Airway · Last updated 2026-05-27 · Methodology & sources
Weight
2060100140180
Height
140155170185200+
Sex
RAPID SEQUENCE INTUBATION
Enter weight above for calculated drug doses · Evidence: UpToDate RSI, ACEP 2020, Weingart Push-Dose Pressors
Difficult Airway Assessment — LEMON Before Every RSI
Assess ALL 5 criteria before intubation. Any positive predictor = plan for backup airway (VL, LMA, surgical).
L
Look Externally
Small jaw, large tongue, short neck, obesity, facial trauma, beard, blood/vomit in airway, trismus, prior neck surgery/radiation
E
Evaluate 3-3-2 Rule
3 finger breadths mouth opening · 3 finger breadths hyoid-to-chin · 2 finger breadths thyroid notch-to-hyoid. Any <3 fingers = difficult
M
Mallampati Score
Class I (uvula visible) = easy · Class II (partial) = some difficulty · Class III (soft palate only) = difficult · Class IV (hard palate only) = very difficult
O
Obstruction
Angioedema, abscess, epiglottitis, haematoma, Ludwig's angina, foreign body, tumour, tracheal deviation
N
Neck Mobility
Cervical spine injury, arthritis, collar, halo, prior cervical surgery. Reduced extension = reduced laryngeal view
RSI Protocol — Step by Step
1
Pre-oxygenation (3+ minutes)
Goal: SpO2 100% — denitrogenate lungs to maximise apnoea safe time (3–8 min normoxic, vs 1 min without pre-ox).
• Flush-rate O2: NRB at 15 L/min + nasal cannula 15 L/min beneath mask
• Upright position 20–30° head-up (increases FRC by 15–30%)
• BVM with PEEP valve 5–10 cmH2O if obtunded
• Apnoeic oxygenation: leave NC at 15 L/min during laryngoscopy
2
Preparation — "STOP MAID"
Suction on · Team roles assigned · O2 flush rate · Position optimal · Monitoring (ECG/SpO2/EtCO2) · Airway equipment laid out · IV access confirmed · Drugs drawn up
Push-dose pressor ready: Ephedrine 5 mg/mL (1 mL ephedrine 50 mg/mL + 9 mL NS) OR Epinephrine 10 mcg/mL (1 mL 1:10,000 + 9 mL NS)
3
Pre-treatment (optional, 3 min before induction)
Blunts haemodynamic response to laryngoscopy. Indicated in TBI (prevents ICP spike), cardiovascular disease, reactive airway.
Fentanyl: — (1–3 mcg/kg, max 200 mcg) IV over 1–2 min · 3 min before induction
4
Induction Agent — choose one
Give rapidly IV. Onset 30–60 sec. Patient loses consciousness.
Ketamine: — (1.5 mg/kg) — preferred in haemodynamic instability, bronchospasm
Etomidate: — (0.3 mg/kg) — haemodynamically stable; avoid in sepsis (adrenal suppression)
Propofol: — (1.5 mg/kg) — only if haemodynamically stable; significant hypotension risk
5
Neuromuscular Blockade — give immediately after induction
Succinylcholine: — (1.5 mg/kg, max 200 mg) — fastest offset; avoid in hyperkalaemia/burns/crush >48h
Rocuronium: — (1.2 mg/kg) — preferred if succinylcholine contraindicated; reverse with sugammadex 16 mg/kg
⚠ Succinylcholine contraindicated: K+ >5.5, burns >24–48h, crush >72h, denervation/UMN injury, muscular dystrophy, personal/family history MH, pseudocholinesterase deficiency
6
Laryngoscopy & Intubation (60–90 sec after NMB)
Optimise with: BURP manoeuvre (Backwards-Upwards-Right-Pressure on thyroid cartilage) · External laryngeal manipulation · Ramped position for obese patients (ear-to-sternal-notch alignment).
Confirm: Bilateral breath sounds · EtCO2 waveform (gold standard) · Chest rise · SpO2 improving · CXR for depth
7
Post-intubation Management
Sedation: Propofol 5–50 mcg/kg/min OR Midazolam 0.03–0.1 mg/kg/hr
Analgesia: Fentanyl — (1–2 mcg/kg q1h or 25–100 mcg/hr infusion)
Ongoing NMB (if needed): Rocuronium — (10–12 mcg/kg/min infusion)
Initiate ventilator: start with lung-protective settings (see Ventilator tab). Target SpO2 92–98%, EtCO2 35–45 mmHg. Head of bed 30–45°.
