ICU Procedure Guide

Endotracheal Intubation & Rapid Sequence Intubation

A physiologically safe ICU intubation workflow from preparation and preoxygenation through laryngoscopy, tube confirmation and post-intubation stabilization.

Competency & safety: For clinicians trained and credentialed in airway management. Use a local difficult-airway algorithm and call for experienced airway help early when difficulty is predicted.

AI-generated ICU Knowledge Map summary infographic for rapid sequence intubation, including indications, physiologic and airway risk, preparation, intubation sequence, waveform capnography confirmation, and complications. — AI-generated educational illustration reviewed for alignment with the accompanying ICU Knowledge Map topic. The topic text and cited references remain the source of truth for clinical decisions. Tap or click the image to open it full size.

Educational ICU procedure visual: ICU Rapid Sequence Intubation — Safe Sequence. — AI-generated educational illustration reviewed for alignment with the accompanying ICU Knowledge Map topic. The topic text and cited references remain the source of truth for clinical decisions. Tap or click the image to open it full size.

Educational ICU procedure visual: Post-Intubation Confirmation & Failed-Airway Rescue. — AI-generated educational illustration reviewed for alignment with the accompanying ICU Knowledge Map topic. The topic text and cited references remain the source of truth for clinical decisions. Tap or click the image to open it full size.

Post-procedure imaging

Verify it on ICU Imaging

Practice recognizing correct device position, malposition and imaging complications after this procedure.

🩻 CXR Case 002 →🩻 CXR Case 003 →🩻 CXR Case 025 →

Decide first

Indications & contraindications

Indications

Failure to oxygenate or ventilate
Loss or threatened loss of airway protection
Expected clinical deterioration requiring controlled airway management
Procedural or transport requirements when benefits outweigh risk

Contraindications / reasons to change strategy

No absolute contraindication when an airway is immediately required
Delay RSI when a safer awake or alternative airway strategy is indicated by predicted anatomic difficulty
Severe physiologic instability is a reason to optimize first when time permits, not a reason to ignore the airway

Before starting

Equipment checklist

□01Monitoring: ECG, pulse oximetry, blood pressure; waveform capnography ready before induction

□02Primary laryngoscope (video preferred when available/expertise exists) plus backup device

□03Appropriate cuffed endotracheal tubes, stylet and/or bougie

□04Bag-mask with PEEP valve; suction on and tested

□05Supraglottic airway rescue device

□06Emergency front-of-neck airway kit

□07Induction agent and neuromuscular blocker selected for physiology

□08Vasopressor bolus/infusion and IV/IO access

□09Tube securing device and post-intubation ventilator setup

Know what you should see

Airway view & landmarks

Landmarks

Epiglottis
Arytenoids/interarytenoid notch
True vocal cords
Posterior glottic opening
Tube passing through the cords

Visual target

Identify every listed landmark before advancing to the next irreversible step.

Danger zones

Esophageal inlet posterior to larynx
Trauma from repeated forceful attempts
Loss of oxygen reserve during prolonged laryngoscopy
Hemodynamic collapse after induction/positive pressure

Watch the technique

Procedure video

Source-hosted video

Endotracheal Intubation via Video Laryngoscopy

This source uses its own hosted player. Open the original unchanged video at the source below.

Open procedure video ↗

Clinical-use note: This is an actual video-laryngoscopy intubation demonstrating bougie passage and endotracheal tube placement. It supplements the RSI page; preoxygenation, induction, paralysis, hemodynamic preparation and post-intubation care must follow the audited ICU Knowledge Map guide rather than this clip alone.

Reuse note: The NCBI/StatPearls work is NoDerivatives. The original source is opened unchanged rather than clipped, edited, rehosted or transformed.

Source: NCBI Bookshelf / StatPearls ↗Creator: Aaron Lacy, Andrew Pirotte, Melissa D. Kohn; Airway Management Video RepositoryLicense: CC BY-NC-ND 4.0 ↗Noncommercial / restricted use

Set up for success

Preparation

Assign roles and verbalize Plan A/B/C/D
Optimize position; ramp obese patients and align external auditory meatus with sternal notch when appropriate
Preoxygenate aggressively; consider HFNO/NIV/PEEP strategy according to physiology
Treat hypotension before induction when possible and have vasopressor support running/ready
Choose induction/paralytic doses based on shock, RV failure, asthma, intracranial pathology and other physiology
Set the ventilator before the tube is placed

Technique

Step-by-step technique

Perform final team time-out: indication, predicted difficulty, drugs, rescue plan and hemodynamic plan

Preoxygenate to maximize safe apnea time; use apneic oxygenation when appropriate

Administer induction agent then rapid-onset neuromuscular blocker

Perform laryngoscopy and identify the glottis; optimize with positioning/external laryngeal manipulation or adjuncts rather than repeated identical attempts

Pass the tube through the cords to an appropriate depth; inflate cuff

Immediately attach continuous waveform capnography and ventilate

Secure the tube and reassess depth, bilateral ventilation and hemodynamics

Start analgesia/sedation promptly and transition to the pre-planned ventilator strategy

Hard stop points

Stop and reoxygenate when saturation is falling or attempts are becoming prolonged
Escalate immediately if ventilation/oxygenation cannot be restored
Do not continue serial laryngoscopy attempts without changing the strategy

Never assume

How to confirm success

Sustained continuous waveform end-tidal CO2 is the primary confirmation method
Bilateral chest rise and breath sounds support but do not replace capnography
Check tube depth at teeth/lips and confirm position with imaging when clinically indicated
Reconfirm after transfer, proning, major position change or unexplained deterioration

When it does not go to plan

Complications & troubleshooting

Complications to watch for

HypoxemiaHypotension/peri-intubation cardiac arrestEsophageal intubationRight mainstem intubationAspirationDental/oropharyngeal traumaBronchospasmPneumothorax or barotrauma after positive pressure

No sustained capnography waveform

Assume esophageal placement until proven otherwise; remove and reoxygenate unless a clear low-flow arrest explanation exists and tracheal placement is independently confirmed.

Sudden hypotension after intubation

Check tube/ventilator, tension pneumothorax, auto-PEEP, hemorrhage and RV failure; reduce excessive intrathoracic pressure and treat the cause while supporting perfusion.

Cannot intubate

Stop repeated identical attempts, reoxygenate, use adjunct/rescue supraglottic airway and progress to emergency front-of-neck access when cannot-intubate/cannot-oxygenate criteria are met.

Procedure is not finished when the device is in

Aftercare & documentation

Document tube size/depth, device/grade/view, number of attempts and complications
Order/perform appropriate post-intubation imaging
Reassess sedation, analgesia, ventilator targets and VAP-prevention bundle

Procedure competency mode

Test yourself before the bedside

Sequence recognition, hard-stop recall and complication response for RSI / Intubation. This is an educational self-check, not credentialing.

1. Sequence challenge

Score 0/5

Current step

Perform final team time-out: indication, predicted difficulty, drugs, rescue plan and hemodynamic plan

According to this guide, what comes next?

2. Hard-stop recall

Before revealing them, name the situations in which you should stop, change strategy or escalate.

3. Complication response

Say your response first, then reveal the audited guide action.

References

SCCM Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient (2023) ↗Difficult Airway Society Guidelines for Management of Unanticipated Difficult Tracheal Intubation in Adults (2025) ↗ASA Practice Guidelines for Management of the Difficult Airway (2022) ↗