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Tubes, Lines, and Vents in the ICU: Endotracheal Intubation Mechanical Ventilation Central Venous Catheterization Arterial Catheterization Swan Ganz Catheterization Curt Sessler, MD Professor of Medicine Medical Director of Critical Care Virginia Commonwealth University Health System May 4, 2004

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May 4, 2004

Tubes, Lines, and Vents in the ICU:Endotracheal Intubation Mechanical Ventilation Central Venous Catheterization Arterial Catheterization Swan Ganz Catheterization

Curt Sessler, MD Professor of Medicine Medical Director of Critical Care Virginia Commonwealth University Health System

Endotracheal Intubation: OutlineAnatomy z Preparationz

Patient evaluation Equipment / Medications

Pre-intubation patient management z Procedure of intubation z Difficult airwayz

Goals of Endotracheal IntubationSecure and protect airway z Ventilation z Oxygenationz

Anatomy for Tracheal IntubationPathway to vocal cords: mouth, pharynx, larynx z Glottis: vocal cords, epiglottis, valeculae, esophagusz

Pre-Intubation Patient Evaluation: Critical IssuesDifficult mask fit / bag-mask ventilation z Difficult intubation z Medical conditions which influence choice of medications z Alternative airway optionsz

Pre-Intubation Evaluation: NDOTRACParameter Abnormality Action N Neck Short Difficult* D Dentition Loose teeth Caution w blade O Oral cavity Small, limited view Difficult* T Tongue Large Difficult, curved blade R ROM Limited Fiberoptic A Adams apple Prominent (anterior) straight b C Chin Receding Difficult* * consider awake intubation, alternatives, backup

Equipment for Intubationz

z z z z z

Laryngoscope: handle, straight & curved blades Endotracheal tubes Airways Water soluble lubricant Stylet Syringe

z z z z z z z z z

Suction equipment Oxygen Bag and mask Pulse oximetry ET CO2 detector Tape / benzoin Cardiac monitor Defibrillator Medications

Patient PreparationOpen airway by placing patient in sniffing position z Lift at chin or angles of jawz

Patient PreparationTowel / blanket beneath head / upper shoulders z Provide effective mask ventilation with 100% O2z

May need oral airway May need PEEP valvez

Apply pressure to cricoid cartilage

Visualize Vocal CordsAlign axes of pharynx, larynx, mouth z Place towels beneath head to align larynx & pharynx z Using laryngoscope, hyperextend at C1-C2 vertebraz

Orotracheal IntubationPosition patient in sniffing position, hyper-extend at C1-C2 z Laryngoscope blade is inserted into the right corner of the mouth and advanced halfway as moved to the midlinez

Tongue swept out of the way Epiglottis visualized

Orotracheal IntubationCurved blade: tip of blade advanced above epiglottis z Straight blade: tip of blade advanced under epiglottis z Laryngoscope lifted to visualize cordsz

Orotracheal Intubationz

ET tube tip is passed between cords until cuff is beyond cords

How to Hold the Endotracheal Tube?

Steps in Orotracheal IntubationInsert blade z Visualize epiglottis z Reposition blade and visualize vocal cords z Insert ET tubez

Rapid Sequence Intubation (RSI)Short acting sedatives and neuromuscular blocking agent to facilitate immediate intubation in unstable patient z Featuresz

Adequate sedation and amnesia Rapid muscle relaxation Reduced risk of aspiration Reduced rise in ICP

Induction AgentsSmooth rapid amnestic z Short duration of action z Stable hemodynamics z Few side effectsz zEtomidate

(Amidate) zMidazolam (Versed) zThiopental (Pentothal) zMethohexital (Brevitol) zKetamine (Ketalar)

Nasotracheal Intubationz z

Patient selection Must be spontaneously breathing

Useful alternative to orotracheal intubation Cervical spine injury Avoid IV sedatives and NMBA

z

Contra-indications: apnea, upper airway foreignbody, bleeding diathesis, epiglottitis, CSF rhinorrhea / head trauma, nasal polyp or abscess

Nasotracheal Intubation: TechniqueDetermine nasal patency, consider applying vasoconstricting agent z Insert nasal airway coated with topical anesthetic / lubricantz

Nasotracheal Intubation: TechniqueWith patient sitting upright, ET tube is inserted and advanced towards the back of the head above the hard pallet z ET tube advanced toward cords while listening for breath soundsz

Nasotracheal Intubation: TechniqueEndotracheal position confirmed by breath sounds through ET tube, cough. z Methods to improve successful placementz

head in sniffing position protrude tongue cricoid pressure maintain slight downward pressure if meeting resistance and patient cannot speak: tip likely is against cords and will pass when pt breathes

Endotracheal Intubation: ComplicationsTrauma: teeth, mouth, pharynx, nasopharynx, trachea z Esophageal intubationz

Avoid by measuring exhaled CO2 (bag for 5-10 breaths to confirm)

Endotracheal Intubation: Complicationsz

Bronchial intubation Confirm bilateral = BS Confirm ET tube position

22 cm

z

Reflex response to airway stimulation: Tachycardia, hypertension, increased ICP resulting in MI,27 cm

Aspiration of gastric contents z Hypotension: dehydration, poor LV functionz

Difficult Airway: Esophageal Tracheal TubeManually (blindly) inserted. Double lumen tube with 2 cuffs. One tube (arrow) opens to multiple holes between cuffs and is used to ventilate if tip is in esophagus. Other lumen opens beyond distal cuff and is used to ventilate if tip is placed in trachea.Blanda. J Crit Illness 2000

Difficult Airway: Laryngeal MaskManually (blindly) inserted. Slightly inflate cuff and insert to fit over the larynx. Inflate tube and bag.

Cricothyroidotomy / Transtracheal Ventilation

Endotracheal Intubation: Summaryz

Preparation for intubation Patient assessment Equipment Intubation

z

Endotracheal intubation procedure Pre-intubation Procedure

z

Difficult airway management