Endotracheal intubation Endotracheal intubation is a medical procedure in which a tube is placed into the windpipe (trachea), through the

mouth or the nose. In most emergency situations it is placed through the mouth. How the Test is Performed After endotracheal intubation, you will likely be placed on a breathing machine. If you are awake after the procedure, your health care provider may give you medicine to reduce your anxiety or discomfort. Why the Test is Performed Endotracheal intubation is done to: Open the airway to give oxygen, medication, or anesthesia Remove blockages from the airway Allow the doctor to get a better view of the upper airway Protect the lungs in certain patients

Risks Risks for any surgery are: Bleeding Infection Additional risks for this procedure include trauma to the voice box (larynx), thyroid gland, vocal cords and trachea (windpipe), or esophagus. Puncture or perforation (tearing) of body parts in the chest cavity, leading to lung collapse, may also occur.

What is endotracheal intubation? Endotracheal intubation is a procedure by which a tube is inserted through the mouth down into the trachea (the large airway from the mouth to the lungs). Before surgery, this is often done under deep sedation. In emergency situations, the patient is often unconscious at the time of this procedure. Endotracheal intubation is a procedure by which a tube is inserted through the mouth down into the trachea. Intubation is done under deep sedation, or in emergency situations (the patient is often unconscious at the time of the procedures. The purpose of the endotracheal tube is to allow air to pass to and from the lungs for ventilation. Complications of intubation include brain damage, cardiac arrest, pneumonia, ARDS, pneumothorax, or death.

What kind of tube is used? The tube that is used today is usually a flexible plastic tube. It is called an endotracheal tube because it is slipped within the trachea.

How do they put the tube down into the trachea? The doctor often inserts the tube with the help of a laryngoscope, an instrument that permits the doctor to see the upper portion of the trachea, just below the vocal cords. During the procedure the laryngoscope is used to hold the tongue aside while inserting the tube into the trachea. It is important that the head be positioned in the appropriate manner to allow for proper visualization. Pressure is often applied to the thyroid cartilage (Adam's apple) to help with visualization and prevent possible aspiration of stomach contents.

What is the purpose of endotracheal intubation? The endotracheal tube serves as an open passage through the upper airway. The purpose of endotracheal intubation is to permit air to pass freely to and from the lungs in order to ventilate the lungs. Endotracheal tubes can be connected to ventilator machines to provide artificial respiration. This can help when a patient is unconscious and by maintaining a patent airway, especially during surgery. It is often used when patients are critically ill and cannot maintain adequate respiratory function to meet their needs. The endotracheal tube facilitates the use of a mechanical ventilator in these critical situations.

What are the complications of endotracheal intubation? If the tube is inadvertently placed in the esophagus (right behind the trachea), adequate respirations will not occur. Brain damage, cardiac arrest, and death can occur. Aspiration of stomach contents can result inpneumonia and ARDS. Placement of the tube too deep can result in only one lung being ventilated and can result in a pneumothorax as well as inadequate ventilation. During endotracheal tube placement, damage can also occur to the teeth, the soft tissues in the back of the throat, as well as the vocal cords. It is no wonder that this procedure should be performed by a physician with experience in intubation. In the vast majority of cases of intubation, no significant complications occur. Definition Endotracheal intubation is the placement of a tube into the trachea (windpipe) in order to maintain an open airway in patients who are unconscious or unable to breathe on their own. Oxygen, anesthetics, or other gaseous medications can be delivered through the tube. Purpose Specifically, endotracheal intubation is used for the following conditions: respiratory arrest respiratory failure airway obstruction need for prolonged ventilatory support Class III or IV hemorrhage with poor perfusion severe flail chest or pulmonary contusion multiple trauma, head injury and abnormal mental status inhalation injury with erythema/edema of the vocal cords protection from aspiration

Description To begin the procedure, an anesthesiologist opens the patient's mouth by separating the lips and pulling on the upper jaw with the index finger. Holding a laryngoscope in the left hand, he or she inserts it into the mouth of the patient with the blade directed to the right tonsil. Once the right tonsil is reached, the laryngoscope is swept to the midline, keeping the tongue on the left to bring the epiglottis into view. The laryngoscope blade is then advanced until it reaches the angle between the base of the tongue and the epiglottis. Next, the laryngoscope is lifted upwards towards the chest and away from the nose to bring the vocal cords into view. Often an assistant has to press on the trachea to provide a direct view of the larynx. The anesthesiologist then takes the endotracheal tube, made of flexible plastic, in the right hand and starts inserting it through the mouth opening. The tube is inserted through the cords to the point that the cuff rests just below the cords. Finally, the cuff is inflated to provide a minimal leak when the bag is squeezed. Using a stethoscope , the anesthesiologist listens for breathing sounds to ensure correct placement of the tube. Preparation

