ACLS: Airway Management: Endotracheal Intubation

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ACLSAirway ManagementEndotracheal Intubation

• Dr. Linda Frasca
• Edward Via Virginia College of Osteopathic
  Medicine
• Block 12

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Indications Endotracheal Intubation

• Respiratory Failure Hypoxia, Hypercapnia,
  tachypnea, or apnea ie. ARDS, asthma,
• pulmonary edema, infection, COPD exacerbation
• Inability to ventilate unconscious patient
• Maintenance or protection of an intact airway
• Cardiac Arrest
• Medication administration

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Contraindications

• Inability of patient to extend head
• Moderate to severe trauma to the cervical spine
  or anterior neck
• Infection in the epiglottal area
• Mandibular fracture or trismus
• Mild hypoxia
• Uncontrolled oropharyngeal hemorrhage
• Intact tracheostomy

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Equipment

• Laryngoscope
• Blades 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. tube
• Adult men 8.0 to 8.5 mm i.d. tube
• Pediatric size (age in years/4) 4 or width of
  fingernail of the fifth digit

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Continue Equipment for ET intubation

• Lubricant, Malleable stylet
• 10-ml syringe (to inflate ET cuff)
• Oxygen and manual bag valve mask
• Suction apparatus
• Stethoscope
• Sterile gloves and goggles
• Oropharyngeal airway
• CO2 Detector

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How do you confirm the correct placement of the
ET Tube?

• Primary Confirmation
• Secondary Confirmation

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Primary Confirmation By Physical Exam

• Confirm tube placement immediately
• Listen over the epigastrium and observe the chest
  wall for movement
• If stomach gurgling and no chest wall expansion,
  esophagus intubatedremove ET tube
• Reattempt intubation after reoxygenation

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Primary Confirmation cont.

• If chest wall rises and stomach not gurgling,
• perform 5-point auscultation
• If 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 with
  esophageal intubations)

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Secondary Confirmation

• End-Tidal CO2 Detectors
• Commercial device that reacts with a color change
  to CO2 exhaled from the lungs MELLO YELLOW
• Qualitative detection device indicates exhaled
  CO2 indicates proper tracheal tube placement
• Absence of CO2 (unless prolonged CPR), indicates
  esophageal intubation
• False Distended stomach, carbonated beverages
• False- Low or no blood flow state ( as above)

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Endotracheal tube(ET) trachea, endotracheal tube
(arrows) and location of carina ().
University of Virginia
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Complications

• Hypoxia
• Long duration of procedure
• Esophageal intubation ( not visualizing vocal
  cords)
• Intubation of a bronchus ( right more common)
• Failure to secure the placement
• Failure to recognize misplacement of tube
• Aspiration
• Pneumothorax

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Complications continued

• Trauma and adverse effects
• Broken teeth
• Oral lacerations
• Vocal cord injury
• Pharyngeal-esophageal perforation
• Short-term laryngeal edema
• Release of high levels of epinephrine and
  norepinephrine stimulated by tracheal intubation
• can cause elevated blood pressure,
  tachycardia, arrhythmias