Endotracheal intubation, indications, complications.

Endotracheal intubation

1. Endotracheal intubation Prepared by: Sultanat khan Discipline: Emergency care Submitted To: Lec Abdur-Raheem 07-Jan-17 Sultanat khan 1

2. ET intubation is a procedure in which ET tube is placed inside the trachea through the mouth or nostrils. ET intubation is much simpler than tracheotomy surgical procedure that creates an airway opening by cutting into the trachea . In spite of many advantages of a tracheostomy tube, ET intubation is preferred as the initial means of establishing an artificial airway. Introduction Two adult endotracheal tubes (8.0 mm ID). Note that one’s cuff is inflated and the other’s is not. Also note the markings visible on the tubes. 07-Jan-17 Sultanat khan 2

3. In general, if the patient requires an artificial airway for a brief period (e.g., 10 days or less) and full recovery is expected, an ET tube is used . Relief of airway obstruction: ─ Epiglottitis ─Facial burns and smoke inhalation ─Vocal cord edema. Protection of the airway: ─ Prevention of aspiration ─Absence of coordinated swallow. Indications 07-Jan-17 Sultanat khan 3

4. Facilitation of suctioning: ─ Excessive secretions ─Inadequate cough Support of ventilation ─ Ventilatory failure / respiratory arrest ─Chest trauma ─ Postanesthesia recovery ─Hyperventilation to ↓ intracranial pressure Indications 07-Jan-17 Sultanat khan 4

5. An ET tube may be inserted orally (oral intubation) or nasally (nasal intubation) through the larynx into the trachea . Intubation through the mouth is the preferred method of establishing an artificial airway. An oral route provides quick access to the lungs in emergency situations and it allows the passage of a larger ET tube than the nasal route. I ndications 07-Jan-17 Sultanat khan 5

6. Prior to intubation, the patient must be assessed to rule out any potential contraindications to include head injury, cervical spine injury, airway burns, and facial trauma. The degree of difficulty in intubation due to anatomical structures can be evaluated by using the Mallampati classification method: ─Class 1 (easiest) ─Class 2 (Difficult) ─ Class 3 (more difficult) ─Class 4 (most difficult) Initial Intubation procedure 07-Jan-17 Sultanat khan 6

7. Equipment's needed for ET intubation include: (1) laryngoscope handle, (2) blade, (3) ET tube, (4) 10-mL syringe, (5) water-soluble lubricant, (6) tape, and (7) stethoscope. Optional supplies for ET intubation include (8) stylet , (9) topical anesthetic , and (10) Magill forceps . Equipment's 07-Jan-17 Sultanat khan 7

8. The size refers to the internal diameter (ID) of the tube in millimeters (mm ). Neonate (, 1000 grams ) 2.5 mm ID Neonate (1000 to 2000 grams ) 3.0 mm ID Neonate (2000 to 3000 grams) 3.5 mm ID Neonate (. 3000 grams) 4.0 mm ID Child (1 to 2 years) 4.5 mm ID Child (2 to 12 years) 4.5+( age/4) mm ID Adult female 7.0 or 7.5 mm ID Adult male 7.5 or 8.0 mm ID ETT S izes Estimation 07-Jan-17 Sultanat khan 8

9. Neonates 6 + weight >2 years age/2 + 12 Adult: Male : 21----24cm Female : 18----21cm Length──cm 07-Jan-17 Sultanat khan 9

10. 1. Assemble and test supplies (e.g., check light source and ET tube cuff for air leak). 2. Lubricate the deflated cuff with a water-soluble lubricant. 3. Inform or explain procedure to patient. 4. Bag-mask ventilate and preoxygenate patient with 100% oxygen. 5. Tilt the head back and place in the sniffing position ( tilting the forehead back slightly and moving the mandible anteriorly to the patient.) Procedure for Oral Intubation 07-Jan-17 Sultanat khan 10

11. 6. Open mouth, apply anesthetic spray. 7. Hold laryngoscope handle with left hand and insert blade into the right side of the opened mouth . 8. Slide blade to the base of tongue and sweep blade to the left. 9. Maneuver the tip of straight blade underneath the epiglottis (or the tip of curved blade at the vallecula ). 10. Lift handle and blade up anteriorly to displace the tongue and attached soft tissues. Cont … 07-Jan-17 Sultanat khan 11

12. 11. Locate the epiglottis (only with curve blade), larynx, and vocal cords. 12. Insert ET tube through the vocal cords under direct vision. 13. For adults, the centimeter marking on the ET tube should initially be placed at the lips or incisors at 21 to 23 cm. 14. Inflate cuff and confirm endotracheal tube placement (e.g., loss of phonation, rising SpO2, presence of bilateral breath sounds and expired CO2). 15. Verify proper depth of ET tube placement (1.5 inch above carina) with chest radiograph. Cont … 07-Jan-17 Sultanat khan 12

13. 1) During intubation: Trauma to lip, tongue or teeth Hypertension and tachycardia or arrhythmia Pulmonary aspiration Laryngospasm Bronchospasm Esophageal intubation Complications 07-Jan-17 Sultanat khan 13

14. 2) During remained intubation: Obstruction from klinking , secretion or overinflation of cuff Accidental extubation or endobronchial intubation Disconnection from breathing circuit Pulmonary aspiration Complications 07-Jan-17 Sultanat khan 14

15. 3) During extubation Laryngospasm Pulmonary aspiration Edema of upper airway Complications 07-Jan-17 Sultanat khan 15

16. 4) After extubation Sore throat Hoarseness Tracheal stenosis (Prolong intubation) Laryngeal granuloma Complications 07-Jan-17 Sultanat khan 16

17. THANKS 07-Jan-17 Sultanat khan 17