Endotracheal Intubation
Endotracheal intubation via [direct / video] laryngoscopy
[Acute hypoxic respiratory failure / Acute hypercarbic respiratory failure / Depressed level of consciousness with GCS [X] / Impending airway loss] requiring emergent endotracheal intubation for [airway protection and ventilatory support / airway protection / ventilatory support].
[The procedure was emergent, and consent was implied / Informed consent was obtained from the [patient / patient's surrogate] after discussion of risks, benefits, and alternatives].
[***, MD/DO]
Rapid sequence induction: [fentanyl [X] mcg IV, then] [etomidate / ketamine / propofol] [X] mg IV for induction and [succinylcholine / rocuronium] [X] mg IV for neuromuscular blockade
The patient was [cooperative / unresponsive / combative] before induction. A Cormack-Lehane grade [I / II / III / IV] view was obtained, with the vocal cords [fully / partially] visualized. The trachea was intubated on the [first / second / third] attempt. Tube position was confirmed by end-tidal CO2 waveform at [X] mmHg, bilateral equal breath sounds, absent epigastric sounds, and rising SpO2. Post-intubation chest radiograph showed the tube tip [X] cm above the carina.
[A time-out was completed confirming the patient and procedure.] The airway was assessed with Mallampati class [I / II / III / IV], [adequate / limited] mouth opening, [normal / limited] neck mobility, and a thyromental distance of [X] fingerbreadths. [Additional difficult airway predictors included [findings].] The patient was preoxygenated with a [non-rebreather mask / bag-valve-mask] for [3–5] minutes to an SpO2 of [X]%.
Rapid sequence induction was performed with the medications listed above. Cricoid pressure was [applied / not applied].
[Direct / Video] laryngoscopy was performed with a [Macintosh 3 / Miller 2 / video laryngoscope] blade. A cuffed endotracheal tube on a stylet was advanced through the vocal cords under visualization, and the stylet was removed.
The cuff was inflated [to a pressure of 20–30 cmH2O], and tube position was confirmed. The tube was secured and connected to the ventilator.
[7.0 / 7.5 / 8.0] mm cuffed endotracheal tube, secured at [X] cm at the [lip / teeth] with a [Thomas holder / tape]
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The patient was placed on mechanical ventilation with initial settings of [AC/VC, tidal volume 6 mL/kg ideal body weight, RR 14, FiO2 100%, PEEP 5]. [Post-intubation sedation and analgesia were started.] An arterial blood gas will be obtained 30 minutes after intubation. SpO2 and end-tidal CO2 are monitored continuously in the [ICU].
Epic SmartPhrase Version
PROCEDURE: Endotracheal intubation via [direct / video] laryngoscopy
INDICATION: *** requiring emergent endotracheal intubation for ***.
CONSENT: [Emergent, consent implied / Informed consent obtained from the [patient / surrogate] after discussion of risks, benefits, and alternatives].
PERFORMED BY: ***, MD/DO
ANESTHESIA: RSI: [fentanyl *** mcg IV, then] *** mg *** (induction) + *** mg *** (paralytic) IV
FINDINGS: Pre-induction mental status ***. C-L grade *** view, cords *** visualized. Intubated on *** attempt. Confirmed by ETCO2 waveform *** mmHg, bilateral equal breath sounds, absent epigastric sounds, rising SpO2. CXR: tip *** cm above carina.
PROCEDURE DETAILS:
[Time-out completed.] Airway assessed: Mallampati ***, mouth opening ***, neck mobility ***, thyromental distance *** fingerbreadths. Preoxygenated via *** x *** minutes to SpO2 ***%.
RSI as above. Cricoid pressure ***. *** laryngoscopy with *** blade. Cuffed ETT on stylet advanced through cords under visualization. Stylet removed, cuff inflated, position confirmed. Tube secured, connected to ventilator.
DEVICE PLACED: *** mm cuffed ETT, secured at *** cm at the [lip / teeth]
EBL: None
SPECIMENS: None
COMPLICATIONS: None
POST-PROCEDURE PLAN: Mechanical ventilation: AC/VC, TV *** mL, RR ***, FiO2 ***%, PEEP ***. ABG 30 minutes post-intubation. Continuous SpO2 and ETCO2 monitoring in ICU.
Signed: .ME, .MYDEGREE
.TODAYVariants
Video Laryngoscopy (GlideScope / C-MAC)
Given [anticipated difficult airway / obesity / limited neck mobility / prior difficult intubation], video laryngoscopy was performed using a [GlideScope / C-MAC] with a [hyperangulated / standard] blade. A Cormack-Lehane grade [I / II] view was obtained on the video screen. A pre-shaped stylet was used to navigate the acute angle. The tube was confirmed in the trachea by ETCO2 and bilateral breath sounds.
Failed Airway: Surgical Airway (Cricothyrotomy)
After [number] failed laryngoscopy attempts with [direct / video] laryngoscopy and failed [LMA / bougie-assisted] rescue attempts, a cannot-intubate, cannot-oxygenate (CICO) situation was declared. An emergent surgical cricothyrotomy was performed: the cricothyroid membrane was identified by palpation, a vertical skin incision was made, and a horizontal stab incision through the membrane was performed. A [6.0] mm cuffed ETT [or tracheostomy tube] was inserted and confirmed by ETCO2 and bilateral breath sounds.
Awake Fiberoptic Intubation
Given the anticipated difficult airway, awake fiberoptic intubation was performed. The posterior pharynx and supraglottic structures were anesthetized with topical [4% lidocaine spray / nebulized lidocaine]. The patient was cooperative throughout. A fiberoptic bronchoscope was passed through a [7.5] mm ETT and advanced nasally [or orally] through the vocal cords under direct visualization. The ETT was railroaded over the scope into the trachea. The scope was removed, cuff inflated, and position confirmed by ETCO2 and CXR.
Charting Tips
- Document ETT confirmation by at least two methods. ETCO2 waveform is the gold standard. Auscultation alone is insufficient. State the ETCO2 value and that bilateral breath sounds were equal with absence of epigastric sounds.
- Record the Cormack-Lehane grade. This documents the difficulty of the airway view and is critical for future airway planning. A grade III or IV view should trigger an anesthesia or ENT difficult airway flag in the chart.
- Document medications, doses, and sequence for RSI. In the event of hemodynamic compromise or adverse reaction, medication documentation is essential. Also note who administered medications and who performed laryngoscopy.
- Fentanyl pretreatment before induction is reserved for hemodynamically stable patients.
Documentation & Reimbursement Considerations
- Primary service: Report Endotracheal Intubation as the primary service when it is the definitive operation performed.
- Emergency endotracheal intubation (2.93 wRVU, 0-day global) is reported for emergency airway placement, not for elective intubation by anesthesia for a scheduled case.
- 0-day global: separately billable from same-day E/M or critical care.
- Video laryngoscopy does not change the code, which applies regardless of technique. Document the device and blade type used for the procedural record.