Endotracheal Intubation

1
Endotracheal Intubation
2
Airway Management

• Expertise in airway management requires knowledge
  of
• Upper airway anatomy
• Use of equipment
• Relevant medicines

3
Indications

• To provide patent airway
• To prevent aspiration of gastric contents
• To facilitate positive pressure for respiration
• To provide ventilation of the lungs
• To enable operative position other than supine

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Indications (contd)

• Operative site near or involving upper airway
• Need for frequent suctioning
• During thoracic operation

5
Assessment

• Mouth opening 2-finger breadth between upper
  and lower incisors
• Look for loose teeth, high arched palate, long
  narrow mouth, temporomandibular joint problems
• Neck masses, mobility, deviation of trachea,
  neck extension lt 30 degree limits laryngoscopy

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Assessment (contd)

• Presence of hoarse voice, stridor, previous
  tracheostomy
• 3 specific tests
• Mallampti test
• Thyromental distance
• Extension at atlanto-occipital joint

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Preparation

• Experienced assistant
• Equipment
• Correct size laryngoscope checked
• Tracheal tube with additional alternative smaller
  sizes
• Tracheal tube connector
• Wire stylette

8
Preparation (contd)

• Equipment
• Gum elastic bougies
• Magills forceps
• Cuff inflating syringe
• Securing tape or bandage
• Catheter mount
• Anesthetic breathing system and face mask
• Drugs for induction and resuscitation

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Tracheal Intubation

• Can Be Done Under/By
• General anesthesia
• Intravenous or inhalation anesthesia with or
  without muscle relaxation
• Local anesthesia
• Topical spray, translaryngeal spray and superior
  laryngeal nerve block

10
Conduct of Laryngoscopy

• Position neck flexed, head extended
• Base of laryngoscope held in left hand
• Blade lifted upward and forward along axis of
  handle, lifting tongue and epiglottis
• Do not use teeth as fulcrum

11
Conduct of Laryngoscopy (contd)

• Curved blade tip advanced to vallecula
• Straight blade tip advanced posterior to
  epiglottis
• Short handle laryngoscope for short neck,
  pregnant woman and woman with large breasts

12
Conduct of Laryngoscopy (contd)

• Gentle external pressure on thyroid cartilage,
  push glottis posterior and bring vocal cord in
  view
• Tube cuff inflated to abolish audible gas leak on
  inflation of lung

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Confirmation of Tracheal Intubation

• Most confirmatory direct visualization of
  endotracheal tube passing between the vocal cords
  
• Air entry on auscultation (both lungs)
• Fiberoptic bronchoscope passed through tube to
  recognize carina

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Confirmation of Tracheal Intubation

• Presence of exhaled CO2
• Antero-posterior and lateral fluoroscope for
  position of tube
• Breath sound difficulty
• Aspiration
• Pneumonia
• COPD

15
Confirmation of Tracheal Intubation

• Less reliable
• Palpation of anterior neck during passage of tube
  
• Condensation inside the tube
• Light visible through skin of anterior neck

16
Intubation Difficulty

• Incorrect position of patient
• Inadequate or improper equipment
• Unusual or abnormal anatomy
• Pathological causes

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Intubation Difficulty

• Incidence of difficult intubation less than 1
  all patients (Cobley and Vaughan 1992)
• Failure to intubate in non-obstetric patients 1
  in 2302(Samsoo and Young 1987)
• In obstetric patients 1 in 300 (Lyons 1985)

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Complications

• Laceration of soft tissue
• Laryngospasm, bronchospasm
• Vocal cord paralysis
• Dislocation of arytenoid cartilage or mandible
• Perforation of trachea or esophagus

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Complications (contd)

• Endobronchial or esophageal intubation
• Dental damage
• Hemorrhage
• Aspiration of gastric contents
• Increased intracranial or intra-ocular pressure

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Complications (contd)

• Hypoxia, hypercarbia
• Fracture and dislocation of the cervical spine
• Spinal cord damage
• Trauma to eye
• Tracheal stenosis late (vocal cord ulcer or
  granuloma)