Cannot Intubate / Cannot Oxygenate (CICO)Emergency
CICO = Immediately life-threatening. Do NOT attempt more than 3 laryngoscopy attempts. Call for help early. Declare CICO loudly.
1
Attempt LMA / Supraglottic Airway
Size 3 (30–50 kg), 4 (50–70 kg), 5 (70–100 kg). Insert, ventilate. May be bridge to surgical airway.
2
Reverse NMB (if rocuronium used)
Sugammadex: — (16 mg/kg IV) — full reversal within 3 min. Only works for rocuronium/vecuronium.
3
Emergency Surgical Airway — Scalpel-Bougie-Tube
Preferred technique: 1) Vertical 3 cm skin incision over cricothyroid membrane · 2) Horizontal stab incision through membrane · 3) Tracheal hook caudally · 4) Bougie inserted · 5) 6.0 ETT railroaded over bougie · 6) Inflate cuff, ventilate, confirm EtCO2
Push-Dose Pressors Peri-intubation Hypotension
Peri-intubation hypotension in 20-35% of ED intubations. Prepare vasopressors BEFORE RSI in haemodynamically compromised patients (SBP <90, shock index >1).
Agent
Preparation
Dose
Onset
Notes
Phenylephrine1st line
1 mL of 10 mg/mL + 9 mL NS = 1 mg/mL. Then 1 mL + 9 mL NS = 100 mcg/mL
50-200 mcg IV q2-5 min
60-90 sec
Pure alpha. No chronotropy. Best when tachycardia present. Reflex bradycardia possible.
EpinephrineBrady + hypotension
1 mL of 1:10,000 (0.1 mg/mL) + 9 mL NS = 10 mcg/mL
10-20 mcg IV q2 min
30-60 sec
Alpha + beta. Use when bradycardia + hypotension. Bridges to infusion.
VasopressinAlternative
1 mL of 20 units/mL + 19 mL NS = 1 unit/mL
1-2 units IV q5-10 min
1-2 min
Non-adrenergic. Useful in distributive shock. No tachycardia.
Post-Intubation Checklist Immediately Post-RSI
1
Confirm ETT Position
EtCO2 waveform (gold standard) + bilateral breath sounds + CXR tip 2-3 cm above carina
2
Secure & Document
Tape or commercial holder. Note lip depth. Bite block if biting risk.
3
Ventilator Settings
AC/VC: TV 6-8 mL/kg IBW, RR 14-16, PEEP 5, FiO2 1.0 initially then wean
4
Sedation & Analgesia
Propofol 5-50 mcg/kg/min OR midazolam 0.02-0.1 mg/kg/h + fentanyl 25-100 mcg/h. RASS target -2
5
Pressure Targets
Peak <35 cmH2O. Plateau <30 cmH2O. Driving pressure <15 cmH2O.
6
HOB + OG/NG
Head of bed 30-45 degrees. Gastric decompression via NG/OG.
7
VAP Bundle
Cuff pressure 20-30 cmH2O. Oral care. Daily interruption planning.
8
Disposition
ICU handover: indication, settings, drugs given, exam findings, plan.
VENTILATOR SETTINGS
Enter height + sex above for IBW-based tidal volume · Evidence: ARDSNet NEJM 2000, GOLD 2024, ATS/ESICM Guidelines
Tidal volume is based on Ideal Body Weight (IBW), not actual weight — obese patients have the same lung size as their height-matched non-obese counterparts. Using actual weight causes volutrauma.
Live Calculated Settings
Enter weight + height + sex above to generate calculated vent settings
IBW
—
Tidal Volume (6 mL/kg)
—
ARDSNet / lung-protective
Tidal Volume (8 mL/kg)
—
Normal lungs / post-op
Min Ventilation (6×14)
—
TV × RR target range
Min Ventilation (6×20)
—
Upper end for ARDS
Min TV (4 mL/kg)
—
Absolute minimum (ARDS refractory)
ARDSNet Protocol (NEJM 2000): 6 mL/kg IBW reduces mortality vs 12 mL/kg. Plateau pressure <30 cmH2O. Driving pressure <15 cmH2O. Accept permissive hypercapnia (pH >7.20). SpO2 target 88–95%.
Mode
AC/VC
Volume-controlled. Guarantees tidal volume delivery.
Tidal Volume
— mL
6 mL/kg IBW (range 4–8). Calculated from height/sex above.
