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Placement, Care, & Removal of Endotracheal Tubes (3.43)

Placement, Care, & Removal of Endotracheal Tubes (3.43) - Policies, Clinical, UWHC Clinical, Department Specific, Respiratory Care Services, Airway Care


3.43 Placement, Care & Removal of Endotracheal Tubes
Category: UWHC Patient Care Policy
Effective Date: October 1, 2016
Version: Revision
Manual: Respiratory Care Services


Placement: Endotracheal intubation is a medical procedure in which a tube is placed into the trachea,
through the mouth or the nose. Intubation is done to open the airway, provide mechanical ventilation,
and deliver medication or anesthesia. It may also be done to remove blockages (foreign bodies) from
the airway or to allow the doctor to get a better view of the upper airway.
Care: The endotracheal tube (ETT) must be correctly positioned and secured in the airway.
Removal: An endotracheal tube should be removed from the airway when the indication for placement
no longer exists.



A. Placement:
1. Physicians are responsible for determining the indications for the placement of
endotracheal tubes. The intubating physician or anesthetist and respiratory therapist are
responsible for assessing appropriate placement of the endotracheal tube.
a. At a minimum, auscultation and CO2 assessment must be completed by the
physician/anesthetist or the respiratory therapist immediately after intubation.
b. The performance of a CO2 assessment may be delegated to a respiratory therapist,
(RT) but the physician or anesthetist must remain in attendance until the results of
such assessment are known.
c. An RT has the authority to perform a CO2 assessment at any time without a
physician order. A respiratory therapist should perform such an assessment
whenever there is doubt about endotracheal ventilation of patient due to suspicion
of inappropriate endotracheal tube placement. The RT should immediately report
the results of a CO2 assessment. The responsible physician must take appropriate
action if the results are negative for the presence of CO2 in the exhaled gases.
2. The intubating physician or anesthetist, AND RT are required to remain in attendance
a. Appropriate ventilation has been verified.
b. The endotracheal tube has been secured.
c. All required documentation in the medical record has been made.
B. Care:
RT and Nursing are responsible for the ongoing maintenance of the endotracheal tube.
1. Respiratory Therapy will monitor cuff/leak pressures as ordered/indicated.
2. Suctioning will be performed only after assessment of need, not on a routine basis.
3. Assessing the position of the ETT and the integrity of the commercial ET holder will be
done with every ventilator system check.
C. Removal:
Extubation will be carried out in accordance with a physician’s order. Orders to “wean to
extubate” do not constitute an extubation order. The physician must be contacted prior to


A. Suction equipment
B. Endotracheal tubes
1. 2 of the same size
2. 1 each larger and smaller than estimated size
C. Intubation tray or cart
D. Commercial ETT holder or twill tape, white or pink tape
E. Gauze and tincture of benzoin
F. Syringe
G. Manual Resuscitator and mask
H. Oral airway
I. Oxygen
J. Disposable CO2 detector or ETCO2 monitor

A. Review patient's chart.
B. Obtain the appropriate equipment.
C. Introduce yourself to the patient and family. Explain the reason for the procedure.
D. During intubation, the respiratory therapist may need to assist the physician with bag/mask
ventilation, suction, and head positioning. Cricoid pressure may be applied prior to intubation to
occlude the esophagus, preventing regurgitation of gastric contents into the trachea, and often
improves visualization of the larynx.
E. Upon placement of the ETT, the respiratory therapist will remove the stylet, inflate the cuff
(when applicable) and assess the following:
1. Infants and children: auscultate the stomach then the lungs for equal bilateral breath
2. Adults: auscultate the lungs for equal and bilateral breath sounds.
3. CO2 detector or monitor must be used to determine proper endotracheal tube placement.
4. Look for vapor in the ETT
F. Stabilize the ETT to avoid excessive movement or inadvertent extubation.
1. For adults: The ETT will be secured with a commercial ET holder. In emergency
situations, twill tape may be used.
2. Infants and children: Apply benzoin to the ETT at the nose or lip and to the cheeks. Place
white tape on the ETT to indicate the position at the nares or lip. Place a piece of wide
pink tape on either side of the patient’s cheek. Cut two separate pieces of white tape and
design each into an "H" shape. The top of one side of a horizontal "H" will go around the
ETT and the bottom on the pink tape on the cheek. Reverse that with the other side of
the cheek.
3. Oral airways or bite blocks may be used to prevent orally intubated patients from biting
on the ETT.
G. Measure and record cuff pressure with a cuff pressure manometer.
1. Intra-cuff pressure should be maintained at a minimum of 20-25cm H2O to reduce the
occurrence of microaspiration and a maximum of 34 cm H2O to decrease the incidence
of mucosal ischemia and subsequent stenosis.
2. Cuff pressure assessment will be done on all patients.
a. Immediately upon placement of the airway.
b. Twice daily
c. Before and after patient transports

3. When assessing cuff pressure using minimal occluding volume, auscultate over the
patient’s trachea. Inject air slowly into the cuff during inspiration to the point where the
audible leak around the ETT cuff is abolished using the smallest possible pressure.
4. Infants and children who have cuffed ETT, but do not require inflation, should have a
small amount of air added to the cuff to smooth out the wrinkles.
H. Infant and pediatric patients require leak pressure measurement at intubation, extubation, and as
needed. Place stethoscope on patient's neck and manually ventilate the patient slowly. The first
audible sound of air moving around the ETT on inspiration is the recorded leak pressure.
I. In the case of a leak or cut pilot line, use the pilot repair kit.
J. Prior to extubation, review and acknowledge provider’s order.
K. Obtain a leak pressure when indicated. If the leak pressure is greater than 15 cm H2O, consider
the following:
1. Notify the physician
2. IV steroids may be required.
3. Infants and children will have racemic epinephrine available at bedside.
L. Suction the patient via ETT and orally.
M. Remove the tape securing the ETT.
N. Deflate the cuff.
O. Instruct the patient to deep breathe and cough so as to open the vocal cords while withdrawing
the tube.
P. Uncooperative patients, infants, and children may require manual ventilation during extubation.
Extubation should occur at the end of inspiration during a delivered breath.
Q. Instruct the patient to continue to cough after extubation until the secretions are cleared from the
airway. Patients may require nasotracheal or orotracheal suctioning to clear secretions.
R. Auscultate the chest for breath sounds and the neck for stridor.


A. Hospital Policies
1. Respiratory Care Services (RCS) P&P: 3:42 Suctioning
2. UWHC Administrative Policy: 8.57 Monitoring Placement of endotracheal tubes outside
of the OR or other anesthetizing locations
3. UWHC Departmental Policy: 7.11 Care of the Intubated Patient
B. References:
1. AARC Clinical Practice Guidelines: Removal of the Endotracheal Tube-2007 Revision &
2. "Egan's Fundamentals of Respiratory Care"
3. Fuhrman & Zimmerman, “Pediatric Critical Care"
4. Kacmarek etal., "The Essentials of Respiratory Care"
5. Posey Cufflator Product information

Approved by Director and Medical Director of Respiratory Care:

Original copy of this Policy & Procedure is available in the Respiratory Care Office [E5/489].