In endotracheal intubation, a tube is placed in the trachea to allow a ventilator to blow oxygen into the lungs under pressure, raising the blood oxygen and removing CO2 in patients who have respiratory failure. The ventilator does not fix the respiratory failure; it keeps the patient alive while giving other therapies time to work. Critically ill ICU patients not anticipated to be difficult require rapid sequence intubation (RSI). An RSI refers to an intubation preceded by the administration of a rapid-acting sedative to render the patient unconscious which is then immediately followed by a neuromuscular blocking agent to paralyze the muscles. The sedative ensures the patient will have no pain or recall, and the paralyzing drug relaxes the jaw muscles, preventing the patient from biting or clenching the teeth, and also preventing gagging and vomiting. This process provides the greatest chance of first-pass success. If there is concern the airway will be difficult, then the patient is intubated awake or with light sedation.
If legitimate and persistent concerns are raised about tube position, particularly in a patient whose oxygen sat and heart rate are falling, the standard of care requires the ETT must be removed and the patient bagged until the ETT can be properly placed. If the ETT is in the esophagus and the patient is being bagged through it, the oxygen is going into the stomach, and thus failing to oxygenate the lungs. If the tube is removed and the patient is bagged with a mask on the face, oxygen can then get into the lungs.
Endotracheal intubation using video laryngoscopy (e.g., Glidescope) involves the use of a device to improve the view of the vocal cords and increases the likelihood of first-pass success at intubation. In a patient who is already quite hypoxemic in the ICU, a Glidescope would improve the view of the vocal cords and significantly decrease the chances of esophageal intubation. The special stylet for the Glidescope can be helpful, but it is not mandatory. The standard stylet placed in the ETT allows it to be bent so it can be directed through the vocal cords more easily. If that stylet is bent to the proper shape, it can function much like the special Glidescope stylet. The lack of the special stylet does not preclude use of the Glidescope. A Glidescope needs to at least be immediately available for backup if direct laryngoscopy fails. Furthermore, the Glidescope would be the preferred first choice for a critically ill patient.
Endotracheal intubation medical expert witness specialties include anaesthesiology, cardiac anaesthesiology, obstetric anaesthesiology, otolaryngology, forensic pathology, and head and neck surgery.