Resp Rate
14–20
Start 14–16. Increase to compensate for low TV if needed. Max 35.
PEEP
5
Start 5. Use ARDSNet PEEP/FiO2 table below to titrate.
FiO2
0.60
Titrate to SpO2 88–95%. Use PEEP/FiO2 table — increase together.
I:E Ratio
1:2
Standard. Avoid inverse ratio (risk of auto-PEEP).
Plateau Limit
<30
Check q4h. If >30: reduce TV by 1 mL/kg to minimum 4 mL/kg. Accept lower pH.
Driving Pressure
<15
Plateau − PEEP. Independent mortality predictor. Reduce TV or PEEP if >15.
ARDSNet PEEP / FiO2 Table (Lower PEEP Strategy)
FiO20.300.400.500.600.700.800.901.00
PEEP55–88–101010–121414–1818–24
Auto-PEEP risk: Obstructive physiology traps air → dynamic hyperinflation → haemodynamic collapse. Prioritise full exhalation: low RR, low I:E, high flow rate. Permissive hypercapnia acceptable (pH >7.20).
Mode
AC/VC
Volume control ensures delivered volume despite high airway resistance.
Tidal Volume
— mL
6–8 mL/kg IBW. Small volumes reduce hyperinflation risk.
Resp Rate
10–14
Low RR = more time for exhalation. Start 10–12. Permissive hypercapnia.
PEEP
3–5
Low extrinsic PEEP (3–5 cmH2O). Must measure intrinsic/auto-PEEP. Extrinsic PEEP <80% of auto-PEEP.
FiO2
Titrate
COPD: target SpO2 88–92% (avoid hypoxic drive suppression). Asthma: 92–98%.
I:E Ratio
1:3 – 1:5
Prolonged expiratory phase — essential. Use highest flow rate to shorten inspiratory time.
Flow Rate
60–80 L/min
High inspiratory flow shortens Ti, maximises expiratory time.
PaCO2 Target
45–60+
Permissive hypercapnia acceptable if pH >7.20. Do NOT hyperventilate — causes severe auto-PEEP.
Lung-protective ventilation for all intubated patients — not just ARDS. Even normal lungs develop VILI with high tidal volumes. Start conservative; wean FiO2 and PEEP as tolerated.
Mode
AC/VC or PRVC
Volume or pressure-regulated. PRVC adapts to compliance changes.
Tidal Volume
— mL
6–8 mL/kg IBW. Even normal lungs: avoid >8 mL/kg.
Resp Rate
12–16
Targeting normocapnia (PaCO2 35–45 mmHg).
PEEP
5
Standard physiological PEEP. Prevents alveolar derecruitment at end-expiration.
FiO2
Titrate
Start 0.60, wean to <0.60 to avoid O2 toxicity. Target SpO2 92–98%.
I:E Ratio
1:2
Standard 1:2. Adjust if patient-ventilator dyssynchrony noted.
Plateau
<30
Monitor plateau. In normal lungs plateau usually <25 with these settings.
PaCO2 Target
35–45
Normocapnia unless underlying condition warrants otherwise.
TBI/Neuro: Hypoxia (SpO2 <90%) and hypocapnia (PaCO2 <35) are BOTH harmful — cause secondary brain injury. Normocapnia mandatory. Hyperventilation only for impending herniation (brief, bridge to intervention).
Mode
AC/VC
Tidal Volume
— mL
6 mL/kg IBW. Lung-protective even in TBI.
Resp Rate
14–16
Titrate to PaCO2 35–40 mmHg. Serial ABG essential. EtCO2 correlation variable in TBI.
PEEP
5
Standard PEEP 5. Higher PEEP reduces cerebral venous drainage — balance with oxygenation needs.
FiO2
Target 94–98%
SpO2 >94% mandatory. Avoid hyperoxia (PaO2 >300 — associated with worse outcomes).
PaCO2 Target
35–40
Normocapnia. Prophylactic hyperventilation is HARMFUL (cerebral vasoconstriction → ischaemia).
Herniation Protocol
PaCO2 30–35
Brief hyperventilation for acute herniation ONLY — bridge to mannitol/hypertonic saline/surgery. Not sustained.
Head Position
HOB 30°
Head of bed 30–45°, neutral alignment. Reduces ICP, improves CPP.
Cardiogenic pulmonary oedema: high PEEP recruits flooded alveoli, reduces preload (beneficial in LV failure), and offloads work of breathing. Higher FiO2 requirements initially.
