Endotracheal Endotracheal Intubation/ExtubatiIntubation/Extubati

onon

Upper Airway AnatomyUpper Airway Anatomy (p. 158) (p. 158)

Visualization of Vocal CordsVisualization of Vocal Cords

Indications for IntubationIndications for Intubation

In conditions of, or leading to resp. failure, In conditions of, or leading to resp. failure, such as;such as; - trauma - trauma to the chest or airwayto the chest or airway - - neurologic involvement from drugs neurologic involvement from drugs myasthenia gravis, poisons, etc.myasthenia gravis, poisons, etc. --CV involvement leading to CNS CV involvement leading to CNS impairment from strokes, tumors, impairment from strokes, tumors, infection, pulmonary emboliinfection, pulmonary emboli --CP arrestCP arrest

Indications (cont’d)Indications (cont’d)

Relief of airway obstructionRelief of airway obstruction Protection of airway (I.e. seizures)Protection of airway (I.e. seizures) Evacuation of secretions by tracheal Evacuation of secretions by tracheal

aspirationaspiration Prevention of aspirationPrevention of aspiration Facilitation of positive press. ventilationFacilitation of positive press. ventilation

Relieving Airway ObstructionRelieving Airway Obstruction

Obstruction classified as Obstruction classified as upperupper ( above ( above the glottis and includes the areas of the the glottis and includes the areas of the nasopharynx, oropharynx, and larynx) or nasopharynx, oropharynx, and larynx) or lowerlower (below the vocal cords) (below the vocal cords)

Can also be classified as partial or Can also be classified as partial or complete obstructioncomplete obstruction

Causes include trauma, edema, tumors, Causes include trauma, edema, tumors, changes in muscle tone or tissue supportchanges in muscle tone or tissue support

Hazards of tracheal tubes & cuffsHazards of tracheal tubes & cuffs

InfectionInfection TraumaTrauma DehydrationDehydration ObstructionObstruction TraumaTrauma

Hazards (cont’d)Hazards (cont’d)

Accidental intubation of the esophagus Accidental intubation of the esophagus or right mainstem bronchusor right mainstem bronchus

Bronchospasm, laryngospasmBronchospasm, laryngospasm Cardiac arrhythmias resulting from Cardiac arrhythmias resulting from

stimulation of the vagus nervestimulation of the vagus nerve Aspiration pneumoniaAspiration pneumonia Broken or loosened teethBroken or loosened teeth

Later Complications of Later Complications of IntubationIntubation

Paralysis of the tongueParalysis of the tongue Ulcerations of the mouthUlcerations of the mouth Paralysis of the vocal cordsParalysis of the vocal cords Tissue stenosis and necrosis of the Tissue stenosis and necrosis of the

tracheatrachea

Routes for IntubationRoutes for Intubation

OrotrachealOrotracheal NasotrachealNasotracheal TracheotomyTracheotomy

Oral IntubationOral Intubation

Advantages of Oral IntubationAdvantages of Oral Intubation

Larger tube can be insertedLarger tube can be inserted Tube can be inserted usually with more Tube can be inserted usually with more

speed and ease with less traumaspeed and ease with less trauma Easier suctioningEasier suctioning Less airflow resistanceLess airflow resistance Reduced risk of tube kinkingReduced risk of tube kinking

Disadvantages of Oral IntubationDisadvantages of Oral Intubation

Gagging, coughing, salivation, and Gagging, coughing, salivation, and irritation can be induced with intact irritation can be induced with intact airway reflexesairway reflexes

Tube fixation is difficult, self-extubationTube fixation is difficult, self-extubation Gastric distention from frequent Gastric distention from frequent

swallowing of airswallowing of air Mucosal irritation and ulcerations of Mucosal irritation and ulcerations of

mouth (change tube position)mouth (change tube position)

Nasal IntubationNasal Intubation

Advantages of Nasal IntubationAdvantages of Nasal Intubation

More comfort long termMore comfort long term Decreased gaggingDecreased gagging Less salivation, easier to swallowLess salivation, easier to swallow Improved mouth careImproved mouth care Better tube fixationBetter tube fixation Improved communicationImproved communication

Disadvantages of Nasal Intub.Disadvantages of Nasal Intub.

