient's spontaneous breath, reducing the risk of laryngeal trauma.
  9. Post-Extubation Monitoring: Monitor the patient closely after extubation for signs of respiratory distress, stridor, or other complications.
  10. Supplemental Oxygen: Administer supplemental oxygen as needed post-extubation to maintain adequate oxygenation.
  1. Document Extubation Details: Document the details of the extubation process, including the reason for extubation, the condition of the patient, and any relevant observations.
  1. Post-Extubation Plan: Develop a post-extubation plan, which includes monitoring for potential complications, administering respiratory treatments, and determining the need for further respiratory support.


It's crucial to individualize weaning and extubation protocols based on the patient's specific clinical condition and response to the weaning process. Continuous assessment, close monitoring, and prompt intervention in case of complications are essential components of successful weaning and extubation.


How does the presence of an endotracheal tube impact oral and dental care?

The presence of an endotracheal tube impacts oral and dental care by contributing to dry mouth, accumulation of oral secretions, and dental plaque formation. Adequate oral hydration and regular suctioning are crucial to prevent complications such as aspiration and ventilator-associated pneumonia (VAP). Prolonged intubation leads to gum and mucosal health issues, necessitating gentle oral care. Proper securement of the endotracheal tube is essential to prevent oral trauma, and alternative communication methods should be employed to address communication challenges. Patients with dentures or oral appliances require careful maintenance, and hospitals often implement oral care protocols to guide healthcare providers in maintaining oral hygiene and preventing complications. Regular monitoring and collaboration among healthcare professionals are key components of comprehensive oral care for intubated patients.


How does endotracheal tube management differ in mobile settings from stationary medical facilities?

Endotracheal tube management in mobile settings, such as ambulances and helicopters, requires special considerations due to limited space, vibrations, and potential movement during transport. Securing the tube is critical to prevent dislodgment. Healthcare providers must adapt to challenges in communication, monitoring, and ventilation, ensuring efficient interventions in time-sensitive situations. Training and protocols focus on the unique demands of mobile environments for optimal patient care.




  • American Heart Association (AHA) Guidelines for CPR and Emergency Cardiovascular Care.
  • Difficult Airway Society (DAS) Guidelines for the Management of Tracheal Intubation in Critically Ill Adults
  • American Society of Anesthesiologists (ASA)
  • American Association for Respiratory Care (AARC)