endotracheal intubation

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ENDOTRACHEAL INTUBATION. Indication for endotracheal intubation. 1) For supporting ventilation in patient with some pathologic disease. : U pper airway obstruction. : R espiratory failure. : L oss of conciousness. Indication for endotracheal intubation (con’t). - PowerPoint PPT Presentation




Indication for endotracheal intubation1) For supporting ventilation in patient with some pathologic disease : Upper airway obstruction : Respiratory failure : Loss of conciousness

Indication for endotracheal intubation (cont)2) For supporting ventilation during general anesthesia

Type of surgery : Operative site near the airway : Abdominal or thoracic surgery

Indication for endotracheal intubation (cont): Prone or lateral position: Long period of surgery Patient has risk of pulmonary aspiration

Difficult mask ventilation

ANATOMY OF AIRWAYAIRWAY ASSESSMENTS: Congenital anomalies ---> Pierre Robin syndrome , Downs syndrome: Infection in airway--> Retropharyngeal abscess, Epiglottitis: Tumor in oral cavity or larynx

1) Condition that associated with difficult intubationAIRWAY ASSESSMENT: Enlarge thyroid gland

trachea shift to lateral or compressed tracheal lumen

1) Condition that associated with difficult intubation (cont)AIRWAY ASSESSMENT: Maxillofacial ,cervical or laryngeal trauma: Temperomandibular joint dysfunction: Burn scar at face and neck

: Morbidly obese or pregnancy

1) Condition that associated with difficult intubation (cont)AIRWAY ASSESSMENT2) Interincisor gap : normal -> more than 3 cms

AIRWAY ASSESSMENT3) Mallampati classification: Class 3,4 -> may be difficult intubation

Soft palateUvulaAIRWAY ASSESSMENTgrade 3,4 -> risk for difficult intubation

Laryngoscopic viewAIRWAY ASSESSMENT4) Thyromental distance : more than 6 cms

AIRWAY ASSESSMENT5) Flexion and extension of neck

AIRWAY ASSESSMENT6) Movement of temperomandibular joint (TMJ)

GrindingEquipment preparation

1) Laryngoscope : handle and blade

LARYNGOSCOPIC BLADE Macintosh (curved) and Miller (straight) blade Adult : Macintosh blade, small children : Miller blade

Miller bladeMacintosh blade2) Endotracheal tube

Endotracheal tube Male: ID 8.0 mms . Female : ID 7.5 mms New born - 3 months : ID 3.0 mms 3-9 months : ID 3.5 mms 9-18 months : ID 4.0 mms 2- 6 yrs : ID = (Age/3) + 3.5 > 6 yrs : ID = (Age/4) + 4.51) Size of endotracheal tube : internal diameter (ID)3) Endotracheal tube cuff

High volume Low pressure cuff Low volume High pressure cuff2) Material : Red rubber or PVC4) Bevel5) Murphys eye

6) Depth of endotracheal tube : Midtrachea or below vocal cord ~ 2 cms Adult -> Male = 23 cms ,Female = 21 cms Children Oral endotracheal tube = (Age/2) + 12 (cm)Nasal endotracheal tube = (Age/2) + 15 (cm)7) Tube markings

Z-79Disposible (Do not reuse)Oral/ NasalRadiopaque marker

3) Other equipments3.1 Stylet

3.2 Oropharyngeal or nasopharyngeal airway

Oral airway Nasal airway

3.3) Suction catheter3.4) Slip joint

3.5) Face mask and self inflating bag

3.6) Magill forcep

SyringeLubricating jellyPlaster for strap endotracheal tubeMonitoring success of endotracheal intubationStethoscopeEndtidal - CO2 Pulse oximeter

Sniffing position Flexion at lower cervical spine Extension at atlanto-occipital jointSniffing position

Steps of oroendotracheal intubation

Steps of oroendotracheal intubationSteps of oroendotracheal intubation

Steps of oroendotracheal intubation

Steps of oroendotracheal intubation

Nasoendotracheal intubation

Nasoendotracheal intubation Advantage1) Comfortable for prolong intubation in postoperative period2) Suitable for oral surgery : tonsillectomy , mandible surgery3) For blind nasal intubation4) Can take oral feeding5) Resist for kinking and difficult to accidental extubationDisadvantage1) Trauma to nasal mucosa2) Risk for sinusitis in prolong intubation3) Risk for bacteremia4) Smaller diameter than oral route -> difficult for suctionContraindication for nasoendotracheal intubation1) Fracture base of skull2) Coagulopathy3) Nasal cavity obstruction4) Retropharyngeal abscessComplication of endotracheal intubation1) During intubation: Trauma to lip, tongue or teeth: Hypertension and tachycardia or arrhythmia: Pulmonary aspiration: Laryngospasm: Bronchospasm

Complication of endotracheal intubation (Cont)1) During intubation : Laryngeal edema

: Arytenoid dislocation -> hoarseness: Increased intracranial pressure: Spinal cord trauma in cervical spine injury: Esophageal intubation

Complication of endotracheal intubation(Cont) : Obstruction from klinking , secretion or overinflation of cuff : Accidental extubation or endobronchial intubation : Disconnection from breathing circuit 2) During remained intubationComplication of endotracheal intubation(Cont)2) During remained intubation : Pulmonary aspiration: Lib or nasal ulcer in case with prolong period of intubation: Sinusitis or otitis in case with prolong nasoendotracheal intubationComplication of endotracheal intubation(Cont)3) During extubation Laryngospasm Pulmonary aspiration Edema of upper airwayComplication of endotracheal intubation(Cont)4) After extubation Sore throat Hoarseness Tracheal stenosis (Prolong intubation) Laryngeal granuloma