Key messages

• Ensure that the appropriate equipment is available and checked.

• Ensure that head positioning is correct.

• Rapid-sequence induction is almost always indicated in the critically ill patient. Equipment

1. Endotracheal tube: choose the appropriate size, but have one tube each of a size larger and smaller than calculated. Cut to the calculated length and insert a 15-mm male connector.

2. A 10-ml syringe is required to inflate the tracheal cuff. Check the function of cuffs before use.

3. A catheter mount is required to connect the endotracheal tube to the ventilating circuit.

4. A heat and moisture exchanger/bacterial filter is interposed between the catheter mount and the ventilating circuit, preventing contamination of the ventilator by any pathogens in the expired gases or respiratory secretions.

5. Magill's forceps allow manipulation of the distal endotracheal tube into the larynx, if necessary, and removal of foreign bodies.

6. Gum elastic bougie: if placement of the endotracheal tube proves difficult, this flexible introducer can be passed through the cords and a tube 'railroaded' over it.

7. Oral airways (Guedel airways) in a range of sizes.

8. Laryngoscope: in adults a Macintosh blade is appropriate (both right- and left-handed instruments are available).

9. Face mask: select a moulded face mask of appropriate size for preintubation oxygenation and manual ventilation of the lungs if intubation proves prolonged and difficult, or impossible. These should be of the contoured type with a cushioned edge to allow a leak-free seal around the mouth and nose.

10. Ventilating bag and oxygen connection: a high-flow oxygen circuit with a non-rebreathing ventilating bag (2-liter capacity) and an adjustable pressure-limiting valve.

11. Nasal airways are required if there is intra-oral injury or a good airway is not obtained with the use of an oral airway.

12. Medical suction for aspiration of vomitus, blood, and airway secretions.

13. Resuscitation drugs and equipment.

14. A laryngeal mask can be used as a temporary aid to ventilating a patient if intubation with an endotracheal tube proves impossible. Head position

In order to minimize the angle difference between the oral cavity and the larynx, the ideal position is for the cervical spine to be slightly flexed by placing the head on a low pillow or in a head ring, and for the head to be extended on the neck by tilting it back towards the intubator. Care must be taken for those with limited cervical mobility or cervical spine injury. While the laryngoscope is held in one hand, the free hand can maintain the head position and can also be used to keep the lips clear of the laryngoscope blade and so prevent damage to them.

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