Endotracheal

Intubation/Extubation
Upper Airway Anatomy (p. 158)
Visualization of Vocal Cords
Indications for Intubation
 In conditions of, or leading to resp. failure,
such as; - trauma to the chest or
airway - neurologic involvement from
drugs myasthenia gravis, poisons, etc.
-CV involvement leading to CNS
impairment from strokes, tumors,
infection, pulmonary emboli -CP arrest
Indications (cont’d)
 Relief of airway obstruction
 Protection of airway (I.e. seizures)
 Evacuation of secretions by tracheal
aspiration
 Prevention of aspiration
 Facilitation of positive press. ventilation
Relieving Airway Obstruction
 Obstruction classified as upper ( above
the glottis and includes the areas of the
nasopharynx, oropharynx, and larynx) or
lower (below the vocal cords)
 Can also be classified as partial or
complete obstruction
 Causes include trauma, edema, tumors,
changes in muscle tone or tissue support
Hazards of tracheal tubes & cuffs
 Infection
 Trauma
 Dehydration
 Obstruction
 Trauma
Hazards (cont’d)
 Accidental intubation of the esophagus
or right mainstem bronchus
 Bronchospasm, laryngospasm
 Cardiac arrhythmias resulting from
stimulation of the vagus nerve
 Aspiration pneumonia
 Broken or loosened teeth
Later Complications of
Intubation
 Paralysis of the tongue
 Ulcerations of the mouth
 Paralysis of the vocal cords
 Tissue stenosis and necrosis of the
trachea
Routes for Intubation
 Orotracheal
 Nasotracheal
 Tracheotomy
Oral Intubation
Advantages of Oral Intubation
 Larger tube can be inserted
 Tube can be inserted usually with more
speed and ease with less trauma
 Easier suctioning
 Less airflow resistance
 Reduced risk of tube kinking
Disadvantages of Oral Intubation
 Gagging, coughing, salivation, and
irritation can be induced with intact airway
reflexes
 Tube fixation is difficult, self-extubation
 Gastric distention from frequent
swallowing of air
 Mucosal irritation and ulcerations of mouth
(change tube position)
Nasal Intubation
Advantages of Nasal Intubation
 More comfort long term
 Decreased gagging
 Less salivation, easier to swallow
 Improved mouth care
 Better tube fixation
 Improved communication
Disadvantages of Nasal Intub.
 Pain and discomfort
 Nasal and paranasal complications, I.e.,
epistaxis, sinusitis, otits
 More difficult procedure
 Smaller tube needed
 Increased airflow resistance
 Difficult suctioning
 Bacteremia
Intubation Equipment
 Endotracheal Tube and stylet
 Laryngoscope
 Sterile water-soluble jelly
 Syringe to inflate cuff
 Adhesive tape or tube fixation device
 Bite block to prevent biting oral ET tube
 Suction Equipment, bag- mask, O2
 Local anesthetic
 Stethoscope
Endotracheal Tube
Endotracheal Tube
 ET tube size and depth of insertion (see
p. 594)
 For children older than 2 years - tube
size = age/4 + 4 - depth = age/2 + 12
 Adult - tube size female = 8.0, male =
9.0- depth female = 19-21 and 24-26
male = 21-23 and 26-28
Stylet
Light stylet (light wand)
Laryngoscope
Laryngoscope
 Blade and handle
 Blade - has a flange, spatula, light,
and tip - curved blade (Macintosh) -
straight blade (Miller, Wisconsin)
 Fiber optic vs. traditional laryngoscope
 Blade size: 0 - 1 infant, 2 from 2-8 years
3 from age 10 - adult, 4 large adult
Straight blade (Miller)
Curved blade (Macintosh)
Oral Intubation Procedure
 Assemble and check equipment
- suction equipment
- laryngoscope
- select proper size tube, check tube
 Position patient
- align mouth, pharynx, larynx
- “sniffing” position
Patient Positioning
Oral Intubation Proced. (cont’d.)
 Preoxygenate the patient - bag-valve
mask - *intubation attempt should take no
longer than 30 sec, if unsuccessful,
then ventilate again with bag and
mask for 3-5 minutes
 Insert laryngoscope - hold laryngoscope
in left hand & insert in right side of
mouth, displace tongue toward center
Oral procedure (cont’d.)
 Visualize glottis and displace epiglottis
Oral proced. (cont’d.)
 Insert ET tube - do not use laryngoscope
blade to guide tube - once you see
the tube pass the glottis, advance the cuff
passed the cords by 2 -3 cm
 Hold tube with right hand and remove
laryngoscope & stylet - inflate cuff with 5 -
10 cc of air - ventilate with bag
Oral proced. (cont’d)
 Inflate cuff with 5 - 10 cc of air
 Ventilate with “bag”
 Assess tube position - auscultation of
chest & epigastric - cm mark at teeth -
capnometry/colorimetry- light “wand”
 Stabilize tube/Confirm placement - chest
x-ray
Extubation
 Guidelines for extubation (see table, p.
613)
 Cuff-leak test
Extubation Procedure
 Assemble Equipment - intubation
equipment - in addition to intubation
equipment, O2 device and humidity,
SVN with racemic epi
 Suction ET tube
 Oxygenate patient
 Unsecure tube, deflate cuff
Extubation proced. (cont’d.)
 Place suction catheter down tube and
remove ET tube as you suction
 Apply appropriate O2 and humidity
 Assess/Reassess the patient