For endotracheal intubation, the patient is placed on the operating table lying on the back with a pillow under the head. The anesthesiologist wears gloves, a gown and goggles. General anesthesia is administered to the patient before starting intubation. Risks The anesthesiologist should evaluate and follow the patient for potential complications that may include edema; bleeding; tracheal and esophageal perforation; pneumothorax (collapsed lung); and aspiration. The patient should be advised of the potential signs and symptoms associated with life-threatening complications of airway problems. These signs and symptoms include but are not limited to sore throat, pain or swelling of the face and neck, chest pain, subcutaneous emphysema, and difficulty swallowing. Normal results The endotracheal tube inserted during the procedure maintains an open passage through the upper airway and allows air to pass freely to and from the lungs in order to ventilate them. Assistance in Endotracheal Intubation INTRODUCTION Endotracheal intubation is the insertion of an endotracheal tube through the mouth or nose into the trachea beyond the vocal cords for e.g., establishment of an artificial airway, protection of the airway, provision of continuous ventilator assistance, facilitation of airway clearance and provision of an alternative route for administration of resuscitation medication. Facilities where Endotracheal Intubation is performed should develop local policies and procedures that adhere to these standards. 1. STANDARDS RELATED to Design and Environment

1.1 The area in which the procedure is to be carried out provides safety and comfort to the patient, the doctor performing and the nurse(s) assisting with endotracheal intubation. Examples of safety and comfort include but are not limited to: Adequate space to perform / assist with the procedure. Adequate lighting. Emergency resuscitation equipment Oxygen supply and saturation monitoring system. Suction device Cardiac monitor Privacy.

Adequate working conditions to prevent work related injuries such as back injuries, spilling of secretions.

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Appropriate medical waste disposal facilities. STANDARDS RELATED TO PATIENT AND EQUIPMENT SAFEGUARDS

2.1 Nurses assess the patient, in collaboration with the doctor, to determine the need for endotracheal intubation Assessment includes but is not limited to: Vital signs (heart rate, blood pressure). Level of consciousness

Airway anatomy and function (e.g., mouth opening and denture, neck mobility, size of tongue) Most appropriate size and choice of endotracheal tube. SpO2 ABGs results Chest X-Ray result

2.2 Nurses confirm the procedure has been explained to the patient and/or relatives/significant others and informed consent has been given. 2.3 Nurses ensure the availability, working order and cleanliness of equipment prior to commencing procedure. 2.4 Practices to prevent infection are based on research evidence and are applied to the insertion of the endotracheal tube, the management of the tubings and care of oral or nasal orifices. 2.5 Nurses ensure medical waste materials are disposed of in accordance with the Ministry of Health and local facility policies. 3. STANDARDS RELATED TO PREPARATION OF PERSONNEL AND PATIENT

3.1 Nurses assisting in endotracheal intubation must possess the knowledge and skills to assist with this procedure and understand the related potential risks and complications. 3.2 The patient is positioned on his/her back with a small blanket under the shoulder blades if not contraindicated. 3.3 Maintain patient's privacy and dignity and ensure comfort at all times. 4. STANDARDS RELATED TO DOCUMENTATION

4.1 Nurses ensure the procedure is recorded in the relevant nursing and patient documents in accordance with federal and facility policies. Documentation may include but is not limited to:-

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Pre-procedure assessment Date and time of intubation. Endotracheal tube type and size. Level of endotracheal tube. Cuff pressure Unusual occurrences / complications during the procedure. Sputum sample collected. Patients condition during and post procedure. Follow up nursing/doctors orders. STANDARDS RELATED TO EDUCATION AND TRAINING

5.1 Nursing staff identified to assist with this procedure undergo a specific facility developedtraining/competency program. 5.2 The training/competency program prepares nurses with the knowledge and skills to competently assist in the procedure of endotracheal intubation. Examples of areas for training focus may include but are not limited to: Review of the anatomy and physiology of the respiratory system. Definition, indications and complications of endotracheal intubation.

Review of current local policy, equipment and actual procedure which should include the following: infection control and aseptic technique. medical waste disposal. documentation requirements. Return demonstrations with specific criteria to be met.

5.3 Facilities develop a system for validating the skill level of nurses who assist in endotracheal intubation. 5.4 Nurses undergoing training in assisting endotracheal intubation are supervised by a trained and competent member of staff. ENDOTRACHEAL INTUBATION 1. INTRODUCTION

This information sheet is intended to provide current, at the time of publication, and relevant information on endotracheal intubation to aid facilities with the development of local endotracheal intubation policies and procedures.

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INFORMATION

2.1 Clinical indications Acute respiratory failure (CNS depression, neuromuscular disease, pulmonary disease, chest wall injury) 2.2 Upper airway obstruction Cardio-respiratory arrest/ Shock Provision of mechanical ventilation and oxygen therapy Fracture of cervical vertebrae with spinal cord injury requiring ventilatory assistance. Complications Significant alterations in hemodynamics Pharyngeal, laryngeal or tracheal injury (Edema, stenosis). Hypoxia, Hypercapnia during procedure Damaged teeth, lips, gingival Malpositioned tube Gastric distention and aspiration of gastric contents Pulmonary infection and sepsis (Nosocomial Pneumonia). Post-intubation pneumothorax Dependence on artificial airway Parotrauma from high PEEP.

