Endotracheal intubation extubation

1. Endotracheal Endotracheal
Intubation/ExtubationIntubation/Extubation

2. Upper Airway AnatomyUpper Airway Anatomy (p. 158) (p. 158)

3. Visualization of Vocal CordsVisualization of Vocal Cords

4. Indications for IntubationIndications for Intubation
nIn conditions of, or leading to resp. In conditions of, or leading to resp.
failure, such as;failure, such as;
- trauma to the chest or airway- trauma to the chest or airway
- neurologic involvement from - neurologic involvement from
drugs drugs myasthenia gravis, poisons, myasthenia gravis, poisons,
etc.etc. -CV involvement leading -CV involvement leading
to CNS to CNS impairment from strokes, impairment from strokes,
tumors, tumors, infection, pulmonary infection, pulmonary
emboliemboli -CP arrest-CP arrest

5. Indications (cont’d)Indications (cont’d)
nRelief of airway obstructionRelief of airway obstruction
nProtection of airway (I.e. seizures)Protection of airway (I.e. seizures)
nEvacuation of secretions by tracheal Evacuation of secretions by tracheal
aspirationaspiration
nPrevention of aspirationPrevention of aspiration
nFacilitation of positive press. ventilationFacilitation of positive press. ventilation

6. Relieving Airway ObstructionRelieving Airway Obstruction
nObstruction classified as Obstruction classified as upperupper ( above ( above
the glottis and includes the areas of the the glottis and includes the areas of the
nasopharynx, oropharynx, and larynx) nasopharynx, oropharynx, and larynx)
or or lowerlower (below the vocal cords) (below the vocal cords)
nCan also be classified as partial or Can also be classified as partial or
complete obstructioncomplete obstruction
nCauses include trauma, edema, tumors, Causes include trauma, edema, tumors,
changes in muscle tone or tissue changes in muscle tone or tissue
supportsupport

7. Hazards of tracheal tubes & cuffsHazards of tracheal tubes & cuffs
nInfectionInfection
nTraumaTrauma
nDehydrationDehydration
nObstructionObstruction
nTraumaTrauma

8. Hazards (cont’d)Hazards (cont’d)
nAccidental intubation of the esophagus Accidental intubation of the esophagus
or right mainstem bronchusor right mainstem bronchus
nBronchospasm, laryngospasmBronchospasm, laryngospasm
nCardiac arrhythmias resulting from Cardiac arrhythmias resulting from
stimulation of the vagus nervestimulation of the vagus nerve
nAspiration pneumoniaAspiration pneumonia
nBroken or loosened teethBroken or loosened teeth

9. Later Complications of Later Complications of
IntubationIntubation
nParalysis of the tongueParalysis of the tongue
nUlcerations of the mouthUlcerations of the mouth
nParalysis of the vocal cordsParalysis of the vocal cords
nTissue stenosis and necrosis of the Tissue stenosis and necrosis of the
tracheatrachea

10. Routes for IntubationRoutes for Intubation
nOrotrachealOrotracheal
nNasotrachealNasotracheal
nTracheotomyTracheotomy

11. Oral IntubationOral Intubation

12. Advantages of Oral IntubationAdvantages of Oral Intubation
nLarger tube can be insertedLarger tube can be inserted
nTube can be inserted usually with more Tube can be inserted usually with more
speed and ease with less traumaspeed and ease with less trauma
nEasier suctioningEasier suctioning
nLess airflow resistanceLess airflow resistance
nReduced risk of tube kinkingReduced risk of tube kinking

13. Disadvantages of Oral IntubationDisadvantages of Oral Intubation
nGagging, coughing, salivation, and Gagging, coughing, salivation, and
irritation can be induced with intact irritation can be induced with intact
airway reflexesairway reflexes
nTube fixation is difficult, self-extubationTube fixation is difficult, self-extubation
nGastric distention from frequent Gastric distention from frequent
swallowing of airswallowing of air
nMucosal irritation and ulcerations of Mucosal irritation and ulcerations of
mouth (change tube position)mouth (change tube position)

14. Nasal IntubationNasal Intubation

15. Advantages of Nasal IntubationAdvantages of Nasal Intubation
nMore comfort long termMore comfort long term
nDecreased gaggingDecreased gagging
nLess salivation, easier to swallowLess salivation, easier to swallow
nImproved mouth careImproved mouth care
nBetter tube fixationBetter tube fixation
nImproved communicationImproved communication

16. Disadvantages of Nasal Intub.Disadvantages of Nasal Intub.
nPain and discomfortPain and discomfort
nNasal and paranasal complications, I.e., Nasal and paranasal complications, I.e.,
epistaxis, sinusitis, otitsepistaxis, sinusitis, otits
nMore difficult procedureMore difficult procedure
nSmaller tube neededSmaller tube needed
nIncreased airflow resistanceIncreased airflow resistance
nDifficult suctioningDifficult suctioning
nBacteremiaBacteremia

