[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Nursing](https://durgical.com/en/nursing/) › [Critical care](https://durgical.com/en/nursing/areas/critical-care/) › Assisting endotracheal intubation: preparing, rapid sequence from the nursing side and confirming tube position

# Assisting endotracheal intubation: preparing, rapid sequence from the nursing side and confirming tube position

- Procedure

The nurse prepares the team, equipment and drugs, watches the patient through the intubation and helps confirm the tube with capnography.

Updated Nov 13, 2026

## Key points

- Preoxygenate: WHO describes about 5 minutes at FiO2 1.0 with a device that delivers it reliably, starting again if the mask seal is broken.
- Anticipate shock: induction drugs and the switch to positive pressure can drop blood pressure suddenly; have a vasopressor ready as ordered.
- A persistent CO2 waveform on capnography is the gold standard to confirm the tube is in the trachea.
- Record the tube depth at the teeth or lips and secure the tube before anything else.
- Check suction, a bag-valve device with oxygen, two laryngoscopes and a rescue airway before any drug is given.

On this page

- The basics Key points
- What it is
- Indications
- Equipment
- Step by step (and why)
- Next step: when to call for help
- Elsewhere in DurgiPedia

- Clinical Complications

- Safety Contraindications and precautions

- Study Test yourself

- Connections Connections

## What it is

Endotracheal intubation places a tube through the vocal cords into the trachea to keep the airway open, protect the lungs from aspiration and allow mechanical ventilation. In critically ill patients it is a high-risk procedure: in a large international study, more than 40% of ICU intubations were complicated by cardiovascular instability. Rapid sequence intubation uses drugs that quickly abolish reflexes and muscle tone so the tube can be placed; it suits patients at risk of aspirating stomach contents. A trained and experienced provider intubates. The nurse prepares the equipment and drugs, monitors the patient aloud for the team, gives drugs as ordered, records times and helps confirm the tube position. Drug choice and amounts belong to the medical order and the institutional protocol.

## Indications

- Hypoxaemia that does not respond to supplemental oxygen or to noninvasive support.
- Depressed consciousness with an airway the patient cannot protect, or a high risk of aspiration.
- Severe shock or haemodynamic instability.
- Severe hypercapnia that does not respond to noninvasive ventilation.
- Airway obstruction, or the need to give anaesthesia or to view the upper airway.

## Contraindications and precautions

- The indication and the drugs are decided by the provider who intubates, under the institutional protocol; the nurse does not decide them.
- Expect an anatomically difficult airway and a physiologically difficult one (hypoxaemia, shock, acidosis).
- Children, infants, obese and pregnant patients desaturate quickly: preoxygenation must be thorough.
- Suspected airborne infection: airborne precautions, as few staff as possible in the room, avoid bag-mask ventilation when possible and use an in-line filter if it is needed.
- Have a plan B ready: a supraglottic airway and the surgical airway kit.

## Equipment

- Working suction with a rigid tip, within reach.
- Self-inflating bag with oxygen, PEEP valve and mask; a backup oxygen source.
- Tubes of the right size with the cuff tested, stylet, bougie, oropharyngeal airway and two working laryngoscopes.
- Syringe to inflate the cuff, tube holder or tape, stethoscope and capnography set up.
- Ventilator checked, with filter and closed in-line suction in place.
- Patent IV access, drugs prepared as ordered, and monitoring of SpO2, ECG and frequent blood pressure.

## Step by step (and why)

- Confirm the patient, the order and allergies, and brief the team on roles — a shared plan reduces errors and delays.
- Check suction, bag, oxygen, laryngoscopes, tubes and the rescue airway, and set up capnography — gaps are found before apnoea.
- Confirm a patent IV line and prepare the ordered drugs and vasopressor, labelled — induction can cause sudden hypotension.
- Position the patient as the provider asks and preoxygenate for about 5 minutes at FiO2 1.0 — it lengthens safe apnoea time.
- Set blood pressure to cycle about every minute and report SpO2, heart rate and rhythm — early warning of hypoxaemia or collapse.
- Give each drug when the provider calls for it and record the times — rapid sequence depends on precise timing.
- Once the tube is in, inflate the cuff and connect capnography — a persistent waveform confirms the trachea.
- Listen to both lungs and watch chest rise and SpO2 — unequal breath sounds suggest a tube in one mainstem bronchus.
- Note the depth at the teeth or lips, secure the tube and request the chest X-ray — it confirms the tip sits above the carina.
- Connect to the checked ventilator and keep measuring blood pressure — hypotension after intubation is common.

