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ENDOTRACHEAL INTUBATION PRESENTED BY : R.PRASANTH MSC(N) 2 ND YEAR

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ENDOTRACHEAL INTUBATION

ENDOTRACHEAL INTUBATIONPRESENTED BY : R.PRASANTH MSC(N) 2ND YEAR

DEFINITIONIt is a procedure of passing of an endotracheal tube into trachea through the nose or mouth.

PURPOSE It is performed to establish and maintain a patent airway, facilitate oxygenation and ventilation, reduce the risk of aspiration, and assist with the clearance of secretions. INDICATIONSANDCONTRAINDICATIONSADVANTAGESDISADVANTAGESNeed advanced training to properly perform procedure Bypasses the nares function of warming and filtering the air Increased incidence of trauma due to neck manipulation when spinal cord injury is suspected May increase respiratory resistance Improper placement

EQUIPMENTS

LARYNGOSCOPE : handle & blade

Macintosh (curved) and Miller (straight) blade Adult : Macintosh bladesmall children : Miller blade

LARYNGOSCOPIC BLADE:

Mc coy blade Miller bladeMacintosh bladeENDOTRACHEAL TUBE

TYPES OF ETTs:1) Portex tubes:Semirigid, with little tendency to kink. Most commonly used.2) Rubber tubes:Soft, easily kinked.3) Reinforced tubes: - Cuffed or non cuffed. Reinforced with wire to prevent kinking.4) Special tubes:Double lumen (Robertshaw

ENDOTRACHEAL TUBE: (ETT) Male: ID 8.0 mms Female: ID 7.5 mmsNew born - 3 mths : ID 3.0 mms3-9 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 ETT : internal diameter (ID)2) MATERIAL : Red rubber or PVC3) ETT CUFF

High volume Low pressure cuff Low volume High pressure cuffETT CUFFcuff inflating system consisting of:valve, balloon, inflating tube & cuff.Uncuffed tubes used in children to minimise pressure injuryPurpose of cuff is:seal between tube & tracheaProtect from aspiration of blood, mucus or vomitus.

4) BEVEL5) MURPHYS EYE

6) Depth of insertion:Midtrachea or below vocal cord~2 cmAdult Male ~23 cmFemale ~21 cmChildrenOral ETT= (Age/2) + 12 (cm)Nasal ETT= (Age/2) + 15 (cm)

OTHER EQUIPMENTS:STYLET(malleable)

FACE MASK & SELF INFLATING BAG

MAGILL FORCEPS

LOCAL ANAESTHETIC SPRAY

SyringeLubricating jellyDynaplast/ tape to strap endotracheal tubeMonitoring success of intubation:StethoscopeEndtidal - CO2 Pulse oximeter

PREOXYGENATIONPROCEDUREventilate with 100 % oxygen for approximately 3 min

Position bed / table height:bring the patient's head to naval height

SNIFFING POSITIONExtension at atlanto-occipital jointFlexion at lower cervical spine Neck flexion is maintained by placing a fewinches of padding behind the head

Sniffing position

STEPS OF OROENDOTRACHEAL INTUBATION

BAG MASK VENTILATIONThumb and index finger of left hand in the shape of a C press down

The other 3 fingers at the inferior ramus of the mandible and lift the mandible up (jaw thrust) E

CE

HOLDING A LARYNGOSCOPEHold the handle ofthe laryngoscope with your left hand

OPEN MOUTH TECHNIQUES

Hyper-extension technique (no touch technique) Cross fingers techniquesINTUBATION TECHNIQUEintroduce the blade into the right side of the patient's mouthmove the blade posteriorly and toward the midline, sweeping the tongue to the left and keeping it away from the visual path with the flange of the bladeensure the lower lip is not being pinched by the lower incisors and laryngoscope bladeadvance the laryngoscope until the epiglottis is in viewINSERTING THE BLADE

INTUBATION TECHNIQUElift the laryngoscope upward and forwardinsert the ETT from the right angle of mouth with its concave curve facing downward and to the right side of the patientmaneuver the endotracheal tube into the larynx, midway between the cricoid cartilage and the sternal angleLIFTING UP A LARYNGOSCOPE:

Pull the blade forward and upward using firm but Steady pressure without rotating the wristAvoid leaning on the upper teeth with the bladeEXPOSURE OF THE LARYNX:

In most situations vocal cords should become visible If not, exert gentle pressure over the cricoid area to help bring them into view

BURP Maneuver:

ON THYROID CARTILAGE

Backward:against the cervical Vertebrae

Upward

Right: lateral pressure to the rightHOW TO CONFIRM THE CORRECT PLACEMENT OF ETT?Primary ConfirmationSecondary ConfirmationPRIMARY CONFIRMATION :By Physical ExamConfirm tube placement immediatelyListen over the epigastrium and observe the chest wall for movementIf stomach gurgling and no chest wall expansion esophagus intubated: deflate the cuff and remove ET tubeReattempt intubation after re -oxygenationPRIMARY CONFIRMATION: CONTD.If chest wall rises and stomach not gurgling, perform 5-point auscultationIf still doubt, use laryngoscope to see the tube passing through the vocal cords (best)Secure the tube Look for moisture condensation on the inside of the tracheal tube(not 100%: false +ve with esophageal intubations)SECONDARY CONFIRMATION End-Tidal CO2 DetectorsCommercial device that reacts with a color change to CO2 exhaled from the lungs: Qualitative detection device indicates exhaled CO2 indicates proper tracheal tube placementAbsence of CO2 (unless prolonged CPR), indicates esophageal intubationFalse +ve: Distended stomach, carbonated beveragesFalse - ve: Low or no blood flow states

Endotracheal tube(ET) trachea, endotracheal tube (arrows) and location of carina (^).

AFTER CARE OF THE PATIENTPROCEDURE FOR REMOVALTHANK YOU