THE ENDOTRACHEAL TUBE IS YOUR FRIEND

7 Jan 2026THE ANESTHESIA CONSULTANT

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Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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Anesthesiologists are recognized as the airway experts of medicine. All acute medical care requires the management of Airway-Breathing-Circulation, in that order, which places anesthesiologists at a high rank in terms of importance in emergent patient care. A scenario familiar to all medical trainees is a Code Blue on a medical or surgical ward. For example, at 2 a.m. a nurse finds a hospitalized patient unresponsive without a heartbeat, and calls a Code Blue. The first to arrive are usually the interns, residents, or hospitalists who are sleeping in house. They initiate chest compressions and Ambu bag/mask ventilation, and within minutes an anesthesia resident arrives to place an endotracheal tube via video laryngoscopy or direct laryngoscopy. After injections of IV epinephrine and bicarbonate, and perhaps defibrillation if necessary, oxygenation and the spontaneous return of a heartbeat are restored, and the patient’s life is saved. The endotracheal intubation was critical to the successful resuscitation.

Prior to becoming an anesthesiologist, I trained for three years as an internal medicine resident, and I attended countless Code Blue resuscitations. I was knowledgeable in the Advanced Cardiac Life Support skills needed to keep the patient alive—except for the most important skill of all—that of placing an endotracheal tube in a patient of any size, shape, weight, age, or airway difficulty.

Prior to becoming an anesthesiologist, my understanding of anesthesiologists was they are the specialists who know how to place endotracheal tubes in anybody. Now that I’ve been an anesthesiologist for decades, my understanding of anesthesiologists is still they are the specialists who know how to place endotracheal tubes in anybody. It’s true that anesthesiologists have a myriad of additional perioperative skills, but the ability to save a life by placing an endotracheal tube in adverse circumstances is still our superpower.

In my experience as a medical-legal expert witness I’ve consulted on numerous cases that included mistakes regarding endotracheal intubation in emergent situations—specifically delayed endotracheal intubation, an erroneous choice of an alternative airway when an endotracheal intubation was required, as well as removal of an endotracheal tube prior to a time when extubation was safe. Let’s look at some representative educational examples:

A 40-year-old male with a Body Mass Index (BMI) of 38 presents for sinus endoscopy. He’s otherwise healthy. Anesthetic induction includes 100 micrograms of fentanyl, 300 mg of propofol, and the insertion of a #5 laryngeal mask airway (LMA). Maintenance anesthesia includes remifentanil and propofol infusions, and the patient is mechanically ventilated at a tidal volume of 500 cc and a rate of 10 breaths per minute. The operating room table is turned 90 degrees away from the anesthesiologist. Fifteen minutes after the beginning of surgery, the patient coughs and his oxygen saturation decreases from 98% to 88%. The anesthesiologist bag-ventilates the patient, but the oxygen saturation drops further to 85%. Auscultation of the chest reveals rhonchi and stridor. The oxygen saturation drops further to 70%. The surgery is stopped. The operating room table is returned to its original position. The anesthesiologist suctions through the LMA, and there is no blood or fluid. The oxygen saturation drops to 60%. The anesthesiologist removes the LMA, and mask ventilation is performed without success. The oxygen saturation drops to 60%. The anesthesiologist decides to intubate the patient and injects 100 mg of succinylcholine. Direct laryngoscopy is difficult, and the anesthesiologist is unable to visualize the vocal cords. He calls for a GlideScope, which arrives one minute later. With the GlideScope he is easily able to intubate the trachea, and the oxygen level returns to 100% within one minute, but the oxygen saturation was less than 90% for 5 minutes. The surgery is cancelled, and the patient is awakened. Postoperatively the patient has new cognitive deficits, and neurology consultation diagnoses hypoxic brain damage.

A 65-year-old male with a BMI of 36 has common bile duct gallstones and presents for an Endoscopic Retrograde cholangiopancreatography (ERCP). The procedure is performed in the prone position, and the anesthesiologist chooses to sedate the patient without any airway tube. The initial sedation is with 100 mcg of fentanyl and 2 mg of midazolam, followed by increments of propofol 50 mg X three. Twenty minutes into the procedure, the patient’s heart rate drops from 70 beats per minute to 45 beats per minute. The anesthesiologist treats with 0.2 mg of IV glycopyrrolate. The heart rate does not accelerate, and the oxygen saturation drops from 96% to 85%. The patient is unconscious, his breathing is obstructed, his heart rate continues in the 40s, and his oxygen saturation continues to drop into the 70s. After 5+ minutes of this trend, the anesthesiologist and the gastroenterologist agree to stop the procedure and turn the patient supine. It’s 4 minutes later before the anesthesiologist is able to intubate the trachea. The patient is taken to the intensive care unit. He never wakes, and the diagnosis is anoxic brain damage.

