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Five Ways to Save Your Tube

Below are five easy ways to save your ET tube:

  1. Do what’s best for your patient.
  2. Be responsible for and highly critical of your patient care.
  3. Take charge of your training.
  4. Know and follow your protocols.
  5. Keep up with science.

For more, read “Get With It!


  1. Sirenhead:
    Please tell us something we don’t know…. no offense, but this kinda struck me as a, “duh!!!” I know a lot of our colleagues don’t do this basic stuff, so I guess it’s good that you put it in here. BTW, your step 4 won’t do squat to help you keep or save your (the patient’s) tube.

    Here’re practical things that will help you “save your tube”
    1. Keep available and know how to use a gum-elastic bougie
    2. Prep the skin before taping the tube down or using a commercial tube-holder device.
    3. Use c-collars on anybody intubated with a non-cuffed ETT so limit lateral neck/head movement.
    4. Know your approved methods to keep patients from clenching down on their tubes – both pharmacological and mechanical methods.
    5. Immediately replace any newly inserted endotracheal tube that won’t hold pressure in the cuff.

    • Don’t forget about the Bougie. It is a great, inexpensive tool that can really make a difference with a MP Score of 3-4 or a bloody airway. It is also great for a cric. if you have an expanding neck hematoma or just different anatomy.

  2. Here are a few more ways to “save your tube”

    “Look at where you are going!” Watch your landmarks as you insert the laryngoscope. Don’t just jam the blade in, which would be like starting your car, closing your eyes and stepping on the gas. You’ll go somewhere, but it might not be where you want to go.

    “Do not use the largest blade you can.” Many of the paramedics I’ve come in contact with use a Macintosh No. 4 for everyone. Why? The No. 4 is too big for most patients. Size your blade the same way you size a tube: the right blade for the patient. I happen to prefer a straighter blade (I’ve been using a Philips for 27 years) but I am always willing to try another style if I’m not getting the view I want.

    “If you don’t know where you are, always look up!” In our usual posture for intubating, the trachea is always above the esophagus. Again, look for landmarks: they are always there.

    “Always have a ‘Plan B’ in place and ready!” Being prepared and ready to fail will actually help prevent you from failing. Have your bougie ready, along with your King-LT, or your iGel, or your LMA. If you wait until you know you need your back-up device to look for it, to get it ready, you’ll be in bigger trouble. Having a back-up plan in place will actually help keep you confident, making it psychologically easier for you to get the job done the first time.

    “Give it up!” If you cannot do it, do not keep trying and trying. Do not let your ego – as huge as it is – prevent you from accepting the fact that no one can get every tube that they attempt. Be prepared and willing to hand the intubation off to your partner.

    “Take your time.” That is to say don’t start rushing, cutting corners, skipping steps. Incomplete preparation is a sure way of causing you to make a mistake. Make certain that you have all of your equipment ready. Have a stylet ready. Have a tie of some sort, a syringe, BVM, suction, back-up devices, all that stuff on hand and ready. If you don’t need it, don’t use it, but have it ready.

    “Check your tube… for real!” Don’t settle for ‘I think it’s in…?’ Watch your tube go through the cords. Listen for leaks, look for condensation. Listen for breath sounds – all over! Listen to the belly. Look again with the laryngoscope – is the tube in the glottis? Use end-tidal CO2. Don’t let your pride make you lie to yourself.

    “When in doubt, fall back to BLS!!” This is by far the most important ‘tip.’ Most airways can be very efficiently managed by mechanically opening the airway, maintaining a good mask seal, and using suction. If you have having difficulty intubating, remember BLS before ALS. Better for the patient – and for you – to have a patent BLS airway than a failed or too-long-time ALS airway.

    Thanks for listening!

  3. Eugene,

    Thanks so much for sharing these tips!

    Jennifer Berry
    Managing Editor
    JEMS and JEMS.com

  4. It is true; these are things we all know. Unfortunately they are not things which are always practiced. The additional hints shared by everyone here are all very helpful. I would add, in reference to BLS airway management, BMV/BVM is generally underappreciated, and not often done correctly or effectively. This is an area where skills are lost quickly – though is some cases, the skills never existed because they were never emphasized as being important.
    I have watched interns, nurses, paramedics, basics, and techs use sloppy techniques, and display almost complete disinterest as they squeezed too hard, too fast, failed to establish and maintain a proper mask seal and so on.
    As with anything we do, if we are going to do it, we should take it seriously and do it correctly. Like it or not, when you encounter a difficult intubation, the proper use of a BVM may be your patient’s only tether to this world. Use OPAs, NPAs, or both, properly position your patient, use at least two people to ventilate with the BVM. Lower tidal volume, lower pressure, slightly more rapid ventilations per minute will all help most patients. If your patient’s compliance is so low you have to squeeze the bag hard with both hands, a BVM is not the right tool. The esophagus will open at higher pressures, and the air destined for the patient’s lungs will end up, at least temporarily in the patient’s stomach. Of course, it will probably make a later appearance, accompanied by the partially digested corn dog your patient enjoyed an hours or so before. Worse yet, the distended stomach will inflate and press the diaphragm upward, further reducing the volume and increasing the pressure in the thoracic cavity.
    This isn’t a “Basic’s” skill, it is one we all share and should excel at. It is another weapon in our airway management arsenal we will have to use again and again throughout our careers.

  5. I am a Nurse Anesthetist and in the near future will be involved in teaching the airway anatomy/assessment/management component in a newly formed paramedic program. I have found this particular blog entry helpful, as well as the rest of the website in terms of getting an idea for the frequency of ETI and the challenges presented to Emergency Responders. The most important aspect in airway management is to not continue to do the same thing over and over when it is ineffective in securing the airway. We always prepare so that our first attempt at intubation is our best attempt based on assessment of the airway. There is always a plan B and C. In anesthesia we always fall back to BVM when we find tracheal intubation is difficult and we are preparing to move to the next step in the difficult airway algorithm. If we find BVM ventilation is not achievable after induction, and intubation is difficult or worse impossible, LMA placement is a good technique to ventilate until a secured airway can be achieved with an alternative intubating technique or (in the case of the OR) the patient awakened for an awake intubation. An adequate mask airway, as you have noted, is better than an unrecognized improperly placed ETT, or multiple futile attempts at intubation resulting in hypoxia.
    Thanks for the great insights!

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