endotracheal intubation by junaedi student post graduate of nursing brawijaya university- indonesian

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Endotracheal IntubationByJUNAEDISTUDENT POST GRADUATE OF NURSINGBRAWIJAYA UNIVERSITY- INDONESIAN1Definition:Introducing a tube through the mouth (or nose) into the trachea to secure open airways.

Advantages:Cuffed E.T tubes protect the airway from aspiration.E.T tube provides access to the tracheobronchial tree for suctioning of secretions.E.T tube does not cause gastric distention and associated danger of regurgitation.E.T tube maintains a patent airway and assists in avoiding further obstruction.E.T tube enables delivery of aerosolized medication.the mouth (or nose) into the trachea to secure open airways.

2Indication Endotracheal Intubation:Respiratory Failure: Hypoxia, Hypercapnia, tachypnea, or apnea ; ie. ARDS, asthma, pulmonary edema, infection, COPD exacerbationInability to ventilate unconscious patientMaintenance or protection of an intact airwayCardiac ArrestMedication administration

3Contraindication :Inability of patient to extend headModerate to severe trauma to the cervical spine or anterior neckInfection in the epiglottal areaMandibular fracture or trismusMild hypoxiaUncontrolled oropharyngeal hemorrhageIntact tracheostomyBasilar skull fracture (during nasal intubation)

4Complications:Hypoxia (Long duration of procedure, Intubation of a bronchus ( right more common,Failure to recognize misplacement of tube, Aspiration)Pneumothorax (resulting from over ventilating with a BVM without a pressure release valve)Trauma (to the teeth, vocal cords, soft tissues of the larynx and related structures)Hypertension and tachycardia (can occur from the intense stimulation of intubation. This is potentially life-threatening in the cardiac patien)Gastric distention and regurgitasi (Failure to secure the placement into esophagus).Cardiac arrhythmias (related to vagal stimulation or sympathetic nerve stimulation may occur)

5Difficult to intubation:Difficult to bag (MOANS) :Mask Seal : Small Hands, Wrong Mask Size, Oddly Shaped Face, Bushy Beard, Blood/Vomit, and Facial TraumaObesity or Obstruction: Heavy chest, Abdominal contents inhibit movement of the diaphragm, Increased supra glottic airway resistance, Billowing cheeks, Difficult mask seal, Quicker desaturationAge > 55: Associated with BVM difficulty, possibly due to loss of tone in the upper airwayNo Teeth: Face tends to cave in, Consider leaving dentures in for BVM and remove for intubation.Stiff : Refers to Poor Compliance, Reactive Airway Disease, COPD, Pulmonary Edema/Advance Pneumonia, History of Snoring/Sleep Apnea, Also predicts a higher Mallampati score

6Difficult to Laringoscopy and intubation:LEMONS:Look Externally : Beards or facial hair, Short, fat neck, Morbidly obese patients, Facial or neck trauma, Broken teeth (can lacerate balloons), Dentures (should be removed), Large teeth, Protruding tongue, A narrow or abnormally shaped face.Evaluate 3-3-2 : Bottom of Jaw/Chin to Neck > 3 fingers, Jaw/Palate > 3 fingers wide, Mouth opens > 2 fingers wide.

7Mallampati Score :

Obstruction : Anatomy, Trauma, Foreign body obstruction, Edema (burns). Best view grade 1

Grade 18Neck Mobility : Ideally the neck should be able to extend back approximately 35 Problems: Cervical Spine Immobilization, Ankylosing Spondylitis, Rheumatoid Arthritis, Halo fixation

Scene and Situation : Scene safety and EnvironmentDo you have a reasonable chance to get the tube?Space, positioning, access EgressWill you be able to ventilate during egress?A respiratory rate of 4 is better than a rate of 0!Enough meds for a long extrication?

9Oral Intubation With local anesthesia:It is also practical to apply surface anesthesia: vagal excitation is less, the patient may tolerate the tube better, arrhytmias and laryngospasm after extubation are rare. Apply 10% Lidocain spray (2 or 3 spurts - 1 spurt=4.8 mg)

If the distal end of tube is also sprayed with Lidocain before intubation, the patient will also tolerate the tube after recovering consciousness. Except : Reserved for the completely unconscious, unresponsive, and apneic, and Arrest situations only (without drug).

10Equipment11Equipment Endotracheal Intubation:LaryngoscopeBlades: curved (MacIntosh) and straight (Miller)Endotracheal tubes of various sizes: Neonates and full term infants: no. 0 and 1, Adult women: 7.0 mm i.d., Adult men: 7.0 to 8.5 mm i.d. Pediatric size: (age in years/4) + 4 or width of fingernail of the fifth digit

12Lubricant, Malleable stylet10-ml syringe (to inflate ET cuff)Oxygen and manual bag valve maskSuction apparatusStethoscopeSterile gloves and gogglesOropharyngeal airwayCO2 Detector


14Handle and Blade (Laryngoscope)

Blade tipe Macintosh (curve blade)

Blade tipe Miller (straight blade)

15Engaging laryngoscope blade and handle

16ETT, Stylet, and Syringe


High volume Low pressure cuff Low volume High pressure cuff

18Magil Forceps, sterile gloves and goggle

19Procedure20Position patiens head

Position yourself at the patients headInspect the oral cavity for secretions or foreign material.Suction if necessary4 rules of suctioning:Never suction further than you can see.Always suction on the way out.Never suction for longer than15 seconds.Always oxygenate the patient before and after suctioning21Hiper ventilate with 100 % oxygen for approximately 1 min (prior 2 minutes)


23Intubation Technique

22 cmBring your body down to the airway levelWith the laryngoscopeheld in the left hand, insert the blade into the right side of the mouth displacing the tongue to the leftWhen using a curved blade, advance the tip of the blade into the vallecula (the space between the base of the tongue and the pharyngeal surface of the epiglottis)When using a straight blade, insert the tip under the epiglottis. The glottic opening is exposed by exerting upward traction on the handleTo allow full visulization of the vocal cords, it may be helpful for an assistant to employ the Sellecks Maneuver (applying moderate pressure to the cricoid cartilage)Resist the urge to use a prying motion with the handle. Lift only upward to avoid damaging the patients bottom teethAdvance the ET tube through the right corner of the mouthUnder direct vision, continue advancing the tube through the vocal cords

24Sellick Manuver

Helps prevent regurgitation and reduces gastric distention.Locate the cricoid cartilage by palpating the thyroid cartilage and the feel the depression just below it (cricothyroid membrane).Using your thumb and index finger of one hand, apply pressure to the anterior and lateral aspects of the cricoid cartilage just next to the midline.

25Laringoscopic View


CO2 exhaled from the lungs: color change to MELLO YELLOW

During ventilation, confirm proper tube placementFirst auscultate the abdomen while visualizing chest expansionThen auscultate the chest bilaterally ensuring equal breath sounds

27NEVER let go of the tube until secured (Tape, Commercial tube holder), ETT easily displaced so requires ongoing assessment

Oro Pharyngeal Airways (OPA)Secure the tube in place using a tube holder and cloth tapeIf no tube holder is available, the tube may be secured using cloth tape and an oropharyngeal airwayContinue with ventilating the patient


29Documentation ET Tube Placement On patient care report:

ET (size)___depth___cm Post ET lung sounds ET Attempt (x___) Capnography Checked Suction

Boxes used to indicate crew member activity3030Thank you31

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