ENDOTRACHEAL TUBE INTUBATION II Parts II Details II Clinical Discussion

What is endotracheal intubation?

Endotracheal intubation is a procedure by which a tube is inserted through the mouth down into the trachea (the large airway from the mouth to the lungs). Before surgery, this is often done under deep sedation. In emergency situations, the patient is often unconscious at the time of this procedure.


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1. Swatilekha Das
(RN,MSN)

2. The patient in the ICU often requires
mechanical assistance to maintain airway
patency. Inserting a tube into the trachea,
bypassing upper airway and laryngeal
structures, creates an artificial airway. The tube
is placed into the trachea via the mouth or nose
past the larynx (endotracheal [ET] intubation) or
through a stoma in the neck (tracheostomy). ET
intubation is more common in ICU patients. It
can be performed quickly and safely at the
bedside.

3. Endotracheal intubation involves passing an
endotracheal tube through mouth or nose into
the trachea.

Intubation provides a patent airway when the
patient is having respiratory distress that cannot
be treated with simpler methods. It is the method
of choice in emergency care.

Endotracheal intubation is a means of providing
an airway for patients who cannot maintain an
adequate airway on their own, for patients
needing mechanical ventilation and for
suctioning secretions from the pulmonary tree.

4. Endotracheal tube

6. An endotracheal tube :
provides a passage for gases to flow between
a patients lungs and an anaesthesia breathing
system .
allows one to provide positive pressure
ventilation.
protects the lung from contamination from
gastric contents and nasopharyngeal matter
such as blood.

7. Indications for ET intubation include :
Upper airway obstruction (e.g. secondary to
burn, tumor, bleeding)
Apnea
High risk of aspiration
Ineffective clearance of secretions
Respiratory distress
Respiratory arrest.
Cardiac arrest

8. The following are only relative contraindications to
tracheal intubation:
Severe airway trauma or obstruction that does
not permit safe passage of an endotracheal tube.
Emergency cricothyrotomy is indicated in such
cases.
Cervical spine injury, in which the need for
complete immobilization of the cervical spine
makes endotracheal intubation difficult.
Mallampati Classification of class III / IV or other
determination of potential difficult airway.

9. Endotracheal tube for proper size
Average female size, 7.5-8.0 mm
Average male sixe, 8.5-9.0 mm
Stylet (metal wire)
Larynscope and blade
Straight blade (Miller)
Curved blade (Macintosh)
Suction
Tonsil tip (Yankauer)
Suction kit

10. Syringe to inflate balloon
Topical anesthetic
Lidocaine jelly or other agent
Water soluble lubricant
Tape or device to secure tube
Stethoscope
Bag-valve device/ manual bag
With reservoir
Connected to oxygen at 15 L/min
Optional equipment
Magill forceps
Oropharyngeal airway

15. Preformed endotracheal tubes

20. The ET tube is passed through the mouth and
vocal cords and into the trachea with the aid of
a laryngoscope or bronchoscope.

21. The patient is placed in a “sniffing” position to align the airway
structures. Placing a folded towel or bath blanket under the
head may help achieve this position.

If the procedure is performed electively, a topical anesthetic
and/or premedication with sedative or paralytic agent may be
used so that the patient better tolerates the procedure.

Before the procedure is performed, the patient is
hyperoxygenated and hyperventilated with 100% oxygen by
use of a bag-valve device with a face mask.

The proper sized tube is chosen.

All ETTs is increase the work of breathing; however a tube that
is too small substantially increases the work of breathing and
may make ventilation and weaning difficult.

22. The average sized ETT used for females ranges from 7.5
to 8.0 mm, whereas the average sized ETT used for
males ranges from 8.5 to 9.0 mm.

After the tube is selected, the cuff on the balloon is
inflated to check for proper functioning and/or any leaks.

A stylet is used to stiffen the ETT and facilitate insertion.

