Can Nurses Intubate? Clarifying Critical Code Blue Roles

For nurses working in a hospital, the code blue scenario is a familiar and crucial aspect of our profession. The rush of adrenaline, the urgent call for action, and the need for swift decision-making can be both challenging and rewarding. One common question, especially during code blue situations, is can nurses intubate? This article will delve into the intricacies of intubation within the nursing scope of practice.

What is Intubation?

Intubation is a medical procedure that involves inserting a flexible plastic tube, known as an endotracheal tube, into the trachea (windpipe) through the mouth or nose. This invasive intervention is typically performed to secure and maintain a patent airway, ensuring air passage to the lungs. 

The tube is subsequently connected to a device designed to supply air. This apparatus may be a manually operated bag manipulated by a healthcare provider (like a nurse or respiratory therapist) to deliver air into your body. Alternatively, the device could be a ventilator, a mechanical apparatus that propels oxygen into your airway and lungs.

Common Reasons for Intubation

According to Cleveland Clinic, the primary reasons for intubation include:

1. Airway obstruction (something stuck in the trachea or farther down, preventing airflow in or out of the lungs)
2. Cardiac arrest (heart stopped or in a lethal rhythm)
3. Injury or trauma to the neck, abdomen, or chest impacting the airway
4. A loss or low level of consciousness that leads to the loss of the ability to maintain one’s airway
5. The necessity for surgery rendering autonomous breathing impossible, respiratory failure, or apnea
6. Risk for aspiration (food, fluids, or saliva going into the lungs)

Intubation Techniques

The techniques healthcare providers employ during intubation are critical for the success and safety of the procedure. Here is a brief information about the two techniques of advanced airway management:

Endotracheal Intubation

Endotracheal intubation is the most common intubation procedure involving the insertion of a breathing tube, known as an endotracheal tube (ETT), through the mouth or nose into the trachea. This technique is commonly employed in emergencies, surgeries, and critical care settings to secure a patent airway and facilitate mechanical ventilation.

A laryngoscope is often used to visualize the vocal cords, providing a clear passage for the ETT insertion. This method is preferred in scenarios requiring rapid airway control and is associated with a lower risk of tube displacement.

Below is an example of a patient in the operating room getting intubated.

Nasotracheal Intubation

Nasotracheal intubation is an alternative technique where the breathing tube is inserted through the nose into the trachea. This method is often chosen in situations where oral intubation may be challenging or contraindicated. It is commonly used in elective surgeries, certain medical conditions, or when oral access is restricted.

Nasotracheal intubation may offer benefits such as decreased risk of oral trauma and improved patient comfort during prolonged ventilation. Careful attention to proper tube size, patient positioning, and anatomical considerations is essential to ensure successful and safe nasotracheal intubation.

Generally speaking, if you work in an intensive care unit, you will rarely see nasotracheal intubations. (I worked in one for four years and only saw one nasotracheal.)

Equipment Needed for Intubation

The essential equipment includes a laryngoscope (for visualization), endotracheal tubes or nasotracheal tubes, stylet (if needed for shaping the tube), bag-valve-mask device, suction equipment, and a device for confirmation of tube placement (such as capnography).

Hospitals often have an “intubation kit” with the necessary supplies. When indicated, grab the kit, set up suction (which is hopefully already set up), and get a ventilator. Your unit’s respiratory therapist will likely help you gather this equipment.

Can Nurses Intubate?

Many healthcare providers are qualified to perform this skill. However, they must have additional training and be checked off on competencies before being allowed to perform it.

Here’s a list of different types of healthcare providers who routinely intubate patients:

• Anesthesiologists
• Certified Registered Nurse Anesthetists (CRNAs)
• Critical care providers (physicians, NPs, PAs)
• Emergency department providers (physicians, NPs, PAs)
• Neonatal providers (physicians, NPs, PAs)
• Pediatric providers (physicians, NPs, PAs)
• Flight nurses
• Paramedics
• Critical care nurses

To answer the question: Can nurses intubate? The short answer is yes, they can. However, just because someone could do something doesn’t mean it is routine. It makes a lot more sense in a hospital setting for other people (CRNAs, MDs/DOs, APPs, and RTs) to perform this complex skill while the nurse monitors the patient during the procedure.

Patients who need intubation will require multiple medications to be administered and their hemodynamic status monitored closely. Nurses are more than qualified to do this, which is why it just makes more sense for them to perform that part of the procedure and leave the actual intubation piece to others who do not routinely give meds and monitor patients like nurses do.

Most states permit nurses with additional training to intubate. Each state’s Nursing Practice Act determines the scope of practice of nurses. You need to check the board of the state you are licensed to practice in to learn what you are allowed to perform with patients. 

Depending on the state board of nursing and advanced certifications received, you can be authorized to perform this procedure. It also depends on the employer policy and your competence level, meaning how many intubations per year you are required to maintain competence in performing the procedure successfully. Some hospitals may allow nurses to intubate, but it is often reserved for advanced practice providers and some respiratory therapists, depending on their policy.

Also is essential to mention that even if you are not authorized to perform intubation you can participate in assisting the procedure by performing regular nursing tasks such as monitoring the vital signs, reviewing the chart and labs, and managing the fluids, among others. 

Who Can’t Intubate?

The people who can perform this skill are the exception, not the rule. Most people on your standard nursing unit cannot perform intubation because the proper training to do this is so extensive, and again, it just makes more sense for people other than the nurse to do this. Therefore it is not a standard practice for nurses.

