Sep 282013
Intubation Checklists in the ICU and ED

Can They Save Lives?

Endotracheal intubation in the ICU or emergency department is often challenging, to understate by a lot. Intubations outside the operating room are often emergent rush jobs on crashing, hypotensive, severely hypoxemic patients, or people with who have just self-extubated. Pulmonologists' and emergency physicians' familiarity with these uncontrolled, chaotic intubations may have some advantages, but consistent adherence with perfect intubation technique is probably not among them.

As a profession, anesthesiologists have achieved stunning success over decades in reducing complications during intubation and anesthesia, largely by systematizing and standardizing processes and teaching them as their core of professional training. This focus includes a heavy reliance on checklists and algorithms. Despite their track record of success, though, such checklists haven't become an integral part of most training in pulmonary and critical care fellowships. Maybe that stems from the unpredictability of intubations in the ICU, each with its own unique urgencies and conditions (unlike in the assembly-line operating theater), or perhaps from "cultural differences" between the specialties.

Although a few highly experienced pulmonologists and emergency physicians have performed more than 1,000 intubations, the average anesthesiologist has done at least that many, and has significantly greater experience with advanced airway management techniques (other than bronchoscopy). Pulmonary critical care fellows need only perform 20 intubations over three years to graduate and practice independently (a number achieved in an average week for an anesthesia resident); one study suggested that an average of 57 intubations are required to achieve 90% proficiency.

Few would dispute that these differences result in a proficiency gap. In a widely cited pro/con in Chest, "Should An Anesthesiologist Be the Specialist of Choice in Managing the Difficult Airway in the ICU?", while the anesthesiologist barked "Yes," all the proud pulmonologist could muster was a "not necessarily."

No study I'm aware of has tested the effects of an intubation checklist on the quality of intubations and outcomes, either from anesthesia or in the ICU. But anesthesiology achieved its successes not through randomized controlled trials, but through iterative process improvement and quality review. Each item on a checklist addresses a failure that has occurred and will continue to occur with predictable frequency. For those who want to borrow some of that hard-won knowledge and hard-wire it into your own practice, here are some free online resources to help you standardize and improve your own endotracheal intubation technique, and the processes at your institution.

Scott Weingart's EMCrit's Intubation Checklist

"Safer Intubation" Checklist

The VORTEX Approach from Clinical CrEd

EMCrit's Intubation Checklist Webcast:

Direct Laryngoscopy Video from EMCrit:

VORTEX Checklist for Emergent and Elective Intubations:

Using a Bougie for Endotracheal Intubation (Larry Mellick):

Vanderbilt Emergency Medicine's Rapid Sequence Intubation Pre-Induction Checklist: 


More Intubation Checklists and Resources:

Fiberoptic intubation checklist (with bronchoscopy, fiberoptic light wand, etc)

Additional Intubation Checklists

The "EDICT" checklist from EMUpdates (

The VORTEX Approach


This is only a start, I hope. Got a suggestion to add to this list? Please share it in the comments below.

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Intubation Checklists — are theirs better than yours?