Intubation

Endotracheal Intubation

• A medical procedure in which a tube is placed into the windpipe (trachea) through the mouth or nose. 

Endotracheal Intubation Advantages

• Isolates airway
  
• Reduces aspiration risk
  
• Permits tracheal suctioning
  
• Medication route
  
• Precise tidal volume with vents

Endotracheal Intubation Disadvantages

• High level of proficiency required
  
• Special equipment needed
  
• Bypasses physiologic upper airway (warming and humidification)
  
• Requires direct visualization of vocal cords in most cases

Endotracheal Intubation Indications

• At risk of airway maintenance failure or protection
  
• Risk of failure of oxygenation/ventilation
  
• Poor clinical course expected

Endotracheal Intubation Contraindications

• FBAO
  
• Epiglottitis (relative)

ET tube

• a flexible translucent tube open at both ends and available in lengths ranging from 12-32 cm

ET Tubes Measured

• Measured by internal diameter in mm
• ET Uncuffed tube size measurement
  • (age in years/4) + 4
• ET Cuffed tube size measurement
  • (age in years/4) + 3

Stylet

• a plastic covered metal wire that may be placed inside the ETT, stopping just short of the distal end, to allow the tube to be stiffened and maintained in the optimal shape for intubation

ET Tube Introducer

• gum elastic Bougie
  
• 60-70 cm straight semi rigid stylet like device with a distal bent tip that is covered with a protecting resin

Laryngoscope

• an instrument for lifting the tongue and epiglottis out of the line of sight so that you can see the vocal cords

Laryngoscope Types

• Miller – Straight
  • If using a straight blade, insert tip of blade under epiglottis
• Macintosh – Curved
  • When using a curved blade advance tip of blade into valecula
• Glydoscope – Video Laryngoscope

Assembling ET tube equipment involves

• Correct style tube (cuffed vs. uncuffed)
  
• Correct size
  
• Stylette
  
• 10cc syringe
  
• Suction equipment
  
• Laryngoscope
  
• Stethoscope
  
• Something to secure the tub
  
• Tube verification method

Endotracheal Intubation Procedure

• Preoxygenate with 100% oxygen and Ventilatory rate 12-20/min
• Assemble equipment and Lubricate distal end of tube (optional)
• Position yourself at patients head and Inspect mount for foreign material
• Open patients mouth with fingers of right hand
• Grasp lower jaw with right hand and Hold Laryngoscope in left hand
• Insert blade into right side of mouth, Displace tongue to left
• Identify uvula
• BURP
• Insert blade exposing the glottic opening by exerting upward traction on handle
• Advance ET tube through the vocal cords about 1-2.5cm and remove stylet if used
• Inflate cuff and begin ventilation and oxygenation
• Confirm tube placement and secure

ET tube verification methods

• EDD
  
• Colorimetric
  
• Capnography

Confirming ET Tube Placement

• Primary:
  • *Direct visualization of tube passing cords
    
  • *Quantitative CO2 detection
    
  • Colormetric device
    
  • Esophageal detection device
    
  • *Auscultation of all lung fields and epigastrium
    
  • Bilateral, symmetrical expansion of thorax
• Secondary:
  • Auscultation of the epigastrium, midaxillary, anterior chest line (left and right sides)

Transillumination Technique (lighted stylet)

• High intensity light
  
• Little neck manipulation
  
• Thyroid and cricoid illuminated by light and ET tube advanced

Digital Intubation

• Direct palpation of glottic structures to intubate trachea
  
• Patient entrapment
  
• Equipment failure
  
• Copious blood

Intubation Complications

• *Esophagus may be intubated
  
• Lacerated lips or tongue
  
• Dental trauma
  
• Lacerated Pharyngeal or tracheal mucosa
  
• Tracheal rupture
  
• Vocal cord injury
  
• Vomiting and aspiration
  
• Vagal stimulation 
  • Bradycardia and hypotension

Nasotracheal Intubation

• Is a blind procedure

Nasotracheal Intubation Indications

• Spontaneous respirations when limited neck movement desired
  
• OD
  
• Asthma/anaphylaxis
  
• COPD
  
• Stroke
  
• Status Epilepticus

Nasotracheal Intubation Contraindications

• Apnea
  
• Midfacial/nasal fractures

Nasotracheal Intubation Relative Contraindications

• Basilar skull fracture

NT intubation equipment includes

• ET tube (no Stylette) (ex Endotrol tube)
  
• 10c syringe
  
• Lubricating jelly
  
• Tape
  
• Nasoscope

Nasotracheal Intubation Procedure

• Prepare equipment
  
• Preoxygenate patient
  
• Measure tube
  
• Dilate naris
  
• Lubricate
  
• Insert through largest nare
  
• List for airflow over tube
  
• Advance on inhalation
  
• Verify placement
  
• Ventilate patient
  
• Secure tube

Nasotracheal Intubation Complications

• Epistaxis
  
• Vagal stimulation
  
• Injury to nasal septum or turbinates
  
• Retropharyngeal laceration
  
• Vocal cord injury
  
• Esophageal Intubation

Gum Elastic Bougie

• Facilitated intubation
  
• May be used when Mallampati 2 or 3
  
• Still requires laryngoscope

Gum Elastic Bougie Procedure

• Use laryngoscope
  
• Apply BURP
  
• Visualize tip behind epiglottis
  
• Feel for tracheal rings
  
• Assistant slides ETT over proximal end
  
• Rotate ETT 90 degree to facilitate bevel past epiglottis
  
• Advance until tube is 20-24cm
  
• Verify positioning using regular methods

Extubation Procedure

• Suction oral cavity
  
• Deflate cuff
  
• Withdraw tube or exhalation
  
• Assess patient
  
• Oxygenate

Pediatric intubation issues

• Infant airway small with large tongue
  
• Epiglottis omega shaped and narrow
• Larynx more anterior and elevated
  
• Infant’s cords slope back to front
  
• Cricoid cartilage narrow
  
• Distance from carina to cords variable
  
• Diaphragm primary muscle for breathing
  
• Loose teeth may fall out

Verification of Placement Devices

• Quantitative Capnography (gold standard)
  
• Colormetric devices
  
• Esophageal detector devices