Endotracheal intubation is a critical lifesaving procedure commonly performed in emergency departments, ICUs, and operating rooms. It involves inserting a tube into the trachea to maintain an open airway, deliver oxygen, or administer anesthesia. Understanding when and why to intubate a patient is fundamental to safe and effective medical care.
This article explains the indications for intubation, using the mnemonic “Get your Music CD Repaired Please, I’ll Appreciate” to cover the main clinical scenarios that demand this procedure. Whether you're a medical student, emergency physician, or ICU nurse, this evidence-based overview will clarify the rationale, criteria, and steps for intubation.
Mnemonic for Indications of Intubation
"Get your Music CD Repaired Please, I’ll Appreciate"
Each word in the mnemonic corresponds to a clinical indication:
| Mnemonic Part | Clinical Indication |
|---|---|
| Get | General anesthesia |
| your Music | Multisystem disorder |
| CD | Cardiac arrest, Respiratory arrest |
| Repaired | Respiratory arrest |
| Please | Protect airway from aspiration |
| I’ll | Inadequate oxygenation or ventilation |
| Appreciate | Airway obstruction |
This structure helps clinicians recall key indications in high-pressure situations.
1. General Anesthesia
Intubation is essential during major surgeries that require deep sedation and complete control of the airway. General anesthesia leads to loss of airway reflexes, muscle tone, and spontaneous breathing.
Why Intubate?
- Prevent hypoventilation and airway collapse.
- Facilitate mechanical ventilation.
- Allow for delivery of anesthetic gases and oxygen.
Procedures Requiring Intubation:
- Neurosurgery
- Cardiothoracic surgery
- Major abdominal or orthopedic operations
2. Multisystem Disorder
Patients with multiple organ failures or systemic illnesses may require intubation to prevent respiratory decompensation.
Common Scenarios:
- Septic shock
- Multi-organ dysfunction syndrome (MODS)
- Acute pancreatitis with respiratory compromise
- Trauma with compromised airway reflexes
Indications:
- Rising work of breathing
- Impaired consciousness
- Need for hemodynamic and respiratory control
3. Cardiac Arrest
During cardiopulmonary resuscitation (CPR), early airway management is essential for effective oxygen delivery and carbon dioxide removal.
Intubation Role in Cardiac Arrest:
- Secure airway during chest compressions
- Enable delivery of 100% oxygen
- Reduce risk of aspiration
Considerations:
- Intubation should not delay chest compressions.
- Use of supraglottic airways may precede intubation in some protocols.
4. Respiratory Arrest
Respiratory arrest is the complete cessation of breathing and represents an absolute indication for immediate intubation.
Causes of Respiratory Arrest:
- Drug overdose (e.g., opioids, benzodiazepines)
- Stroke
- Airway obstruction (e.g., choking, anaphylaxis)
- Neuromuscular disorders (e.g., Guillain-Barré)
Goals of Intubation:
- Restore oxygenation and ventilation
- Prevent brain injury due to hypoxia
- Enable mechanical support
5. Protection Against Aspiration
When a patient cannot protect their airway, for example, due to impaired consciousness, vomiting, or severe reflux, intubation is needed to prevent aspiration pneumonia.
High-Risk Situations:
- Coma or GCS ≤ 8
- Seizures
- Drug intoxication
- Post-trauma
Preventive Role:
- Maintains airway patency
- Allows suctioning of secretions or gastric contents
- Avoids life-threatening aspiration events
6. Inadequate Oxygenation or Ventilation
This is one of the most common reasons for emergency intubation, especially in ICU and emergency settings.
Signs of Inadequate Oxygenation:
- SpO₂ < 90% despite high-flow oxygen
- Arterial PaO₂ < 60 mmHg
- Cyanosis
- Accessory muscle use
Signs of Inadequate Ventilation:
- Rising PaCO₂ > 50 mmHg
- Acidosis on ABG (e.g., pH < 7.2)
- Tachypnea or bradypnea
- Exhaustion or altered mental status
Conditions Requiring Support:
- Acute Respiratory Distress Syndrome (ARDS)
- Severe asthma or COPD exacerbation
- COVID-19 pneumonia with hypoxemia
7. Airway Obstruction
Obstruction due to tumor, trauma, foreign body, anaphylaxis, or swelling requires urgent airway securing. Failure to act promptly can result in respiratory failure or death.