Mode
AC/VC or PRVC
Tidal Volume
— mL
6–8 mL/kg IBW.
Resp Rate
14–18
Targeting normocapnia. High RR compensates for low TV if needed.
PEEP
8–12
Higher PEEP recruits flooded alveoli. Reduces preload (good in LV failure). Monitor for RV afterload increase.
FiO2
High initially
Start 0.80–1.0. Wean as oedema clears. Target SpO2 92–98%.
I:E Ratio
1:2
Plateau
<30
Note
High PEEP reduces RV preload too — monitor for RV failure in acute RV dysfunction/massive PE.
Obese patients: use IBW (not actual weight) for tidal volume. Higher PEEP needed to overcome chest wall weight and recruit dependent atelectasis. Ramped position for intubation and ventilation.
Mode
AC/VC or PRVC
Tidal Volume
— mL
6–8 mL/kg IBW — critical. Using actual weight causes severe volutrauma.
Resp Rate
14–18
Higher RR may be needed due to reduced FRC and increased O2 consumption.
PEEP
8–12
Higher PEEP needed to overcome chest wall weight and recruit dependent atelectasis. Titrate to oxygenation.
FiO2
Titrate
Often need higher FiO2 initially. Target SpO2 92–98%.
Position
HOB 30–45°
Reduces diaphragmatic compression, improves FRC.
Recruitment
Consider
PEEP trial or recruitment manoeuvre (sustained inflation 30–40 cmH2O × 30 sec) for refractory hypoxia.
IBW Formula
Enter height above
BiPAP / NIV / CPAP
Non-invasive ventilation — avoids intubation in appropriate patients · Evidence: NICE NG38, BTS NIV Guidelines 2016, AHA/ACC CPE Guidelines
NIV Absolute Contraindications: Respiratory arrest / Apnoea · Unable to protect airway · Facial trauma/burns/anatomy precluding mask fit · Uncooperative/agitated patient (relative) · Vomiting/high aspiration risk · Haemodynamic instability not responsive to fluids · Recent upper GI/oesophageal surgery
Live NIV / BiPAP Quick Reference
Select condition below — settings shown. Enter weight for any weight-related context.
IPAP Start
12–16
cmH2O — titrate up by 2 q15 min
EPAP Start
4–6
cmH2O
Pressure Support
8–12
cmH2O (IPAP − EPAP)
Backup RR
14–16
/min
SpO2 Target
88–92%
Controlled O2
Reassess ABG
1–2 hours
If pH not improving → intubate
COPD + acute hypercapnic RF: NIV reduces intubation rate by 65%, mortality by 50% (Brochard 1995, Plant 2000). First-line treatment. Target pH >7.25 on NIV; if <7.25 after 1h → intubate.
Mode
BiPAP (S/T)
IPAP Start
12–16 cmH2O
Increase by 2 cmH2O q15 min to max 20–30. Target: ↓RR, ↑TV, ↓accessory muscle use.
EPAP Start
4–6 cmH2O
Low EPAP (3–5) for COPD — avoid dynamic hyperinflation. Higher EPAP (6–8) if significant secretions or OSA component.
Pressure Support
8–14 cmH2O
PS = IPAP − EPAP. Aim 8–14 cmH2O. Drives ventilation.
Backup RR
14–16 /min
FiO2 Target
SpO2 88–92%
Controlled O2 — avoid suppressing hypoxic drive. Titrate.
Reassess
ABG at 1–2h
If pH not improving >7.25 → escalate to intubation. Do not delay.
Evidence
Brochard 1995, Plant 2000, BTS NIV 2016
Cardiogenic pulmonary oedema: CPAP equivalent to BiPAP for most patients (3CPO trial). Both superior to O2 alone — reduces intubation rate ~50%. CPAP is simpler. Use BiPAP if hypercapnia.
Mode (1st choice)
CPAP
If normocapnic — equivalent to BiPAP (3CPO trial). Simpler, better tolerated.
CPAP Level
5–10 cmH2O
Start 5 cmH2O. Increase by 2 cmH2O every 5–10 min to max 10–12. Reduces preload and afterload.
Mode (if hypercapnia)
BiPAP (S/T)
BiPAP IPAP
10–16 cmH2O
BiPAP EPAP
5–8 cmH2O
FiO2
High — SpO2 >94%
Reassess
15–30 min
If not improving → reassess diagnosis. Add GTN infusion, furosemide. Early escalation if deteriorating.
