endotracheal intubation

Endotracheal intubation involves passing a cuffed tube through the vocal cords into the trachea, typically guided by direct or video laryngoscopy. Indications include failure to oxygenate or ventilate, inability to protect the airway (e.g., decreased GCS, absent gag reflex), anticipated clinical course (e.g., worsening airway edema in burns/anaphylaxis), and need for general anesthesia or paralysis. Rapid sequence intubation (RSI) is commonly used, combining an induction agent (e.g., etomidate, propofol, ketamine) with a paralytic (succinylcholine or rocuronium) to optimize intubating conditions and minimize aspiration risk. Correct placement is confirmed by direct visualization of the tube passing through the cords, bilateral breath sounds, absence of epigastric sounds, condensation in the tube, and most reliably by end-tidal CO2 detection (capnography) and chest X-ray showing tip 3-5 cm above the carina. Complications include esophageal intubation (life-threatening if missed), right mainstem bronchus intubation, dental/oral trauma, vocal cord injury, laryngospasm, aspiration, hypoxia during attempts, and post-extubation complications like laryngeal edema or subglottic stenosis with prolonged intubation. Difficult airway predictors are assessed using tools like the Mallampati score, thyromental distance, and LEMON criteria. Alternatives/adjuncts for difficult airways include video laryngoscopy, bougie, laryngeal mask airway (LMA), and surgical airway (cricothyrotomy) as a last resort. Contraindicated relative situations include severe laryngotracheal trauma where surgical airway may be preferred. Ventilator management post-intubation requires setting appropriate tidal volume (6 mL/kg ideal body weight in ARDS), PEEP, and FiO2 to avoid ventilator-induced lung injury.