17. Intubation EquipmentIntubation Equipment
nEndotracheal Tube and styletEndotracheal Tube and stylet
nLaryngoscopeLaryngoscope
nSterile water-soluble jellySterile water-soluble jelly
nSyringe to inflate cuffSyringe to inflate cuff
nAdhesive tape or tube fixation deviceAdhesive tape or tube fixation device
nBite block to prevent biting oral ET tubeBite block to prevent biting oral ET tube
nSuction Equipment, bag- mask, O2Suction Equipment, bag- mask, O2
nLocal anestheticLocal anesthetic
nStethoscopeStethoscope

18. Endotracheal TubeEndotracheal Tube

19. Endotracheal TubeEndotracheal Tube
nET tube size and depth of insertion (see ET tube size and depth of insertion (see
p. 594)p. 594)
nFor children older than 2 yearsFor children older than 2 years
- tube size = age/4 + 4- tube size = age/4 + 4
- depth = age/2 + 12- depth = age/2 + 12
nAdult Adult
- tube size female = 8.0, male = 9.0- tube size female = 8.0, male = 9.0
- depth female = 19-21 and 24-26- depth female = 19-21 and 24-26
male = 21-23 and 26-28 male = 21-23 and 26-28

20. StyletStylet

21. Light stylet (light wand)Light stylet (light wand)

22. LaryngoscopeLaryngoscope

23. LaryngoscopeLaryngoscope
nBlade and handleBlade and handle
nBlade Blade
- has a flange, spatula, light, and tip- has a flange, spatula, light, and tip
- curved blade (Macintosh)- curved blade (Macintosh)
- straight blade (Miller, Wisconsin)- straight blade (Miller, Wisconsin)
nFiber optic vs. traditional laryngoscopeFiber optic vs. traditional laryngoscope
nBlade size: Blade size: 0 - 10 - 1 infant, infant, 22 from 2-8 years from 2-8 years
33 from age 10 - adult, from age 10 - adult, 44 large adult large adult

24. Straight blade (Miller)Straight blade (Miller)

25. Curved blade (Macintosh)Curved blade (Macintosh)

26. Oral Intubation ProcedureOral Intubation Procedure
nAssemble and check equipmentAssemble and check equipment
- suction equipment- suction equipment
- laryngoscope- laryngoscope
- select proper size tube, check tube- select proper size tube, check tube
nPosition patientPosition patient
- align mouth, pharynx, larynx- align mouth, pharynx, larynx
- “sniffing” position- “sniffing” position

27. Patient PositioningPatient Positioning

28. Oral Intubation Proced. (cont’d.)Oral Intubation Proced. (cont’d.)
nPreoxygenate the patientPreoxygenate the patient
- bag-valve mask- bag-valve mask
- *intubation attempt should take no - *intubation attempt should take no
longer than 30 sec, if unsuccessful, longer than 30 sec, if unsuccessful,
then then ventilate again with bag and ventilate again with bag and
mask for 3-5 minutesmask for 3-5 minutes
nInsert laryngoscopeInsert laryngoscope
- hold laryngoscope in - hold laryngoscope in leftleft hand & hand &
insert in right side of mouth, displace insert in right side of mouth, displace
tongue toward centertongue toward center

29. Oral procedure (cont’d.)Oral procedure (cont’d.)
nVisualize glottis and displace epiglottisVisualize glottis and displace epiglottis

30. Oral proced. (cont’d.)Oral proced. (cont’d.)
nInsert ET tubeInsert ET tube
- do not use laryngoscope blade to - do not use laryngoscope blade to
guide tubeguide tube
- once you - once you seesee the tube pass the the tube pass the
glottis, advance the cuff passed the glottis, advance the cuff passed the
cords by 2 -3 cmcords by 2 -3 cm
nHold tube with right hand and Hold tube with right hand and
remove laryngoscope & styletremove laryngoscope & stylet
- inflate cuff with 5 - 10 cc of air- inflate cuff with 5 - 10 cc of air
- ventilate with bag- ventilate with bag

31. Oral proced. (cont’d)Oral proced. (cont’d)
nInflate cuff with 5 - 10 cc of airInflate cuff with 5 - 10 cc of air
nVentilate with “bag”Ventilate with “bag”
nAssess tube positionAssess tube position
- auscultation of chest & epigastric- auscultation of chest & epigastric
- cm mark at teeth- cm mark at teeth
- capnometry/colorimetry- capnometry/colorimetry
- light “wand”- light “wand”
nStabilize tube/Confirm placementStabilize tube/Confirm placement
- chest x-ray- chest x-ray

32. ExtubationExtubation
nGuidelines for extubation (see table, p. Guidelines for extubation (see table, p.
613)613)
nCuff-leak testCuff-leak test

33. Extubation ProcedureExtubation Procedure
nAssemble EquipmentAssemble Equipment
- intubation equipment- intubation equipment
- in addition to intubation equipment, - in addition to intubation equipment,
O2 device and humidity, SVN with O2 device and humidity, SVN with
racemic epiracemic epi
nSuction ET tubeSuction ET tube
nOxygenate patientOxygenate patient
nUnsecure tube, deflate cuffUnsecure tube, deflate cuff

34. Extubation proced. (cont’d.)Extubation proced. (cont’d.)
nPlace suction catheter down tube and Place suction catheter down tube and
remove ET tube as you suctionremove ET tube as you suction
nApply appropriate O2 and humidityApply appropriate O2 and humidity
nAssess/Reassess the patientAssess/Reassess the patient