Pain and discomfortPain and discomfort Nasal and paranasal complications, I.e., Nasal and paranasal complications, I.e.,

epistaxis, sinusitis, otitsepistaxis, sinusitis, otits More difficult procedureMore difficult procedure Smaller tube neededSmaller tube needed Increased airflow resistanceIncreased airflow resistance Difficult suctioningDifficult suctioning BacteremiaBacteremia

Intubation EquipmentIntubation Equipment

Endotracheal Tube and styletEndotracheal Tube and stylet LaryngoscopeLaryngoscope Sterile water-soluble jellySterile water-soluble jelly Syringe to inflate cuffSyringe to inflate cuff Adhesive tape or tube fixation deviceAdhesive tape or tube fixation device Bite block to prevent biting oral ET tubeBite block to prevent biting oral ET tube Suction Equipment, bag- mask, O2Suction Equipment, bag- mask, O2 Local anestheticLocal anesthetic StethoscopeStethoscope

Endotracheal TubeEndotracheal Tube

Endotracheal TubeEndotracheal Tube

ET tube size and depth of insertion (see p. ET tube size and depth of insertion (see p. 594)594)

For children older than 2 yearsFor children older than 2 years- tube size = age/4 + 4- tube size = age/4 + 4 - - depth = age/2 + 12depth = age/2 + 12

Adult Adult - tube size female = 8.0, male = 9.0- tube size female = 8.0, male = 9.0 - - depth female = 19-21 and 24-26depth female = 19-21 and 24-26 male = 21-23 and 26-28 male = 21-23 and 26-28

StyletStylet

Light stylet (light wand)Light stylet (light wand)

LaryngoscopeLaryngoscope

LaryngoscopeLaryngoscope

Blade and handleBlade and handle Blade Blade

- has a flange, spatula, light, and tip- has a flange, spatula, light, and tip - - curved blade (Macintosh)curved blade (Macintosh) - straight - straight blade (Miller, Wisconsin)blade (Miller, Wisconsin)

Fiber optic vs. traditional laryngoscopeFiber optic vs. traditional laryngoscope Blade size: Blade size: 0 - 10 - 1 infant, infant, 22 from 2-8 years from 2-8 years 33

from age 10 - adult, from age 10 - adult, 44 large adult large adult

Straight blade (Miller)Straight blade (Miller)

Curved blade (Macintosh)Curved blade (Macintosh)

Oral Intubation ProcedureOral Intubation Procedure

Assemble and check equipmentAssemble and check equipment- suction equipment- suction equipment

- laryngoscope- laryngoscope- select proper size - select proper size

tube, check tubetube, check tube Position patientPosition patient

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

Patient PositioningPatient Positioning

Oral Intubation Proced. (cont’d.)Oral Intubation Proced. (cont’d.)

Preoxygenate the patientPreoxygenate the patient - bag-- bag-valve maskvalve mask - - *intubation attempt should take no *intubation attempt should take no longer longer than 30 sec, if unsuccessful, than 30 sec, if unsuccessful, then then ventilate ventilate again with bag and again with bag and mask for 3-5 minutesmask for 3-5 minutes

Insert laryngoscopeInsert laryngoscope - hold - hold laryngoscope in laryngoscope in leftleft hand & hand & insert in insert in right side of mouth, displace right side of mouth, displace tongue toward tongue toward centercenter

Oral procedure (cont’d.)Oral procedure (cont’d.)

Visualize glottis and displace epiglottisVisualize glottis and displace epiglottis

Oral proced. (cont’d.)Oral proced. (cont’d.)

Insert ET tubeInsert ET tube - do - do not use laryngoscope blade to not use laryngoscope blade to guide guide tubetube - once you - once you seesee the tube pass the the tube pass the glottis, advance the glottis, advance the cuff passed the cuff passed the cords by 2 -3 cmcords by 2 -3 cm

Hold tube with right hand and Hold tube with right hand and remove remove laryngoscope & styletlaryngoscope & stylet - inflate - inflate cuff with 5 - 10 cc of aircuff with 5 - 10 cc of air - ventilate with - ventilate with bagbag

Oral proced. (cont’d)Oral proced. (cont’d)

Inflate cuff with 5 - 10 cc of airInflate cuff with 5 - 10 cc of air Ventilate with “bag”Ventilate with “bag” Assess tube positionAssess tube position

- auscultation of chest & epigastric- auscultation of chest & epigastric - cm - cm mark at teethmark at teeth - - capnometry/colorimetrycapnometry/colorimetry - - light “wand”light “wand”

Stabilize tube/Confirm placementStabilize tube/Confirm placement- chest x-ray- chest x-ray

ExtubationExtubation

Guidelines for extubation (see table, p. Guidelines for extubation (see table, p. 613)613)

Cuff-leak testCuff-leak test

Extubation ProcedureExtubation Procedure

Assemble EquipmentAssemble Equipment- intubation equipment- intubation equipment- in addition to intubation - in addition to intubation

equipment, equipment, O2 device and humidity, O2 device and humidity, SVN with SVN with racemic epiracemic epi

Suction ET tubeSuction ET tube Oxygenate patientOxygenate patient Unsecure tube, deflate cuffUnsecure tube, deflate cuff

Extubation proced. (cont’d.)Extubation proced. (cont’d.)

Place suction catheter down tube and Place suction catheter down tube and remove ET tube as you suctionremove ET tube as you suction

Apply appropriate O2 and humidityApply appropriate O2 and humidity Assess/Reassess the patientAssess/Reassess the patient