Evidence
3CPO Trial (NEJM 2008)
Obesity Hypoventilation Syndrome (OHS): chronic hypercapnia + obesity (BMI >30). High EPAP needed to overcome chest wall mass. Often requires high IPAP. Treat as COPD exacerbation approach.
Mode
BiPAP (S/T)
IPAP Start
16–20 cmH2O
Higher IPAP required. Titrate to clinical response and PaCO2.
EPAP Start
8–12 cmH2O
Higher EPAP to overcome chest wall weight and upper airway obstruction.
Backup RR
14–16 /min
FiO2
SpO2 88–92%
Position
HOB 30–45°
Post-extubation NIV: prophylactic BiPAP in high-risk patients (hypercapnia, COPD, CHF, prolonged intubation) reduces re-intubation rate. Not effective once post-extubation respiratory failure is established — treat early or re-intubate.
Mode
BiPAP (S/T)
IPAP
12–16 cmH2O
EPAP
5–8 cmH2O
Schedule
q4h minimum
Prophylactic: scheduled sessions post-extubation × 24–48h. Rescue: apply immediately if deteriorating.
Caution
Early decision
Do not delay re-intubation. NIV should not be used to delay inevitable intubation once failure is established.
Hypoxic respiratory failure: NIV evidence weaker than for hypercapnic failure. HFNC often preferred first-line. NIV for immunocompromised (avoids intubation complications). High failure rate — monitor closely.
Mode
BiPAP or CPAP
IPAP
14–20 cmH2O
EPAP
8–10 cmH2O
Higher EPAP needed for oxygenation in diffuse lung disease.
FiO2
High — SpO2 >92%
ROX Index
Monitor q1–2h
Use ROX index (HFNC tab) as failure predictor. Escalate early.
Neuromuscular disease (MG, GBS, ALS, DMD): ventilatory failure from muscle weakness rather than lung disease. High IPAP needed to overcome weak respiratory muscles. Bulbar dysfunction = relative contraindication (aspiration risk).
Mode
BiPAP (S/T)
IPAP
18–25 cmH2O
High IPAP to compensate for weak inspiratory muscles. Titrate to tidal volume >7 mL/kg.
EPAP
4–6 cmH2O
Backup RR
14–18 /min
Higher backup rate if bulbar weakness — patient may be unable to trigger.
Escalation
VC <1 L or <20 mL/kg
Intubate early in GBS/MG crisis if VC declining rapidly, NIF worsening, or bulbar dysfunction progressing.
CPAP — Settings & Indications
Indications
OSA / home CPAP patients — use home settings
Cardiogenic pulmonary oedema — reduces preload + afterload
Post-extubation prophylaxis (obese, high-risk)
Hypoxia without hypercapnia (consider HFNC first)
CPAP Starting Settings
CPAP Pressure
5-10 cmH2O
Start 5. Titrate by 2 cmH2O. Max 15 cmH2O for CPE.
FiO2
0.40-1.0
Start high, titrate to SpO2 >94%.
CPAP vs BiPAP
Single pressure
BiPAP if hypercapnic or inadequate effort on CPAP alone.
HIGH FLOW NASAL CANNULA
Evidence: FLORALI trial (NEJM 2015), ROX index (Intensive Care Med 2019)
FLORALI trial: HFNC superior to standard O2 and non-inferior to NIV in acute hypoxic respiratory failure. 90-day intubation rate significantly lower. First-line for non-hypercapnic hypoxic RF.
Starting Settings
Flow Rate
30–40 L/min
Start 30 L/min. Increase to 40–60 L/min for severe hypoxia. Max 60 L/min. Higher flow = better FiO2 delivery + PEEP effect (~1 cmH2O per 10 L/min).
FiO2
0.60–1.0
Start high (0.60–1.0 if severe). Titrate to SpO2 target 92–96%. Wean FiO2 first, then flow.
Temperature
37°C
Heated humidified gas. Improves tolerance and mucociliary clearance. 34°C if less tolerated.
Reassess
1–2 hours
Calculate ROX index at 2, 6, and 12h. Clinical reassessment at 30–60 min.
ROX Index CalculatorFailure Predictor
ROX = (SpO2/FiO2) ÷ RR. Predicts HFNC failure and need for intubation. Calculate at 2h, 6h, and 12h.