## Complications

- Severe hypoxaemia during the attempt.
- Hypotension and cardiovascular collapse after induction and the start of positive pressure; cardiac arrest.
- Tube in the oesophagus or in one mainstem bronchus.
- Aspiration of stomach contents.
- Injury to lips, teeth, larynx, vocal cords, trachea or oesophagus, and bleeding.
- Collapsed lung (pneumothorax) from a perforation in the chest.

## Next step: when to call for help

- No CO2 waveform, or one that fades, after intubation: tell the provider at once; the tube may not be in the trachea.
- Falling SpO2, bradycardia or a new arrhythmia during the attempt: say it out loud to the team.
- Blood pressure drop after induction: report it and have the ordered vasopressor ready.
- Unequal breath sounds or rising airway pressures: report them; tube depth and a pneumothorax must be checked.

## Test yourself

Think of the answer, then tap the question to see it.

## What is the gold standard to confirm that the endotracheal tube is in the trachea?

Capnography with a persistent exhaled CO2 waveform. Breath sounds, chest rise and SpO2 help, and the chest X-ray confirms the depth.

## Why should a vasopressor be ready before induction in a critically ill patient?

Induction drugs remove sympathetic drive and positive pressure reduces venous return, so blood pressure can fall suddenly.

## How does WHO describe preoxygenation before rapid sequence intubation?

About 5 minutes at FiO2 1.0 with a device that delivers it reliably, starting again if the mask seal is broken.

## Why is the tube depth at the teeth or lips recorded?

It is the baseline: a tube found deeper than recorded suggests it has moved into one mainstem bronchus.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/nursing/assisting-endotracheal-intubation-preparing-rapid-sequence-from-the-nursing-side/)

## Elsewhere in DurgiPedia

- [Bronchial obstruction syndrome](https://durgical.com/en/clinical-exam/bronchial-obstruction-syndrome/)

## Connections

## Related 4

- [Endotracheal tube care and VAP prevention: securing, cuff pressure, tube depth, oral care, head of bed and unplanned extubation](https://durgical.com/en/nursing/endotracheal-tube-care-and-vap-prevention-securing-cuff-pressure-tube-depth-oral/)
- [Capnography (end-tidal CO2): tube confirmation, the waveform and what a change means](https://durgical.com/en/nursing/capnography-tube-confirmation-the-waveform-and-what-a-change-means/)
- [The crash cart: checks and organisation](https://durgical.com/en/nursing/the-crash-cart-checks-and-organisation/)
- [Airway suctioning: oral, nasal and artificial airways](https://durgical.com/en/nursing/airway-suctioning-oral-nasal-and-artificial-airways/)

## Related conditions 1

- [Acute respiratory failure (hypoxaemic and hypercapnic)](https://durgical.com/en/conditions/acute-respiratory-failure/)

## In Pharmacology 2

- [Propofol](https://durgical.com/en/pharmacology/propofol/)
- [Neuromuscular blockers](https://durgical.com/en/pharmacology/classes/neuromuscular-blockers/)

[← All of nursing](https://durgical.com/en/nursing/)

Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.

Sources: [Clinical care for severe acute respiratory infection: toolkit, update 2022 (COVID-19 adaptation), tool 9.4 and 9.13](https://www.who.int/publications/i/item/clinical-care-of-severe-acute-respiratory-infections-tool-kit) (World Health Organization, 2022); [The hemodynamics of tracheal intubation in critically ill patients: a narrative review](https://pmc.ncbi.nlm.nih.gov/articles/PMC13151387/) (Journal of Intensive Care (open access, PMC), 2026); [Impact of interventions on peri-intubation hypoxemia and hypotension in critically ill patients: systematic review and meta-analysis](https://pmc.ncbi.nlm.nih.gov/articles/PMC12591638/) (Western Journal of Emergency Medicine (open access, PMC), 2025); [Endotracheal intubation](https://medlineplus.gov/ency/article/003449.htm) (MedlinePlus, U.S. National Library of Medicine, 2024).

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/nursing/assisting-endotracheal-intubation-preparing-rapid-sequence-from-the-nursing-side/