Airway management

Immediately after intubation

Reviewed Nov 2026·3 references
New· views rounded down, updated weekly

Confirm and secure the tube, set lung-protective ventilation matched to the patient's prior minute ventilation, treat hypotension, start analgosedation, check the chest X-ray and cuff pressure, and document the airway.

At the bedside

Timed steps
  1. 1

    Confirm

    0-2 min

    Waveform capnography, bilateral chest rise and breath sounds, SpO2 recovery.

  2. 2

    Secure and depth

    0-5 min

    Tube at ~21 cm (women) / 23 cm (men) at the teeth; tie or tape; cuff pressure 20-30 cmH2O with a manometer.

  3. 3

    Ventilator

    0-10 min

    Vt 6-8 mL/kg PBW, PEEP 5-8 (higher if hypoxaemic), FiO2 1.0 then titrate to SpO2 92-96%. In severe metabolic acidosis, match the pre-intubation minute ventilation (often rate 25-30). See module 8.

  4. 4

    Haemodynamics

    0-10 min

    Expect hypotension from induction, positive pressure and loss of sympathetic drive; titrate noradrenaline; exclude tension pneumothorax and auto-PEEP if BP crashes.

  5. 5

    Sedation and analgesia

    0-15 min

    Start analgesia-first sedation (fentanyl infusion + propofol); target RASS according to need (deeper if paralysed).

  6. 6

    Chest X-ray and gas

    30 min

    Tube tip 3-5 cm above carina; check for pneumothorax and NG position; ABG at 30 min. Insert NG/OG tube.

  7. 7

    Airway record

    Document

    Grade of view, device, attempts, adjuncts, difficulty, and a 'difficult airway' alert on the bed and in the notes if relevant.

Red flag · call your senior now
Sudden hypotension and rising airway pressure: tension pneumothorax or auto-PEEP; disconnect briefly and examine.
Red flag
Desaturation after intubation: DOPES (Displacement, Obstruction, Pneumothorax, Equipment, Stacking).
Pitfall
Leaving the patient paralysed without sedation.
Pitfall
Right main bronchus intubation (check depth and breath sounds).
Pearl
Write the tube size and depth on the whiteboard; check it at every handover.

Calculators for this topic

Predicted (ideal) body weight

ARDSNet predicted body weight from height and sex. Use for tidal volume, not for most drug doses.

Tidal volume from predicted body weight

Lung-protective tidal volume (usually 6 mL/kg PBW; range 4-8).

References

  1. 1

    Higgs A, McGrath BA, Goddard C, et al. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018;120(2):323-352

  2. 2

    Myatra SN, Ahmed SM, Kundra P, et al. The All India Difficult Airway Association 2016 guidelines for tracheal intubation in the Intensive Care Unit. Indian J Anaesth. 2016;60(12):922-930

  3. 3

    Acquisto NM, Mosier JM, Bittner EA, et al. Society of Critical Care Medicine clinical practice guidelines for rapid sequence intubation in the critically ill adult patient. Crit Care Med. 2023;51(10):1411-1430

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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.