2.3 Tube Information / preparation Tube types vary according to length and inner diameter, type of cuff, and number of lumens. Most cuffs are high volume, low pressure with self sealing inflation valves or the cuff may be of foam rubber (foam cuff). Most tubes have a single lumen, however dual-lumen tubes may be used to ventilate each lung independently.

 Before tube insertion air is injected into the endotracheal cuff to ensure an intact cuff, then the cuff is deflated The end of the stylet (malleable thick wire with a blunt end) must be kept at least 1 inch (3 cm) from the end of the endotracheal tube 2.4

Cuff inflation Over-inflating the cuff puts undue pressure on the tracheal wall. The cuff should be kept inflated no more than it is necessary to prevent aspiration and loss of tidal volume. Cuff inflation should be checked at least 8 hourly with pressure measurement equipment (high volume, low pressure). The acceptable cuff pressure ranges from 14 to 22 cmH2O The minimum leak technique provides more protection against tracheal wall trauma, while the minimal occlusion volume technique protects better against aspiration and loss of tidal volume. Nurses Role and Responsibilities Suctioning as needed Monitoring the patients SaO2 by pulse oximetry as well as heart rate and blood pressure Using of multiple methods to confirm correct tube placement is now a standard of care: Auscultating the chest bilaterally for equal breath sounds and the abdomen for evidence of esophageal intubation The American Heart Association (AHA) affirmed the importance of using capnography to verify tube placement in their 2005 CPR and ECC guidelines. End-tidal CO2 detector Esophageal Detection Device (EDD) Chest x-ray Keeping the head of bed elevated at 30 degrees after intubation.

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3. NOTE Nasotracheal intubation should be avoided if basilar skull fracture is suspected and in patients with coagulopathy.
The process of intubation As the procedure continues, the patient is given a combination of drugs. Holding the laryngoscope, the anaesthetist looks in the mouth for loose teeth, foreign bodies or dentures, and for key landmarks. The nurse should calmly describe the vital-signs status of the patient regularly as the anaesthetist will be focused on the airway, not the monitor. Be prepared to pass the ET tube and other equipment to the person intubating. Be alert all the time as complications are common (see below).

Once the tube is inserted, the cuff should be inflated and checked for pressure with a manometer. The patient's chest should be observed for equal expansion and auscultation performed at the mid-axillary line (ERC, 2001). Be suspicious if only one side of the chest expands, as this may indicate that the tube has

been pushed in too far. This is more likely to occur into the right main bronchus, due to its anatomical position.

The tube should be secured, the patient attached to an appropriate ventilator and a check X-ray ordered. A high concentration of oxygen should continue and arterial blood gases should be taken. Appropriate humidification is required, as the tube bypasses the upper airway - responsible for warming, moistening and filtering inhaled air. Finally, the patient should be cared for on a one-to-one basis and closely monitored.

Drugs used during intubation In a cardiac arrest situation pharmacological intervention may not be considered necessary. However, in critical care, safe intubation of a deteriorating patient requires drugs to facilitate passage of the ET tube.The choice is up to the anaesthetist (and beyond this Factfile's scope). Nurses should be aware of the Nursing and Midwifery Council Guidelines on the Administration of Medicines (2002). Drugs can be divided into sedatives and drugs producing neuromuscular blockade (depolarising and non-depolarising muscle relaxants): - Neuromuscular blocking agents (depolarising muscle relaxants). The most common is suxamethonium. It imitates acetylcholine and is taken up by post-synaptic receptors producing a lengthened period of depolarisation. Paralysis results for three to four minutes, depending on dosage - Non-depolarising muscle relaxants. These agents antagonise the action of acetylcholine at the neuromuscular junction (Blanchard, 2002). Common drugs include atracurium, pancuronium and vecuronium - Sedatives: a wide variety of sedatives are available for intubation. Administration is dangerous and guidelines (UKAMERC, 2002) have recently became available. Once again, minimal effects on the cardiovascular system are required, which influences drug choice.

Cricoid Cartilage Definition This is a cartilage, or firm elastic tissue that forms the bottom part of the larynx which is more commonly referred to as the voice box. This cartilage is a main element of the structure of the larynx and it provides attachment functions to the ligaments and muscles that coordinate function of the Glottis. Cricoid Cartilage Function The role of this cartilage is to join various muscles, ligaments and cartilages that are involved in closing and opening of the airways. It is also involved in production of speech. It is to be remembered that cartilage is a very firm connective tissue. It forms a covering over the ends at the joints of bones. It functions as a surface for articulation and allows smooth movement of the joints. Cartilage is not as tough as bone. It is one of the structures of the body that is fully or partially flexible. When a person suffers from severe respiratory problems and all other attempts fail to bring about any improvement in the condition, a hollow needle may be inserted in the cartilage to assist in breathing. This process is known as Cricothyrotomy or Emergency Airway Puncture.