FIELD REFERENCE
Full criteria & treatment guidance
Tube confirmation is continuous
- Use clinical findings and sustained quantitative waveform capnography together; ETCO2 alone does not exclude mainstem or oropharyngeal placement.
- Do not exceed three total intubation attempts. Move to BVM or an alternate airway when intubation is unsuccessful or not feasible.
- If epigastric sounds suggest esophageal placement, remove the tube immediately.
- A displaced-tube waveform may show a falling, irregular signal rather than an immediate zero; reassess the patient, tube depth, breath sounds, and capnography trend.
Confirm the indication
- PR-030 applies to an apneic patient weighing more than 80 lb (36 kg), respiratory arrest, respiratory depression with a weak or absent gag reflex, or an unresponsive patient with respiratory depression.
- Do not intubate when there are obvious signs of death or a valid do-not-resuscitate order applies.
Prepare & preoxygenate
- Prepare laryngoscope blades, cuffed 6.5-8.0 tubes with syringe, stylet, Magill forceps, suction, BVM and oxygen, nasal cannula when available, quantitative waveform ETCO2, water-soluble lubricant, a bougie, and a tube-securing device.
- Check the cuff for leaks. Position for the best glottic view, or maintain in-line cervical stabilization for trauma. Suction secretions or blood from the oropharynx.
- Preoxygenate with BVM and high-flow oxygen. Continue BVM support except during tube insertion; use high-flow nasal oxygen during the attempt when time and equipment allow.
Place the tube
- Insert the laryngoscope and optimize the view of the glottic opening. Remove a visualized solid foreign body with Magill forceps.
- Pass the tube through the cords so the cuff rests about 0.5-1 cm below them. If the opening is not well seen, use a bougie in the expected glottic location and advance the tube over it only after the guide is properly placed.
- Secure the tube while removing the stylet, then inflate the cuff until the pilot balloon is firm or with 10 mL. Ventilate with BVM attached to 100% oxygen when available.
Confirm & continuously reassess
- Listen first over the epigastrium. If gastric sounds are present, remove the tube immediately and reattempt as appropriate. Observe chest rise and listen over both lungs.
- Confirm with quantitative waveform ETCO2, secure the tube, and repeatedly reassess bilateral breath sounds, tube depth, and a sustained waveform. ETCO2 does not by itself exclude right-mainstem or oropharyngeal placement.
- In cardiac arrest, ETCO2 values of 10-30 mm Hg may occur because pulmonary blood flow is reduced. A reading below 10 mm Hg requires checking tube position, breath sounds, and epigastric sounds rather than assuming placement is correct.
Failed attempts, extubation & documentation
- Limit the total to three intubation attempts. If intubation remains unsuccessful or is not feasible, maintain ventilation with BVM or an authorized alternate airway. An SGA under PR-135 requires a patient weighing at least 50 kg and all other PR-135 criteria; being eligible for intubation does not by itself establish SGA eligibility. For a short transport, BVM ventilation may be appropriate.
- If only right-sided sounds are present, suspect mainstem placement: deflate the cuff, carefully withdraw the tube 1 cm, and reassess breath sounds. PR-030 permits repeated withdrawal but directs not withdrawing past the 20 cm mark at the upper teeth/gum. If only left-sided sounds are present, consider pneumothorax or another thoracic abnormality and leave the tube in place if adequate ventilation is possible. Continue the complete placement-confirmation and ventilation checks.
- Extubation indications in PR-030 include failure to ventilate despite considering suction, awakening with inability to tolerate the tube, or cuff/equipment failure that prevents adequate ventilation. PR-030 separately addresses coughing or intolerance when the tube is still required to maintain ventilation: consider sedation only within the applicable standing order, perfusion criteria and base-order requirements. Do not treat tube intolerance as an automatic removal instruction. When extubation is indicated, suction, turn the patient or head to the side when appropriate, deflate the cuff, remove during exhalation, and provide oxygen.
- Document tube size, depth at the upper teeth or gums, insertion time, breath sounds, ETCO2 value and waveform confirmation, attempts, problems, and complications.
VISUAL FIELD REFERENCE
Tube confirmation needs more than a number
Over 36 kg · ALS
Confirmation and fallback checkpoints. Follow the full preparation, placement, and reassessment procedure.
Clinical findings
Listen first over the epigastrium. If gastric sounds are present, remove the tube immediately and reattempt as appropriate. Observe chest rise and listen over both lungs.
Sustained waveform + repeated checks
Confirm with quantitative waveform ETCO2, secure the tube, and repeatedly reassess bilateral breath sounds, tube depth, and a sustained waveform. ETCO2 does not by itself exclude right-mainstem or oropharyngeal placement.
- Maximum 3 attempts
If intubation is unsuccessful
Limit the total to three intubation attempts. If intubation remains unsuccessful or is not feasible, maintain ventilation with BVM or an authorized alternate airway. An SGA under PR-135 requires a patient weighing at least 50 kg and all other PR-135 criteria; being eligible for intubation does not by itself establish SGA eligibility. For a short transport, BVM ventilation may be appropriate.
- Use clinical findings and sustained quantitative waveform capnography together; ETCO2 alone does not exclude mainstem or oropharyngeal placement.
Selected checkpoints; read the complete guide for criteria, exclusions, doses, and ongoing care. PR-030
UNDERSTAND THE CARE
Why tube placement and effective ventilation are different checks
Tube passage is only one step in airway management. Preparation includes preoxygenation, suction, appropriate equipment and a plan if the attempt fails. Maintain the source’s attempt limit and coordinate tasks so repeated attempts do not replace necessary ventilation support.
Applying the guidance
Confirmation combines clinical findings with quantitative waveform capnography. Breath sounds and depth remain important because a waveform alone does not exclude mainstem or other malposition described in the source. Reassess after movement and when the waveform, chest rise or clinical state changes. Document attempts, depth, confirmation method and ongoing findings rather than recording only “intubated.”
Repeat airway confirmation
Putting it together
Teaching example: after transfer to the stretcher, chest rise becomes asymmetric and the waveform changes. Reassess position, depth, sounds and ventilation immediately instead of treating the earlier confirmation as permanent.
Diagram text & teaching checkpoints
- Preparation
- Oxygenation, suction, equipment and backup.
- Attempt
- Follow technique and total-attempt limit.
- Confirmation
- Clinical findings AND sustained waveform.
- Reassessment
- Depth, bilateral ventilation and movement checks.
Sources for this explanation
Original OCMedic teaching synthesis of the references below. Educational expansion updated ; this is not a new independent clinical-review date. Source-specific dates and limitations remain in the full guidance.
A complete confirmation report has several parts
Describe tube passage, ventilation and ongoing position as separate observations. Seeing a tube placed is not the same record as demonstrating effective bilateral ventilation afterward. Likewise, an ETCO₂ number without its waveform and clinical context does not explain the entire confirmation assessment described in PR-030.
A handoff should include the tube size, depth reference, attempts and insertion time, followed by the actual confirmation findings and current ventilation assessment. State whether those findings were rechecked after movement. If the depth or breath sounds changed, include the change and response rather than reporting only the original successful placement.
When an attempt is unsuccessful, the count still belongs in the continuing record. Transferring care to another clinician does not erase earlier attempts or the procedure’s total-attempt limit. Explain what ventilation support is currently working and what alternate airway plan is being used. This keeps the focus on the patient’s oxygenation and ventilation while preserving the placement evidence the receiving team needs to assess the airway.
Sources: PR-030