Common Causes:
- Epiglottitis
- Laryngeal edema (e.g., burns, allergies)
- Airway tumors
- Blood clots or foreign objects
- Tracheal compression by thyroid mass
Clinical Clues:
- Stridor
- Drooling
- Inability to speak or swallow
- Paradoxical chest movement
Summary Table: Indications for Endotracheal Intubation
| Indication | Example Conditions |
|---|---|
| General Anesthesia | Surgical procedures |
| Multisystem Failure | Septic shock, MODS |
| Cardiac Arrest | Myocardial infarction, arrhythmias |
| Respiratory Arrest | Opioid overdose, stroke |
| Airway Protection | GCS ≤ 8, seizures, intoxication |
| Hypoxia/Hypercapnia | ARDS, severe pneumonia |
| Airway Obstruction | Foreign body, tumor, anaphylaxis |
Intubation Techniques
Types of Intubation:
- Orotracheal (most common)
- Nasotracheal (less common, used when oral access is limited)
- Surgical airway (e.g., cricothyrotomy or tracheostomy)
Tools and Devices:
- Laryngoscope (Macintosh or Miller blades)
- Endotracheal tube (ETT)
- Stylet
- Bag-valve-mask (BVM)
- Suction apparatus
Confirmation of Placement
Verifying the correct placement of the ETT is crucial to prevent complications.
Confirmation Techniques:
- End-tidal CO₂ detector (gold standard)
- Bilateral chest rise
- Auscultation over lungs and epigastrium
- Chest X-ray (tip 2-3 cm above carina)
- Continuous waveform capnography
Complications of Intubation
| Early Complications | Late Complications |
|---|---|
| Hypoxia during attempts | Tracheal stenosis |
| Aspiration | Ventilator-associated pneumonia |
| Dental trauma | Vocal cord damage |
| Esophageal intubation | Tracheoesophageal fistula |
| Laryngospasm or bronchospasm | Barotrauma from overinflation |
Prevention Tip: Always pre-oxygenate, use sedatives appropriately, and follow difficult airway protocols.
Special Scenarios for Intubation
1. Pediatric Intubation
- Use age-appropriate tube size and blade
- Avoid cuffed tubes in infants unless necessary
- Monitor for bradycardia during insertion
2. Trauma Cases
- Suspect cervical spine injury → inline stabilization
- Consider rapid sequence intubation (RSI)
- Control bleeding or facial fractures first
3. COVID-19 Patients
- Use full PPE
- Prefer video laryngoscopy
- Minimize bag-mask ventilation
Step-by-Step Intubation Checklist
- Assess Indication
- Prepare Equipment
- Position the Patient (Sniffing Position)
- Pre-oxygenate with 100% O₂
- Administer Sedation and Paralysis (RSI)
- Insert Tube under Direct Visualization
- Confirm Placement
- Secure the Tube
- Start Mechanical Ventilation if Needed
Frequently Asked Questions (FAQs)
Q1. When is rapid sequence intubation (RSI) used?
A: RSI is used in emergencies to quickly secure the airway with minimal aspiration risk. It involves sedatives and paralytics without manual ventilation in-between.
Q2. What size ETT should be used for adults?
A: Common sizes: 7.0–8.0 mm for women, 8.0–9.0 mm for men.
Q3. Can intubation be done in conscious patients?
A: Yes, with topical anesthesia and mild sedation in awake fiberoptic intubation.
Q4. What are signs of failed intubation?
A: No chest rise, absent breath sounds, gastric sounds, hypoxia, no capnographic waveform.
Q5. How long can a patient remain intubated?
A: Typically up to 7–10 days. Longer durations may require tracheostomy.
