Indication: Need for ventilator assistance or airway control and other airway management is inadequate or ineffective.
Nasotracheal Intubation: The patient must be ≥ 8 years of age and be breathing spontaneously.
Do not use nasotracheal intubation if the patient is < 50 years of age and suffering from a current episode of asthma exacerbation and not near cardiac arrest or in cardiac arrest, do not use if patient has a suspected basal skull fracture or mid-face fracture, has uncontrolled epistaxis, is on anticoagulant therapy (excluding ASA) or suffers from bleeding disorders.
Clinical Considerations: You may make 2 attempts at intubation / insertion of a supraglotic airway (an attempt is defined by the insertion of laryngoscope blade into the mouth). At least 2 primary and 1 secondary ETT placement methods must be used.
ETT placement must be reconfirmed immediately after the patient is moved.
- Attempt basic manoeuvres as needed: positioning, suctioning, pharyngeal airway insertion, and BVM IPPV in addition to application of 100% O2. Initiate cardiac monitoring, and pulse oximetry (if available).
- If patient has suspected severe head injury or suspected severe CVA, administer Lidocaine 1.0 mg/kg IV over one minute, 3 minutes prior to intubation. *
- When required, administer topical anesthesia and other adjuncts:
o Oral intubation: Administer Lidocaine spray pre intubation in the hypopharynx or directly onto the vocal cords. Wait at least 60 seconds before instrumentation.
o Nasal Intubation (≥ 8 years): Administer phenylephrine spray (0.5%) or xylometazoline (Otrivin) spray (0.1%) x 2 into each nare. Administer Lidocaine spray into each nare. Administer Lidocaine spray in the hypopharynx (if possible). Wait at least 60 seconds before instrumentation.
o Dose of Lidocaine spray for topical anesthesia: Lidocaine spray (10mg/spray) Maximum dose is 5mg/kg (5 sprays per 10 kg). Do not exceed 20 sprays total.
Note total dose of Lidocaine including any given IV is 5 mg/kg.
- Pre-oxygenate the patient for 30-60 seconds with 100% O2 (and IPPV, if required).
- Choose the appropriate size ETT and check the cuff.
- Intubate the trachea, confirm tube placement, and secure the tube (see Intubation Confirmation Protocol). Consider use of C-spine collar to minimize the risk of ETT displacement.
- If intubation is unsuccessful after 30 seconds, stop and re-oxygenate. The paramedic may repeat attempt beginning at Step 4 and/or initiate immediate transport.
- Ventilate the patient with BVM.
- If the patient is combative or agitated refer to the Auxiliary Patient Sedation Protocol.
Confirming Tube Placement
Capnography Device (preferred method)
- Attach the sensor between the BVM and the ETT.
- Verify presence of waveform and document numeric display on monitor.
- If unable to obtain CO2 tracing (including the four-phase waveform) re-confirm ETT by visualization or extubate (unless VSA patient with ETT confirmed by other means).
Capnometer Device (disposable/secondary)
- The colour indicator of the product dome should initially be purple and match or be darker than the “CHECK” strip on the device. If the indicator does not match the “CHECK” strip, then do not use. Attach the device between the BVM and the ETT. Use a device appropriate for pediatric patients if patient <15 kg.
- Administer 6 breaths for purposes of interpretation.
- The colour will fluctuate during inspiration and expiration. Compare colour at full end-expiration. (Device reliable for at least 30 minutes after exposed to the atmosphere.)
Capnometer Colour Ranges
(colours are specific to device manufacturer)
“A” end-tidal CO2 level <4 mmHg (0.03 – 0.5% ETCO2)
- ETT in esophagus OR compromised perfusion/ventilation OR VSA
- Re-confrm ETT placement by visualization of cords or
- Remove ETT and re-intubate as per Intubation Protocol (unless VSA patient with ETT confirmed by other means)
“B” end-tidal CO2 level 4 to 15 mmHg (0.5 – 2% ETCO2)
- Possible retained CO2 in esophagus OR possible low pulmonary perfusion or hypocarbia
- Deliver 6 additional breaths
- If colour shifts to “A” then remove ETT and re-intubate (unless VSA patient with ETT confirmed by other means)
- If colour shifts to “C” then ETT in trachea (confirm with additional methods)
- If colour stays as “B” then indeterminate; confirm ETT placement by other means or remove ETT and re-intubate if unable to confirm.
“C” end-tidal CO2 level 15 to 38 mmHg (2 – 5% ETCO2)
- ETT in trachea
- Confirm tube placement by other criteria outlined in the Intubation Protocol
- Continue with appropriate patient management protocols
- The ETCO detecting devices are not to be used for the detection of hypercarbia or the detection of right main stem bronchial intubation.
- Paramedics should primarily utilize ETCO2 values as an adjunct to assist with ETT confirmation. Continuous ETCO2 may be helpful to assist with determining the appropriate ventilatory rates and volumes, however, monitoring clinical signs and airway resistance with the BVM should be primarily used for determining good oxygenation and ventilation.
- A patient who is VSA or has very poor perfusion may have a very low or non-detectable ETCO2 value. Although ETCO2 should still be determined in a VSA patient, other methods of confirmation should be used if a waveform is not detected or colour B or C is detected. In fact, VSA patients with no detectable ETCO2 have a worse prognosis.
- Re-confirmation should be performed by at least one method any time the patient is moved, or if ETT dislodgment is suspected. When available, capnography should be used. If only a capnometry device is used, it can be re-used reliably for the same patient for at least 30 minutes. Reliability is confirmed by colour change with each respiratory cycle.
- Try to minimize secretion accumulation at sensor/device site.