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Improve endotracheal intubation with First and TEN approach

The “set-up, size-up, scope, secure” mindset of the 1st and TEN approach to intubation may help improve first-pass success


Before an intubation attempt, setting up for success and sizing up the patient’s airway increases the likelihood of first-pass success.

Photo/Nathan Stanaway

This article was originally posted June 20, 2017. It has been updated.

Taking the time to prepare for intubation success on the first pass and following the Tongue, Epiglottis and arytenoid Notch landmarks will stack the cards in your favor during both routine and difficult airway scenarios. When attempting endotracheal intubation, most paramedics focus on quickly visualizing the vocal cords, so I developed the first and TEN approach to slow the process to improve first-pass success, greatly improving outcomes and reducing adverse events. [At the end of this article, download a guide to intubation mnemonics that will increase your first-pass success]

Before an intubation attempt, setting up for success and sizing up the patient’s airway increases the likelihood of first-pass success. Here’s how:

Set-up for endotracheal intubation success

The patient should be positioned in a bed-up and head-elevated position, sitting the patient high enough that their ear canal is on the same horizontal plane as their sternum, tilting their head back slightly. This is the optimum position for ventilation and oxygenation and it is also the optimum position for visualization of the vocal cords.

The great irony of intubation is that the very treatment meant to prevent hypoxia is actually a common cause of hypoxia. The interruption of oxygenation and ventilation necessary to place an advanced airway can often cause more harm than good.

It is therefore important to raise the patient’s oxygenation prior to placing the endotracheal tube. Otherwise, the patient’s oxygen saturation may fall so low as to cause hypoxic damage during the intubation attempt itself.

Methods of pre-oxygenation include clearing the airway, continuous positive airway pressure, pre-intubation ventilation with a BVM and high-flow nasal cannula or apneic oxygenation during the intubation attempt. These methods can help extend the time for intubation before oxygen desaturation and hypoxia require a change in tactics. Pre-oxygenating the patient allows the provider to better prepare for one solid attempt to secure the airway on the first pass rather than several rushed attempts.

While the equipment for intubation may vary from service to service, paramedics should make use of all available airway equipment and medications to help ensure success on the very first intubation attempt. Devices such as the gum-elastic bougie, lighted stylet and video laryngoscopes should be used regularly and not held back for use only after initial attempts at airway management have failed and the patient is determined to have a difficult airway.

Size-up the patient’s airway

A variety of mnemonics exist to help properly evaluate airway management challenges before intubation is attempted. A comprehensive, yet simple one I developed is remember to check if your patient is getting MOUTHI.

  • Mouth. Is there room in the patient’s mouth for good visualization and to move the tongue aside?
  • Obstructions. Are there any airway obstructions?
  • Uvula. Can you see the patient’s uvula? If not, it may be predictive of a poor view of the larynx.
  • Teeth. Are the patient’s teeth large, abnormal or traumatized?
  • Head trauma. Does the patient have significant head trauma?
  • Immobile neck. Is the patient’s neck immobile due to surgical fusions, arthritis or traumatic injury?

If any MOUTHI difficulties are found during the size-up of the patient’s airway, work to correct or adapt to them prior to the intubation attempt to help ensure first-pass success.

Scope the TEN road to endotracheal intubation

When intubating, it can be tempting to place the laryngoscope for a direct view of the vocal cords as rapidly as possible, but this can often lead to a laryngoscope view too deep or otherwise disorienting if the cords do not immediately come into view. For this reason, it can be helpful, especially for new paramedics or paramedics who do not get to make frequent attempts at intubation, to follow the TEN road to intubation.

  • Tongue. The tongue is your first and easiest landmark. Don’t simply push past it. Manage it properly to move it aside and follow it to the base. This will lead you to your next landmark.
  • Epiglottis. Easily overshot by many a zealous paramedic, the epiglottis is a relatively easy landmark to identify, especially when you follow along the tongue. Once the epiglottis is lifted, the paramedic will likely see the arytenoid cartilages and possibly even the vocal cords.
  • Notch. Even if the vocal cords are immediately visible, make note of the notch between the arytenoid cartilages. Should the vocal cords disappear from view during your attempt, you know that they are always positioned just beyond that notch. Should you need to attempt a fully or partially blind intubation, these will guide you towards your target of the vocal cords, especially if you are using a gum-elastic bougie or similar device.

Secure, confirm the endotracheal tube

Once the endotracheal tube has been placed, confirm the placement using more than one method. While many are available, direct visualization of the tube passing through the vocal cords along with continuous end-tidal CO2 monitoring remain the gold standard of ETI placement confirmation and monitoring.

The first and TEN mindset can help put everyone on the EMS crew on the same page. Set yourself up for first-pass success. Be ready to set-up, size-up, ’scope and secure. Following the road to intubation past the tongue, epiglottis and notch between the arytenoid cartilages will help you perform endotracheal intubation with confidence under even the most difficult conditions.

Great airway management comes from using a great process. Each step is important to ensure success and should be outlined and practiced so that EMS providers can work together to effectively manage airway and ventilation for critically ill patients.

Fill out the form below to download the First and TEN Guide to Intubation

Rom Duckworth is a dedicated emergency responder, author and educator with more than 30 years of experience working in career and volunteer fire departments, hospital healthcare systems, and private EMS. He is a career fire captain and paramedic EMS coordinator for the Ridgefield (Connecticut) Fire Department and the founder of the New England Center for Rescue and Emergency Medicine. Duckworth is recipient of the American Red Cross Hero Award, Sepsis Alliance Sepsis Hero Award, and the EMS 10 Innovators Award in addition to numerous awards and citations for excellence in education and dedication to service. Duckworth is a member of numerous national education, advisory and editorial boards, as well as a contributing author to more than a dozen EMS, fire and rescue books, including the IFSTA Pumping Apparatus Driver/Operator textbook as well as over 100 published articles in fire and EMS journals, magazines and websites. Duckworth has a bachelor’s degree in public safety administration from Charter Oak State College in Connecticut. Connect with Duckworth via or or on LinkedIn.