Nursing care
Endotracheal Intubation: the nurse's role, start to finish
Written and reviewed by Dana Whitfield, RN, MSN · 5 min read · Updated September 2026
Short answer
Endotracheal intubation nursing management centres on pre-oxygenation, confirming tube placement with capnography before auscultation, and recording the depth marking at the lip. That marking is the reference point for every check afterward: if it moves, the tube has moved. Monitoring continues for hypoxia, arrhythmia, and accidental extubation throughout ventilation.
When it is done and why
Intubation secures the airway when a patient cannot protect it, cannot oxygenate or ventilate adequately, or is expected to deteriorate before another team can intervene. Common triggers include respiratory failure with rising CO2, GCS at or below 8, status epilepticus, major trauma to the face or neck, and planned surgery under general anaesthesia.
The decision usually sits with the anaesthetist, intensivist, or emergency physician, but the nurse is frequently the one who first flags the trajectory: falling SpO2 despite high-flow oxygen, accessory muscle use, or a patient tiring out on noninvasive support. Recognising that a patient is heading toward a definitive airway, and saying so early, is part of the nursing role even before the tube arrives at the bedside.
Preparing the patient
Pre-oxygenate with 100% oxygen for at least three minutes before induction, using a non-rebreather mask or bag-valve-mask with a good seal. This builds an oxygen reserve that buys time once the patient is paralysed and apnoeic, and it is the single step most likely to be rushed under pressure.
Establish reliable IV access, apply continuous SpO2, ECG, and blood pressure monitoring, and have suction switched on and within reach before the first laryngoscope pass. Confirm the patient's identity and consent status where possible, remove dentures, and note any predictors of a difficult airway — small mouth opening, limited neck extension, high Mallampati score — so the team can plan for a failed first attempt rather than react to one.
The steps that matter for safety
Confirmation of tube placement is not optional and not visual alone. Capnography — a sustained waveform and end-tidal CO2 reading — is the primary confirmation that the tube sits in the trachea rather than the oesophagus. Auscultate bilateral breath sounds and the epigastrium afterward, but capnography comes first because breath sounds can be misleading with a mainstem intubation or a noisy chest.
Once placement is confirmed, note the centimetre marking at the patient's lip or teeth and document it. That number is the baseline every subsequent check is measured against. A tube that has slipped two centimetres deeper, or pulled back two centimetres, shows up as a changed lip marking before it shows up as desaturation, and catching it there is faster and safer than waiting for the patient to decompensate.
During the procedure — the nurse's role
The nurse's job during the intubation attempt is to keep the physiology stable and the equipment ready, not to manage the laryngoscope. Continue to call out SpO2 and heart rate at intervals, prepare and administer induction and paralytic agents as ordered, and apply cricoid pressure only if specifically requested, since routine use is no longer standard.
Hand instruments and the endotracheal tube as directed, have a bougie or second airway device open and ready in case of a failed first pass, and watch the clock: most protocols call for interrupting the attempt and re-oxygenating by bag-valve-mask if intubation is not achieved within roughly 30 to 45 seconds. After the tube is placed and confirmed, secure it, inflate the cuff to the pressure the team specifies, and connect to the ventilator or bag.
After: monitoring and complications
Continuous SpO2, capnography, and cardiac monitoring continue for as long as the tube is in place. Watch for hypoxia, arrhythmias from vagal stimulation during laryngoscopy, aspiration if the stomach was not decompressed, and barotrauma once ventilation begins. Reassess breath sounds and the lip marking with every handover and after any patient repositioning.
Unplanned extubation and mainstem migration are the two complications most tied to nursing vigilance. A sudden rise in peak airway pressures, new asymmetry in chest rise, or a change in the lip marking should trigger an immediate reassessment rather than waiting for oxygen saturation to fall, since desaturation is often the last sign to appear, not the first.
Documentation and teaching
Document the indication for intubation, the time, the number of attempts, the tube size, the confirmed depth at the lip, cuff pressure, capnography reading, and the names of staff present. Record any complications during the attempt, including desaturation episodes, arrhythmias, or difficulty with visualisation, since this shapes the plan for future airway attempts on the same patient.
For a patient who is conscious enough to understand, or for family at the bedside, explain that the tube protects breathing and that the patient will not be able to speak while it is in place. Set up a communication method — a whiteboard, picture board, or hand signals — before sedation deepens, and explain the purpose of restraints or arm boards if used, since unexplained restriction is a common source of distress on waking.
The next step on this is the same as on everything else here: answer questions and read the rationales. Our respiratory practice questions are the closest set to what this page covers.
Common questions
How do you confirm correct endotracheal tube placement?
Capnography is the primary method: a sustained end-tidal CO2 waveform confirms the tube is in the trachea. Follow this with bilateral breath sounds on auscultation and absence of gurgling over the epigastrium, then a chest X-ray to confirm depth above the carina.
What is the nurse's role during rapid sequence intubation?
The nurse pre-oxygenates the patient, prepares and administers induction and paralytic drugs, monitors vital signs throughout, and has suction and backup airway equipment ready. The nurse does not perform the laryngoscopy but supports the physiology and the equipment around it.
Why does the lip marking on an endotracheal tube matter?
The centimetre marking at the lip or teeth is the fixed reference point for tube depth. If that number changes between checks, the tube has migrated, either toward extubation or into a mainstem bronchus, and needs immediate reassessment before waiting for oxygen levels to drop.
What is a common NCLEX question about intubation complications?
Questions often present a sudden change in peak airway pressure or asymmetric chest rise and ask for the priority action. The expected answer is to reassess tube position and breath sounds immediately, since this can indicate mainstem intubation, pneumothorax, or accidental extubation.
How long should pre-oxygenation take before intubation?
At least three minutes of 100% oxygen via a well-sealed mask, when time allows. This builds an oxygen reserve so the patient tolerates the apnoeic period during laryngoscopy without rapid desaturation.