airway in ot
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ENDOTRACHEAL
INTUBATION IN THE
OPERATION THEATRE
DR. RAJESH T EAPEN
SPECIALIST - ANESTHESIA
ATLAS HOSPITAL
RUWI
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Indications forendotracheal intubation
1. Provides relative protection againstpulmonary aspiration.
2. Maintains a patent conduit for respiratorygas exchange.
3. Provides a means for coupling the lungs tomechanical ventilators.
4. Establishes a route for clearance ofsecretions.
5. Provides a route for drug administration.
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Detailed physical examination ofthe airway
The range of motion of the cervical spine: the subject should beable to tilt the head back and then forward so that the chintouches the chest.
The range of motion of the jaw (the temporomandibular joint):
three of the subject's fingers should be able to fit between theupper and lower incisors.
The size and shape of the upper jaw and lower jaw, lookingespecially for problems such as maxillary hypoplasia (anunderdeveloped upper jaw), micrognathia (an abnormally small
jaw), or retrognathia (misalignment of the upper and lower jaw).
The thyromental distance: three of the subject's fingers shouldbe able to fit between the Adam's apple and the chin.
The size and shape of the tongue and palate relative to the sizeof the mouth.
The teeth, especially noting the presence of prominentmaxillary incisors, any loose or damaged teeth, or crowns.
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Classification systems to predictdifficulty of tracheal intubation
Cormack-Lehane grading system
Intubation Difficulty Scale (IDS)
Mallampati score
The Mallampati score most commonly used - is drawn fromthe observation that the size of the base of the tongueinfluences the difficulty of intubation.
Determined by looking at the anatomy of the mouth, and in
particular the visibility of the base of palatine uvula, faucialpillars and the soft palate.
Such medical scoring systems may aid in the evaluation ofpatients but no single score or combination of scores can betrusted to detect all patients who are difficult to intubate.
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Equipment- in Intubation Trolley
Drugs
Difficult intubation
equipment - nearbyMonitors:
Pulse Oximeter
Capnograph
Laryngoscope - 2
Tubes
Anesthetic Machine:
Breathing circuitOxygen source
Bag & Mask
Working Suction
Lubricant / LA sprayForceps (Magill)
Adhesive tape
Stylet / Gum elastic bougie
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Monitors
Electrocardiograph
Pulse Oximeter Capnograph
Shygmomanometer
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Mnemonic for rememberingthe necessary equipment
SOAPME:
S = suction
O= oxygen
A = airway equipment (tracheal tube, oralairway, laryngoscope
P = positioning and pre- oxygenation
M= monitors (cardiac monitor and pulseoximetry)
E = esophageal detection device (end-tidal carbon dioxide [CO2] detector)
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Laryngoscope Blades
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Cuffed Tracheal Tube
Most endotracheal tubes today are constructed of polyvinyl chloride Specialty tubes are constructed of silicone rubber, latex rubber, or
stainless steel. ET Tubes have an inflatable cuff to seal the trachea and bronchial
tree against air leakage and aspiration of gastric contents, blood,secretions, and other fluids.
Cuff inflationtube with pilotballoon
Cuff
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Uncuffed Tracheal Tube
Use is limited mostly to pediatric patients (in small children, thecricoid cartilage, the narrowest portion of the pediatric airway,often provides an adequate seal for mechanical ventilation).
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Intubation
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ETT sizes
Male: No. 8 + 0.5
Female: No. 7 + 0.5
Children: No = + 4 (or 3, for cuffed)Age4
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ETT : sizes (Pediatrics)
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ETT Depth of insertion
Depth(cm) = + 12(children)
Male: 21-24 cm
Female: 20-22 cm
Age
2
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ETT : Depth of insertion
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Sniffing position
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Sniffing Position
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Incorrect position
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Mask ventilation and intubation
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Sellicks maneuver
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Intubation
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Laryngoscope handling
The main lifting force of the laryngoscope is parallel to thehandle. Under no circumstances should the handle of thelaryngoscope be levered backwards.
The handle is gripped down at the base.
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Difficult airway
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But for this we need a capnograph!
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Oral Airway
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Oral Airways
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Rusch Color Coded GuedelAirways
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Nasopharyngeal Airway
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Nasopharyngeal Airway
Flared end
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Rusch Latex-Free NasopharyngealAirway
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Mask and airway tools
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Laryngeal Mask Airway
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Laryngeal Mask Airway
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Laryngeal Mask Airway
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LMA-Fastrach
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LMA- Fastrach
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LMA-Fastrach
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Characteristics of the LMA
Sizes Weight (Kg) Cuff Vol.(ml)
#1
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Disadvantages of LMA over theETT
Lower seal pressure
Higher frequency of gastric
insufflation
Increased Aspiration risk
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LMA Complications
Aspiration
Coughing
Sore Throat
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Fiber optic scope intubation
Laryngoscopy may be contraindicated in a patientwho requires intubation and mechanicalventilation.
Often the case in trauma patients who may have
an unstable cervical spine or in patients with poorrange of motion of the temporo-mandibularjoint.
In such patients, flexible fiber optic bronchoscopyallows for indirect visualization of the larynx.
The endoscope is introduced through the mouthor nose.
Once anatomic structures are recognized, andthe larynx or trachea are entered under direct
visualization.
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Fiber optic scope intubation
OTHER WAYS TO INTUBATE
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OTHER WAYS TO INTUBATE- Nasotracheal Intubation
ETT is advanced through the nose intothe oropharynx before laryngoscopy.
Via laryngoscopy, the tube is thenadvanced in between the abductedvocal cords.
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Bougie
- A straight, semi-rigid stylette-likedevice with a bent tip that can beused when intubation is (or ispredicted to be) difficult often helpful when the tracheal
opening is anterior to the visual field.- During laryngoscopy, the bougie is
carefully advanced into the larynxand through the cords until the tipenters a main stem bronchus.
- While maintaining thelaryngoscope and Bougie inposition, an assistant threads anETT over the end of the bougie,into the larynx. Once the ETT is inplace, the bougie is removed.
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Light Wand
When inserted into anendotracheal tube, useful forblind intubations of thetrachea (when the laryngeal
opening cannot be visualized) End of the ET tube is at the
entrance of the trachea whenlight is well trans-illuminated
through the neck The tube can then be
threaded off the light wandand into the trachea in a blindfashion
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Drugs
A- Neuromuscular blocking drugs (NMBDs):
1- Depolarizing NMBDs-
Succinylcholine (1
1.5 mg/Kg IV)2- Non Depolarizing NMBDs-
Vecuronium (0.25 mg/Kg IV)
Cis-atracurium (0.2 mg/Kg IV)
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Drugs
B- Sedative-hypnotics:
Sodium Thiopental
PropofolC- Benzodiazepines:
Midazolam (0.5 1 mg IV)
Diazepam (2 mg IV)D- Opioids:
Morphine, Fentanyl, Remifentanil
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Drugs
E- Beta-adrenergic blocking drugs:
Esmolol (10 20 mg IV)
F- Local anesthetics agents:Lidocaine ( 1 1.5 mg/Kg IV or
aerosol anesthetic sprays)
G- Nerve blocksH- Reversal agent- Neostigmine 0.05mg/kg
+Glycopyrrolate 0.004mg/kg
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Drugs
Induction agent- Thiopentone, Propofol,Ketamine, Midazolam
Muscle Relaxant Suxamethonium
Consider Rocuronium if Suxcontraindicated
Burns > 3 days
Chronic Spinal injuriesChronic Neuromuscular diseaseHyperkalemia
states (Se. K+ > 5.5)
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Thanks
For YourAttention