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Endotracheal Endotracheal Intubation/Extubat Intubation/Extubat ion ion

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Endotracheal Intubation/Extubation

Upper Airway Anatomy (p. 158)

Visualization of Vocal Cords

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

Indications (contd)Relief of airway obstructionProtection of airway (I.e. seizures)Evacuation of secretions by tracheal aspirationPrevention of aspirationFacilitation of positive press. ventilation

Relieving Airway ObstructionObstruction classified as upper ( above the glottis and includes the areas of the nasopharynx, oropharynx, and larynx) or lower (below the vocal cords)Can also be classified as partial or complete obstructionCauses include trauma, edema, tumors, changes in muscle tone or tissue support

Hazards of tracheal tubes & cuffsInfectionTraumaDehydrationObstructionTrauma

Hazards (contd)Accidental intubation of the esophagus or right mainstem bronchusBronchospasm, laryngospasmCardiac arrhythmias resulting from stimulation of the vagus nerveAspiration pneumoniaBroken or loosened teeth

Later Complications of IntubationParalysis of the tongueUlcerations of the mouthParalysis of the vocal cordsTissue stenosis and necrosis of the trachea

Routes for IntubationOrotrachealNasotrachealTracheotomy

Oral Intubation

Advantages of Oral IntubationLarger tube can be insertedTube can be inserted usually with more speed and ease with less traumaEasier suctioningLess airflow resistanceReduced risk of tube kinking

Disadvantages of Oral IntubationGagging, coughing, salivation, and irritation can be induced with intact airway reflexesTube fixation is difficult, self-extubationGastric distention from frequent swallowing of airMucosal irritation and ulcerations of mouth (change tube position)

Nasal Intubation

Advantages of Nasal IntubationMore comfort long termDecreased gaggingLess salivation, easier to swallowImproved mouth careBetter tube fixationImproved communication

Disadvantages of Nasal Intub.Pain and discomfortNasal and paranasal complications, I.e., epistaxis, sinusitis, otitsMore difficult procedureSmaller tube neededIncreased airflow resistanceDifficult suctioningBacteremia

Intubation EquipmentEndotracheal Tube and styletLaryngoscopeSterile water-soluble jellySyringe to inflate cuffAdhesive tape or tube fixation deviceBite block to prevent biting oral ET tubeSuction Equipment, bag- mask, O2Local anestheticStethoscope

Endotracheal Tube

Endotracheal TubeET tube size and depth of insertion (see p. 594)For children older than 2 years- tube size = age/4 + 4- depth = age/2 + 12Adult - tube size female = 8.0, male = 9.0- depth female = 19-21 and 24-26 male = 21-23 and 26-28


Light stylet (light wand)


LaryngoscopeBlade and handleBlade - has a flange, spatula, light, and tip- curved blade (Macintosh)- straight blade (Miller, Wisconsin)Fiber optic vs. traditional laryngoscopeBlade size: 0 - 1 infant, 2 from 2-8 years 3 from age 10 - adult, 4 large adult

Straight blade (Miller)

Curved blade (Macintosh)

Oral Intubation ProcedureAssemble and check equipment- suction equipment- laryngoscope- select proper size tube, check tubePosition patient- align mouth, pharynx, larynx- sniffing position

Patient Positioning

Oral Intubation Proced. (contd.)Preoxygenate the patient- bag-valve mask- *intubation attempt should take no longer than 30 sec, if unsuccessful, then ventilate again with bag and mask for 3-5 minutesInsert laryngoscope- hold laryngoscope in left hand & insert in right side of mouth, displace tongue toward center

Oral procedure (contd.)Visualize glottis and displace epiglottis

Oral proced. (contd.)Insert ET tube- do not use laryngoscope blade to guide tube- once you see the tube pass the glottis, advance the cuff passed the cords by 2 -3 cmHold tube with right hand and remove laryngoscope & stylet- inflate cuff with 5 - 10 cc of air- ventilate with bag

Oral proced. (contd)Inflate cuff with 5 - 10 cc of airVentilate with bagAssess tube position- auscultation of chest & epigastric- cm mark at teeth- capnometry/colorimetry- light wandStabilize tube/Confirm placement- chest x-ray

ExtubationGuidelines for extubation (see table, p. 613)Cuff-leak test

Extubation ProcedureAssemble Equipment- intubation equipment- in addition to intubation equipment, O2 device and humidity, SVN with racemic epiSuction ET tubeOxygenate patientUnsecure tube, deflate cuff

Extubation proced. (contd.)Place suction catheter down tube and remove ET tube as you suctionApply appropriate O2 and humidityAssess/Reassess the patient