SpO2 FiO2 RR
ROX ≥4.88 at 12h = low risk of intubation
ROX 3.85–4.88 = intermediate — close monitoring
ROX <3.85 = HIGH RISK — prepare for intubation
HFNC Failure Criteria — When to Escalate
Escalate to NIV or Intubation if:
!
ROX index <2.85 at any time or <3.85 at 12h
!
SpO2 <90% on FiO2 1.0 and flow 60 L/min
!
Rising PaCO2 or pH <7.30 (hypercapnia developing)
!
Increasing RR >35/min or worsening accessory muscle use
!
Haemodynamic instability
!
Altered mental status / inability to protect airway
HFNC Weaning Protocol
1
Wean FiO2 first to 0.40 while maintaining SpO2 >92%
2
Then reduce flow rate by 5 L/min increments q4–8h
3
Trial conventional O2 when flow <20 L/min and FiO2 ≤0.40
AIRWAY EQUIPMENT
ETT sizing, blade selection, LMA, surgical airway reference
ETT Size & Insertion Depth
Patient
ETT Size
Depth (lip)
Notes
Adult Male
7.5–8.0
23–25 cm
Cuffed
Adult Female
7.0–7.5
21–23 cm
Cuffed
Newborn
3.0–3.5
9–10 cm
Uncuffed
6 months
3.5
11 cm
Uncuffed
1 year
4.0
12 cm
Uncuffed
2 years
4.5
13 cm
Uncuffed
4 years
5.0
14 cm
Uncuffed or cuffed −0.5
6 years
5.5
15 cm
Uncuffed or cuffed −0.5
8 years
6.0
16 cm
Consider cuffed −0.5
10 years
6.5
17 cm
Cuffed 6.0
12+ years
7.0
18–20 cm
Cuffed
Paediatric formula: Uncuffed: (age/4) + 4 · Cuffed: (age/4) + 3.5 · Depth: (age/2) + 12 cm
Confirm with: bilateral breath sounds + EtCO2 waveform + CXR (tip at carina level)
LMA / Supraglottic Airway Sizing
LMA Size
Patient Weight
Max Cuff Vol
ETT (if converting)
1
<5 kg
4 mL
3.5
1.5
5–10 kg
7 mL
4.0
2
10–20 kg
10 mL
4.5–5.0
2.5
20–30 kg
14 mL
5.0–5.5
3
30–50 kg
20 mL
6.0
4
50–70 kg
30 mL
6.0–6.5
5
70–100 kg
40 mL
7.0
6
>100 kg
50 mL
7.0
Laryngoscope Blade Selection
Blade
Type
Best For
Notes
Mac 3
Curved
Average adult
Most common; sits in vallecula
Mac 4
Curved
Large adult / long neck
Larger mouth / longer blade
Miller 2
Straight
Average adult
Lifts epiglottis directly
Miller 3
Straight
Large adult / anterior airway
Anterior larynx, long epiglottis
Mac 1–2
Curved
Paediatric (toddler–child)
Mac 1 infant; Mac 2 small child
Miller 0–1
Straight
Neonate–infant
Miller 0 neonate; preferred in infants (anterior larynx)
VL (any)
Video
Difficult airway / anticipated difficult
First-line if LEMON positive. Glidescope/McGrath/C-MAC.
Emergency Surgical Airway — Scalpel-Bougie-TubeCICO Protocol
Declare CICO loudly. Stop intubation attempts. Move directly to surgical airway. Hesitation kills. Perform within 2–3 minutes of decision.
1
Position & Identify
Neck extended. Palpate and identify cricothyroid membrane (between thyroid and cricoid cartilages). Stabilise larynx with non-dominant hand.
2
Skin Incision
Vertical 3–4 cm skin incision over CTM — vertical avoids vessels. Index finger palpates through skin to confirm CTM location.
3
Horizontal Stab Incision
Single horizontal stab through CTM with No.10 scalpel. Caudal traction on trachea with hook through incision.
4
Bougie Insertion
Bougie passed caudally through incision into trachea. Feel tracheal rings (clicks) and hold-up at carina to confirm tracheal placement.
5
ETT over Bougie
Cuffed 6.0 ETT railroaded over bougie. Rotate 90° anticlockwise if resistance at arytenoids. Advance to 8–9 cm at skin.
6
Confirm & Ventilate
Remove bougie. Inflate cuff. Ventilate. Confirm EtCO2 waveform + bilateral breath sounds. Secure tube. CXR.