Endotracheal Intubation/Extubation

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Endotracheal Intubation/Extubation
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Upper Airway Anatomy (p. 158)
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Visualization of Vocal Cords
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Indications for Intubation

• In 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

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Indications (contd)

• Relief of airway obstruction
• Protection of airway (I.e. seizures)
• Evacuation of secretions by tracheal aspiration
• Prevention of aspiration
• Facilitation of positive press. ventilation

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Relieving Airway Obstruction

• Obstruction 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
  obstruction
• Causes include trauma, edema, tumors, changes in
  muscle tone or tissue support

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Hazards of tracheal tubes cuffs

• Infection
• Trauma
• Dehydration
• Obstruction
• Trauma

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Hazards (contd)

• Accidental intubation of the esophagus or right
  mainstem bronchus
• Bronchospasm, laryngospasm
• Cardiac arrhythmias resulting from stimulation of
  the vagus nerve
• Aspiration pneumonia
• Broken or loosened teeth

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Later Complications of Intubation

• Paralysis of the tongue
• Ulcerations of the mouth
• Paralysis of the vocal cords
• Tissue stenosis and necrosis of the trachea

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Routes for Intubation

• Orotracheal
• Nasotracheal
• Tracheotomy

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Oral Intubation
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Advantages of Oral Intubation

• Larger tube can be inserted
• Tube can be inserted usually with more speed and
  ease with less trauma
• Easier suctioning
• Less airflow resistance
• Reduced risk of tube kinking

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Disadvantages of Oral Intubation

• Gagging, coughing, salivation, and irritation can
  be induced with intact airway reflexes
• Tube fixation is difficult, self-extubation
• Gastric distention from frequent swallowing of
  air
• Mucosal irritation and ulcerations of mouth
  (change tube position)

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Nasal Intubation
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Advantages of Nasal Intubation

• More comfort long term
• Decreased gagging
• Less salivation, easier to swallow
• Improved mouth care
• Better tube fixation
• Improved communication

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Disadvantages of Nasal Intub.

• Pain and discomfort
• Nasal and paranasal complications, I.e.,
  epistaxis, sinusitis, otits
• More difficult procedure
• Smaller tube needed
• Increased airflow resistance
• Difficult suctioning
• Bacteremia

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Intubation Equipment

• Endotracheal Tube and stylet
• Laryngoscope
• Sterile water-soluble jelly
• Syringe to inflate cuff
• Adhesive tape or tube fixation device
• Bite block to prevent biting oral ET tube
• Suction Equipment, bag- mask, O2
• Local anesthetic
• Stethoscope

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Endotracheal Tube
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Endotracheal Tube

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

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Stylet
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Light stylet (light wand)
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Laryngoscope
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Laryngoscope

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

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Straight blade (Miller)
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Curved blade (Macintosh)
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Oral Intubation Procedure

• Assemble and check equipment - suction
  equipment - laryngoscope - select proper
  size tube, check tube
• Position patient - align mouth, pharynx,
  larynx - sniffing position

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Patient Positioning
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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
  minutes
• Insert laryngoscope - hold laryngoscope in
  left hand insert in right side of mouth,
  displace tongue toward center

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Oral procedure (contd.)

• Visualize glottis and displace epiglottis

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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 cm
• Hold tube with right hand and remove
  laryngoscope stylet - inflate cuff with 5 -
  10 cc of air - ventilate with bag

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Oral proced. (contd)

• Inflate cuff with 5 - 10 cc of air
• Ventilate with bag
• Assess tube position - auscultation of chest
  epigastric - cm mark at teeth -
  capnometry/colorimetry - light wand
• Stabilize tube/Confirm placement - chest x-ray

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Extubation

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

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Extubation Procedure

• Assemble Equipment - intubation
  equipment - in addition to intubation
  equipment, O2 device and humidity, SVN with
  racemic epi
• Suction ET tube
• Oxygenate patient
• Unsecure tube, deflate cuff

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Extubation proced. (contd.)

• Place suction catheter down tube and remove ET
  tube as you suction
• Apply appropriate O2 and humidity
• Assess/Reassess the patient