Confirming Correct Tracheal Intubation

Primary Confirmation Methods

Waveform capnography is the gold standard for confirming tracheal intubation in patients with a perfusing rhythm, with 100% specificity for detecting correct tracheal placement 1
For awake tracheal intubation, a two-point check is required: visualization of the tracheal lumen and capnography to exclude esophageal intubation 3, 4
In cardiac arrest patients, capnography may be less reliable due to low pulmonary blood flow; if exhaled CO2 is not detected, confirm tube position with direct laryngoscopy 5, 1

Auscultation should be performed bilaterally in the axillae and over the epigastrium - gastric insufflation sounds should not be present if the tube is in the trachea 5
Check for oxyhemoglobin saturation with a pulse oximeter if there is a perfusing rhythm, but remember that following pre-oxygenation, saturation may not decline for up to 3 minutes even without effective ventilation 5
An esophageal detector device (EDD) may be considered to confirm endotracheal tube placement in children weighing >20 kg with a perfusing rhythm 5
In hospital settings, perform a chest x-ray to verify that the tube is not in a bronchus and to identify proper position in the midtrachea 5

After tracheal intubation with a left-sided double-lumen tube, confirm bilateral air entry with manual ventilation 6
Inflate the bronchial cuff and check for isolated left-sided air entry when the tracheal lumen is clamped 6
If clinical confirmation is inconclusive, bronchoscopy is essential to verify correct placement 6

The American Heart Association recommends considering the DOPE mnemonic if an intubated patient's condition deteriorates:
- Displacement of the tube 5
- Obstruction of the tube 5
- Pneumothorax 5
- Equipment failure 5

Capnography may be unreliable in cardiac arrest due to low pulmonary blood flow, giving false negatives despite correct tube placement 5, 1
Colorimetric CO2 detectors may show a consistent color rather than breath-to-breath change if contaminated with gastric contents or acidic drugs 5
An IV bolus of epinephrine may transiently reduce pulmonary blood flow and exhaled CO2 below detection limits 5
Severe airway obstruction and pulmonary edema may impair CO2 elimination below detection limits 5
A large glottic air leak may reduce exhaled tidal volume through the tube and dilute CO2 concentration 5

After confirming tracheal placement, secure the tube to prevent displacement 5
Maintain the patient's head in a neutral position, as neck flexion may push the tube further into the airway, and extension may pull it out 5