A 30-year-old male with a BMI of 42 is scheduled for a tonsillectomy. He has a diagnosis of obstructive sleep apnea and uses continuous positive airway pressure (CPAP) nightly. The induction of anesthesia is uneventful, and the trachea is easily intubated using a video laryngoscope. The surgery is done without complication. At the conclusion of surgery, general anesthesia is discontinued. The patient begins to sit up and thrash about with the endotracheal tube in place, and the anesthesiologist chooses to extubate the trachea. The patient’s blood pressure rises to 180/110, and the patient begins bleeding from his throat. He is not fully awake, and because of the blood in his mouth and his stuporous level of consciousness, he is not breathing adequately. Attempts to oxygenate the patient with a mask are unsuccessful. His oxygen saturation drops to below 70% for over 5 minutes before the anesthesiologist replaces an endotracheal tube. Postoperatively the patient suffers from hypoxic brain damage.

A healthy 5-year-old female is scheduled for right middle ear ossiculoplasty. Sevoflurane mask induction is followed by IV placement and endotracheal intubation with a #5 cuffed ET tube. Maintenance anesthesia is sevoflurane and propofol, and a two-hour surgery is performed without complication. At the conclusion of surgery, general anesthesia is discontinued, the patient is awakened, and when she opens her eyes, the anesthesiologist reaches for a syringe to let the air out of the ET tube cuff. At this point, the patient vomits approximately one cup of a chocolate-appearing liquid which fills her mouth and spills out over her cheeks. The fluid is suctioned out of her mouth, and after all vomiting is ceased, and the cuff is then deflated, and the endotracheal tube is removed safely.

Comments:

In Case #1, utilizing an LMA for a patient with an elevated BMI of 38 is risky business. Studies have shown successful ventilation of obese patients with a BMI below 30, but when using an LMA in patients with a body mass index (BMI) over 30, there is a 2.5 times increased risk of having ventilatory problems. A patient this obese will have decreased lung volumes due to his obesity, and his decreased Functional Residual Capacity means he will have a low reservoir for oxygen reserve. It’s predictable that such a patient will develop hypoxia if anything goes less than perfect with his airway or breathing. In this case, the patient developed laryngospasm and possible aspiration of blood, and the anesthesiologist had to be prepared to place an endotracheal tube to salvage the situation without delay. Advice: Consider electively choosing an endotracheal tube on obese patients, rather than rolling the dice on a supraglottic airway like an LMA.

In Case #2, performing an ERCP in an obese patient in the prone position without an endotracheal tube is also risky business. Again, a patient this obese will have decreased lung volumes due to his obesity, and his decreased Functional Residual Capacity means he will have a low reservoir for oxygen reserve. It’s predictable that such a patient will develop hypoxia if anything goes less than perfect with his airway or breathing, and if anything does go less than perfect, the anesthesiologist must be prepared to place an endotracheal tube to salvage the situation without delay. Because the patient is prone, there will be a delay while the patient is turned supine. Advice: For an ERCP, consider controlling the airway electively with an endotracheal tube from the start.

In Case #3, treat extubation with care. Landing the anesthesia plane takes nearly as much skill as starting an anesthetic. Early in my training I was taught that the safest way to guarantee a safe airway at the conclusion of an endotracheal anesthetic is to extubate the patient’s trachea after they open their eyes. Just because a patient is moving, or is agitated, or reaching for the tube, does not mean they are ready to breathe safely without the tube, and without laryngospasm or airway obstruction. The endotracheal tube is your friend, and when you remove it, you’d best be certain you don’t need it anymore. In this case, in a morbidly obese sleep apnea patient, removing the endotracheal tube before the patient is ready to breathe safely on his own is perilous. Wait until he opens his eyes and is in a spontaneous breathing pattern. If his blood pressure climbs during this period, increments of labetalol IV may be indicated to treat and avoid hypertension.

In Case #4, an awake extubation saved an airway disaster. As discussed in Case #3 above, the safest way to control the airway at the conclusion of an endotracheal anesthetic is to extubate the patient’s trachea when they open their eyes. If this child’s endotracheal tube had been removed deep, the patient would likely have suffered an aspiration pneumonia and a hospital admission, and perhaps an adverse outcome. The endotracheal tube is your friend, and when you remove it, you’d best be certain you don’t need it anymore.

Endotracheal intubation does carry the risks of airway trauma, esophageal intubation, and side effects of muscle relaxants, but when a patient is acutely hypoxic, a delay in endotracheal intubation is a critical error. Airway management includes more than just endotracheal intubation. Many anesthesia residency programs, including our department at Stanford, include full rotations on airway management, as well as a specialized fellowship opportunity for advanced airway management. But airway management will always be part of everyday anesthesia care for all of us, and airway management will always offer both the potential for great benefit and the specter for great harm if mismanaged.

Keep your patients oxygenated at all times, but if their oxygen saturation is dropping and you don’t have an endotracheal tube in place, don’t stand around wondering if you should place one. Do it.