The ETT is lubricated with a water-soluble lubricant. The
laryngoscope is attached to the appropriate size and type
of blade (straight or curved). The choice of blades varies.
The straight blade elevates the epiglottis anteriorly to
expose the vocal cords. The tip of the curved blade fits
into the vallecula. When upward traction is placed on the
laryngoscope, the epiglottis is displaced anteriorly.

The person doing the intubation inserts the laryngoscope
into the mouth to visualize the vocal cords.

23. Excess secretions and/or vomitus is suctioned to
facilitate visualization of the vocal cords; the tonsil
suction tip is very efficient in removing the secretion

The ETT is inserted 5 to 6 cm beyond the vocal
cords, and the cuff is inflated.

The procedure should be performed within 30
seconds.

If the intubation is difficult, the patient should be
manually ventilated between intubation attempts.

Frequently, the patient requires endotracheal
suctioning for removal of excess secretions
immediately after intubation.

24. If the patient needs assistance with breathing, ventilation is
achieved with either the bag-valve device or ventilator.

Placement of the ETT is verified by the movement of air in
and out of the tube, observation of bilateral chest expansion
with inspiration and auscultation of bilateral breath sounds
while the patient is ventilated with a bag-valve device.

Another method for verifying tube placement is end-tidal
carbon-dioxide monitoring. If th tube is in the trachea
(versus esophagus), carbon dioxide is detected in exhaled
air.

After intubation a portable chest x-ray study is always
performed for verification of the tube placement. The tip of
the ETT should be approximately 2 to 5 cm above the carina.

Once proper tube placement is verified, the ETT is secured
with tape or another device in order to prevent dislodging.

25. ADVANTAGES
easily and quickly performed
larger tube facilitates suction and procedures
such as bronchoscopy
less kinking of tube

DISADVANTAGES
not recommended in patients with suspended
cervical injury
uncomfortable
mouth care more difficult to perform
impairs ability to gag and swallow
may increase salivation
may cause irritation and ulceration of the mouth

26. NASAL ENDOTRACHEAL INTUBATION
The ET is placed blindingly (ie. Without visualizing the
larynx) through the nose, nasopharynx and vocal cords.

PROCEDURE FOR ORAL INTUBATION
A nasotracheal ETT is usually better tolerated in an alert
patient and may e easier to stabilize. In nasotracheal
intubation, the ETT is usually inserted through the nares
and then passed “blindly” into the glottis during
inspiration.
The blind intubation method is performed in the alert
patient who is capable of spontaneous respirations.
The nose and pharynx are anesthetized before the
procedure.
Nasotracheal intubation can also be performed through
direct visualization. In this method, practitioners may
use a laryngoscope and Magill forceps or fiberoptic
bronchoscopy during the intubation.

27. ADVANTAGES
greater patient comfort and better tolerance
better mouth care possible
fewer oral complication
less risk of accidental extubation
facilitates swallowing of secretions
can administer small amounts of oral liquids if
patient able to swallow

DISADVANTAGES
more difficult to perform
may cause nasal hemorrhage and sinusitis
secretion removal more difficult because of
smaller tube diameter and longer tube length

28. Several complications may occur as a result of
oral endotracheal or nasotracheal intubation.
Complications include-
trauma to airway structures
hypoxia
dysrhythmias
aspiration
accidental intubation of esophagus

29. laryngospasm
bronchospasm
intubation of the right mainstem bronchus
 an endotracheal tube that is mistakenly sized
or misplaced, especially in the apneic patient,
can quickly lead to hypoxia and death
 Broken teeth or dentures

30. Adequate ventilation is dependent on the free
movement of air through the upper and lower
airways. In many conditions, the airway becomes
narrowed or blocked as a result of disease process,
broncho-constriction, foreign body or secretions.

Maintaining a patent (open) airway is achieved
through meticulous airway management, whether
in an emergency situation such as airway
obstruction, or in long term management, as in
caring for a patient with an endotracheal or a
tracheostomy tube.