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Endotracheal Intubation/Extubation

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Upper Airway Anatomy (p. 158)

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Visualization of Vocal Cords

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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

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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

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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

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Hazards of tracheal tubes & cuffs Infection Trauma Dehydration Obstruction Trauma

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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

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Later Complications of Intubation Paralysis of the tongue Ulcerations of the mouth Paralysis of the vocal cords Tissue stenosis and necrosis of the trachea

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Routes for Intubation

Orotracheal Nasotracheal Tracheotomy

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Oral Intubation

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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

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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)

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Nasal Intubation

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Advantages of Nasal Intubation More comfort long term Decreased gagging Less salivation, easier to swallow Improved mouth care Better tube fixation Improved communication

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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

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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

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Endotracheal Tube

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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

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Stylet

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Light stylet (light wand)

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Laryngoscope

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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

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Straight blade (Miller)

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Curved blade (Macintosh)

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Oral Intubation Procedure

Assemble and check equipment - suction equipment - laryngoscope - select proper size tube, check tube

Position patient - align mouth, pharynx, larynx - “sniffing” position

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Patient Positioning

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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

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Oral procedure (cont’d.)

Visualize glottis and displace epiglottis

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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

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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

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Extubation

Guidelines for extubation (see table, p. 613) Cuff-leak test

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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

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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