Tracheal Intubation
Proper Positioning
• Flexion of the neck
• Elevation of head approximately 10 cm
• Goal: Alignment of the three axis
Proper Position of Laryngoscope Blade
Glottic opening during a direct laryngoscopy (elevated epiglottis)
Choose a Blade
Direct Laryngoscopy
• Mac vs Miller– Advantages with each– Disadvantages with each
• Confirmation of ETT placement• Simulation: Demonstrate
intubation with MAC and Miller Blades
Choose a Tube
Optimal External Laryngeal Manipulation
Lehane McKormick Scale: document view for next person in a standard manner
Confirmation of Tube Placement
• End-tidal PCO2• Symmetric bilateral chest movements
– Bilateral breath sounds
• Feel of compliance while manually inflating the lungs– Presence of expiratory refilling of bag
• Condensation of water in the tube lumen
• Arterial hemoglobin oxygen saturation
Securing the Tube
Nasal Intubations
• Indications:– Oral surgery– Emergent intubations
(blind nasal)– Prolonged intubation
• Contraindications:– Basilar skull fracture– Lefort II or Lefort III
fractures
• Complications:– Nasal necrosis– Posterior pharyngeal
wall tear– Nasal/turbinate injury– Epistaxis– Adenoidectomy– Perforation of piriform
sinus– Bactermia– Retropharyngeal
abscess
Nasal Endotracheal Tubes
• Nasal Rae– Advantage is tube
contour facilitates stability
• Endotrol Tubes– Soft– Ability to flex tip
of tube
Equipment Necessary for Nasal Intubation
• Vasoconstrictor (afrin, phenylephrine drops)
• Local anesthetic (lidocaine jelly)• Lubricant• Magills forceps• Possible Fiberoptic if ‘blind’ nasal fails• Simulation: Demonstration of nasal
intubation with Magill forceps
Common Complications of Intubation
• Bronchospasm• Esophageal
Intubation• Dental trauma• Aspiration• Laryngospasm• Endobronchial
Intubation
• Laryngeal/Tracheal Trauma
• Hypertension• Tachycardia• Myocardial
ischemia• Cardiac
dysrhythmias• Pulmonary
barotrauma
Bronchospasm
• Increased airway resistance probably related to reflex response to endotracheal intubation
• Accounts for approximately 5.3% of fatal or near-fatal peri-inducation complications
• Extensive list for differential diagnosis
Evaluation of Bronchospasm
• Auscultate while manually ventilating patient (evaluate compliance)– Bilateral vs Unilateral– Location of wheezing in lung fields (foreign
body; cardiogenic)
• Determine patency of ETT (suction catheter; fiberoptic scope)
• Sequence of Events (induction; central line placement; surgical considerations, extubation)
Differential Diagnosis of Bronchospasm
• Reactive Airway Disease
• Chronic Obstructive Pulmonary Disease
• Endobronchial intubation
• Aspiration/foreign body
• Pneumothorax• Light anesthesia• Obstructed ETT
(kinked; foreign body)
• Cardiogenic• Pulmonary Edema• Pulmonary embolus• Vascular rings• Drug induced
histamine release• Anaphylaxis
Signs of Bronchospasm
• Increased Peak Inspiratory Pressures (PIP)
• Decreased Tidal volumes (pressure ventilation)
• Decreased Compliance to manual ventilation
• Audible wheezing noted• Obstructed wave forms
on Capnogram
• Simulation: Demonstration of Bronchospasm (wheezing)
Treatment
• Supportive and determine cause• Increased Inspired oxygen• Bronchodilators
– Beta-2 Agonists– Anticholinergics– Steroids– Epinephrine
• Treat underlying cause: pass suction catheter, deepen anesthetic, call attending for help----do not panic
Aspiration
• Risk Factors– Full stomach– Hiatal Hernia– GERD– Trauma– Narcotics– Gastroparesis– Uremia– Hypothyroidism
• Risk Reduction– Avoid Mask
Ventilation– Cricoid Pressure– Rapid Sequence
Induction– Consider placing
NG/OG tube and evacuate stomach contents
Management of Patient who Aspirates on Induction• Maintain Cricoid pressure
• Turn head• Suction• Trendelenberg• Broncscopy• Intubation• Supportive Measures (A-line; Oxygen,
PEEP)
Training Exercise:
1. Practice direct laryngoscopy and intubation with feedback from facilitator until advanced beginner
2. Practice nasotracheal intubation using Magil forceps
3. Demonstrate how to secure an endotracheal tube
4. Practice laryngoscopy with a Miller blade