• Registered nurses who do not have the additional training (this would be most nurses)
• LPNs
• Nursing assistants or patient technicians
• Respiratory therapists who have not had the additional training
• Basic EMT’s

Remember, not all physicians or advanced practice providers intubate either. A dermatologist or a nurse practitioner working in a neurology clinic are not trained to do this.

Take home message ➡️ Nurses, physicians, advanced practice providers, and respiratory therapists are all capable of performing intubation due to their professional licenses. However, they must receive additional training to practice this skill legally.

Types of Nurses that Can Intubate

Let’s explore the types of nurses who may be qualified to undertake this essential skill:

1. Critical Care or Emergency Nurses
   • Nurses specializing in critical care, including those working in Intensive Care Units (ICUs) or Emergency Departments (ED), can be trained to perform intubation, but this is uncommon. 
2. Certified Registered Nurse Anesthetists (CRNAs)
   • Anesthesia nurses who work closely with anesthesiologists are well-versed in airway management techniques, including intubation. They are crucial in surgical and procedural settings, ensuring patients are safely intubated and maintained during various medical interventions.
3. Trauma Nurses
   • Whether in emergency departments or trauma units, nurses specializing in trauma care may be trained in intubation. These nurses are equipped to handle patients with severe injuries and respiratory distress.
4. Flight Nurses
   • Nurses involved in air medical transport, such as flight nurses, often need to manage patients in critical conditions. They may acquire the skill of intubation to ensure the stability of patients during transport.
5. Nurse Practitioners (NPs)
   • Some advanced practice nurses, such as Nurse Practitioners, may have the training and authorization to perform intubation. These nurses often work collaboratively with physicians to provide comprehensive patient care.

It’s important to note that the specific scope of practice can vary based on state regulations, institutional policies, and individual nurse certifications. Nurses authorized to perform intubation typically undergo rigorous training and demonstrate competency in airway management skills to ensure patient safety.

Nursing Expertise in Intubation

Nurses undergo extensive training to acquire the necessary skills for intubation. Hospital policies and procedures differ widely. However, the nurse would likely need an ACLS certification, be highly experienced, and undergo additional on-the-job specialty training.

On-the-job training can include things like sim lab and an in-person class with an exam encompassing both a written component and a skills component. They will likely also need to be shadowed by another healthcare provider who is already competent in intubation and checked off for a certain number of successfully performed procedures before being permitted to do so without supervision.

Understanding Code Blue

A “code blue” generally indicates a patient requiring resuscitation or immediate medical attention. This means the person has a grave concern like their heart stopped beating (or went into a lethal arrhythmia) or they stopped breathing.

Many times, intubation is performed during a code blue.

Code Blue Nursing Roles

As integral team members, nurses have distinct roles in optimizing patient outcomes. These roles encompass:

1. Team Coordination
   • Nurses coordinate responsibilities, ensuring effective communication among team members and the smooth execution of the Code Blue protocol.
2. Patient Assessment
   • Rapid and accurate patient assessment is crucial. Nurses contribute by evaluating the patient’s condition, vital signs, and responsiveness to guide subsequent interventions.
3. CPR (Cardiopulmonary Resuscitation)
   • Nurses actively participate in chest compressions and provide ventilations, adhering to CPR guidelines to maintain blood circulation and oxygenation.
   • Important note ➡️ Nursing assistants (CNAs) are qualified to perform CPR. Therefore, if you have limited nursing support available, it is wise to delegate this task to CNAs to free up more nurses.
4. Medication Administration
   • Administering emergency medications, such as epinephrine or antiarrhythmics, as prescribed in the protocol to address cardiac arrest or other life-threatening conditions.
5. Airway Management
   • Nurses may be involved in establishing and maintaining a patent airway, performing endotracheal intubation if necessary, or assisting in other airway maneuvers.
6. Defibrillation
   • Operating defibrillation equipment to deliver electrical shocks when indicated to restore normal heart rhythm.
7. Documentation
   • Ensuring accurate and timely documentation of interventions, medications administered, and patient responses for later review and quality improvement.
8. Family Support
   • Providing support and information to the patient’s family, helping them understand the situation, and addressing their concerns during the event.
9. Post-Code Debriefing
   • Participating in post-code blue debriefing sessions to discuss the event, identify areas for improvement, and enhance the team’s future response.
10. Emotional Support
    • Offering emotional support not only to the patient but also to fellow team members who may experience stress during the high-pressure situation.

If you want to learn more, read my article about surviving your first code blue or RR.

Collaboration within the Code Blue Team

While nurses can play a pivotal role in intubation, it’s essential to emphasize the collaborative nature of code blue response. Physicians, respiratory therapists, and other healthcare professionals contribute unique skills to ensure comprehensive and effective patient care. Communication and teamwork are paramount in such a high-pressure situation.

Can Nurses Intubate? Final Thoughts

In the dynamic realm of code blue scenarios, whether nurses can intubate has a clear and affirmative answer. Nurses are integral members of the code blue team, equipped with the skills and knowledge to perform, in some cases, intubation and, in most cases, other life-saving interventions, participating with the team.

As we navigate emergency response challenges, it’s crucial to recognize and appreciate the collaborative efforts that define our profession, ensuring the best possible outcomes for our patients.

More Resources on Can Nurses Intubate?

• Top Tips for New Nurses Working With Ventilators – From a CRNA!
• Ventilator Settings for Nurses: Demystifying ICU Ventilator Modes
• Mastering Critical Care: Your Guide to 6 Essential Pieces of Common ICU Equipment