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  • Slide 1
  • ENDOTRACHEAL INTUBATION Thida Ua-kritdathikarn, MD. Department Of Anesthesiology Faculty of medicine, PSU
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  • Indication for endotracheal intubation 1) For supporting ventilation in patient with some pathologic disease : Upper airway obstruction : Respiratory failure : Loss of conciousness
  • Slide 5
  • Indication for endotracheal intubation (cont) 2) For supporting ventilation during general anesthesia Type of surgery : Operative site near the airway : Abdominal or thoracic surgery
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  • Indication for endotracheal intubation (cont) : Prone or lateral position : Long period of surgery Patient has risk of pulmonary aspiration Difficult mask ventilation
  • Slide 7
  • ANATOMY OF AIRWAY
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  • AIRWAY 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 intubation
  • Slide 9
  • AIRWAY ASSESSMENT : Enlarge thyroid gland trachea shift to lateral or compressed tracheal lumen 1) Condition that associated with difficult intubation (cont)
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  • 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)
  • Slide 11
  • AIRWAY ASSESSMENT 2) Interincisor gap : normal -> more than 3 cms
  • Slide 12
  • AIRWAY ASSESSMENT 3) Mallampati classification: Class 3,4 -> may be difficult intubation Soft palate Uvula
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  • AIRWAY ASSESSMENT grade 3,4 -> risk for difficult intubation Laryngoscopic view
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  • AIRWAY ASSESSMENT 44) Thyromental distance : more than 6 cms
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  • 5) Flexion and extension of neck
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  • AIRWAY ASSESSMENT 6) Movement of temperomandibular joint (TMJ) Grin ding
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  • Equipment preparation
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  • 1) Laryngoscope : handle and blade
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  • LARYNGOSCOPIC BLADE Macintosh (curved) and Miller (straight) blade Adult : Macintosh blade, small children : Miller blade Miller blade Macintosh blade
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  • 2) Endotracheal tube
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  • 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) + 4.5 1) Size of endotracheal tube : internal diameter (ID)
  • Slide 22
  • 3) Endotracheal tube cuff High volume Low pressure cuff Low volume High pressure cuff 2) Material : Red rubber or PVC
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  • 4) Bevel 5) Murphys eye
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  • 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)
  • Slide 25
  • 7) Tube markings Z-79 Disposible (Do not reuse) Oral/ Nasal Radiopaque marker
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  • 3) Other equipments 3.1 Style t
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  • 3.2 Oropharyngeal or nasopharyngeal airway Oral airway Nasal airway
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  • 3.3) Suction catheter 3.4) Slip joint
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  • 3.5) Face mask and self inflating bag 3.6) Magill forcep
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  • 3.7) Syringe 3.8) Lubricating jelly 3.9) Plaster for strap endotracheal tube 4. Monitoring success of endotracheal intubation 4.1) Stethoscope 4.2) Endtidal - CO 2 4.3) Pulse oximeter
  • Slide 31
  • Sniffing position Flexion at lower cervical spine Extension at atlanto-occipital joint
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  • Sniffing position
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  • Steps of oroendotracheal intubation
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  • Vareculla
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  • Steps of oroendotracheal intubation
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  • Nasoendotracheal intubation
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  • Advantage 1) Comfortable for prolong intubation in postoperative period 2) Suitable for oral surgery : tonsillectomy, mandible surgery 3) For blind nasal intubation 4) Can take oral feeding 5) Resist for kinking and difficult to accidental extubation
  • Slide 40
  • Disadvantage 1) Trauma to nasal mucosa 2) Risk for sinusitis in prolong intubation 3) Risk for bacteremia 4) Smaller diameter than oral route -> difficult for suction
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  • Contraindication for nasoendotracheal intubation 1) Fracture base of skull 2) Coagulopathy 3) Nasal cavity obstruction 4) Retropharyngeal abscess
  • Slide 42
  • Complication of endotracheal intubation 1) During intubation : Trauma to lip, tongue or teeth : Hypertension and tachycardia or arrhythmia : Pulmonary aspiration : Laryngospasm : Bronchospasm
  • Slide 43
  • 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
  • Slide 44
  • 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 intubation
  • Slide 45
  • Complication 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 intubation
  • Slide 46
  • 3) During extubation Laryngospasm Pulmonary aspiration Edema of upper airway Complication of endotracheal intubation(Cont)
  • Slide 47
  • 4) After extubation Sore throat Hoarseness Tracheal stenosis (Prolong intubation) Laryngeal granuloma

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