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 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.

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.

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.

Limit the total to three intubation attempts. If intubation remains unsuccessful or is not feasible, use an alternate airway such as an SGA; for a short transport, BVM ventilation may be appropriate.
If only right-sided sounds are present, suspect mainstem placement and withdraw in 1 cm steps while reassessing, without withdrawing past the 20 cm mark at the upper teeth/gum. If only left-sided sounds are present, consider pneumothorax or other thoracic abnormality.
Extubation is indicated when ventilation through the tube fails despite considering suction, the patient cannot tolerate the tube after awakening, or a cuff/equipment failure prevents adequate ventilation. 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.