Endotracheal tubes.pptx

A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent airway and to ensure the adequate exchange of oxygen and carbon dioxide.

1. Endotracheal tubes krishnakumarm D AVMC&H

2. Introduction: The word  intubation  means to insert a tube. Usually, the word intubation is used in reference to the insertion of an endotracheal tube. Patients may need an endotracheal tube for one of several reasons. An endotracheal tube is needed to mechanically ventilate a patient (or breathe for them by a machine). Each breath is pushed into the endotracheal tube and into the lung.

3. THE ET TUBE HAS THE FOLLOWING COMPONENTS : PROXIMAL END – 15mm adapter (connector) which fits to ventilator or AMBU bag CENTRAL PORTION: A vocal cord guide (black line ) which should be placed at the level of the opening of the vocal cords so that the tip of the ET tube is positioned above the bifurcation if the trachea.

4.  The distance indicator (marked in centimetres) which facilitates placement of ET tube. A radio-opaque marker which is essential for accurate visualization of the position of the ET tube within the trachea by means of an X-ray A cuff- in case of cuff ET tube DISTAL END – has Murphy’s eye (opening in the lateral wall ) which prevents complete blockage of ET tube in case the distal end is impacted with secretion , blood , etc

5. TYPES: ET tubes can be : - cuffed - uncuffed • Cuffed ET tubes are used in children > 8 years. The cuff when inflated maintains the ET tube in proper position and prevents aspiration of contents from GI tract into respiratory tract. In children < 8 uncuffed ET tubes are used because the narrow subglottic area performs the function of a cuff and prevents the ET tube from slipping.

6. Laryngoscopy:

7. Indication Endotracheal Intubation: Respiratory Failure: Hypoxia, Hypercapnia, tachypnoea, or apnoea ; ie . ARDS, asthma, pulmonary oedema, infection, COPD exacerbation Inability to ventilate, unconscious patient Maintenance or protection of an intact airway, Cardiac Arrest, Medication administration.

8. Contraindication: 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 haemorrhage Intact tracheostomy Basilar skull fracture (during nasal intubation)

9. Difficult to intubation: (MOANS) Mask Seal : Small Hands, Wrong Mask Size, Oddly Shaped Face, Bushy Beard, Blood/Vomit, and Facial Trauma Obesity or Obstruction: Heavy chest, Abdominal contents inhibit movement of the diaphragm, Increased supra glottic airway resistance, Billowing cheeks, Difficult mask seal, Quicker desaturation Age > 55: Associated with BVM difficulty, possibly due to loss of tone in the upper airway No Teeth: Face tends to cave in Consider leaving dentures in for BVM and remove for intubation. Stiff : Refers to Poor Compliance, Reactive Airway Disease, COPD, Pulmonary Edema/Advance Pneumonia, History of Snoring/Sleep Apnea, Also predicts a higher Mallam Patti score.

10. Difficult to Laryngoscopy and intubation: LEMONS: Look Externally : Beards or facial hair, Short, fat neck, Morbidly obese patients, Facial or neck trauma, Broken teeth (can lacerate balloons), Dentures (should be removed), Large teeth, Protruding tongue, A narrow or abnormally shaped face. Evaluate : Bottom of Jaw/Chin to Neck > 3 fingers, Jaw/Palate > 3 fingers wide, Mouth opens > 2 fingers wide.

11. Equipment Endotracheal Intubation: 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.,Adult men: 7.0 to 8.5 mm i.d. Pediatric size: (age in years/4) + 4 or width of fingernail of the fifth digit

12. 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 ETT, Stylet, and syringe

13. Emergency drugs: Atropine Glycopyrrolate Lignocaine 1% Lignocaine jelly, aerosol, Midazolam Propofol Saline Suxamethonium Thiopentone Non depolarizing muscle relaxant Morphine/fentanyl

14. Technique: Appropriate preparation and positioning of the patient are essential to successful intubation. The operator should confirm that the light source of the laryngoscope is functioning, and the blade is locked in place. The laryngoscope is held on the operator’s left hand. the operator slides the laryngoscope into the right side of the patient’s mouth and advances inward while applying upward pressure at a 45-degree angle against the tongue.

15. the curved laryngoscope is used to lift the epiglottis and expose the vocal cords. Once the glottis is visualized, the operator will ask the respiratory assistant to place the endotracheal tube with the malleable stylet on the operator’s right hand. The operator then inserts the endotracheal tube to the right of the laryngoscope blade and visualizes passage through the vocal cords. Some brands of endotracheal tubes have a marking proximal to the cuff that indicates the relative level of insertion through the vocal cords.

16.  the first intubation attempt is unsuccessful, operators must be ready to change their approach and method on subsequent attempts. A tracheal tube introducer, also called bougie, can be used if the initial attempt is unsuccessful. The bougie is a flexible device with an anteriorly angulated tip that is introduced in the airway when vocal cord visualization is poor. The introduction of the bougie allows for indirect identification of the cartilaginous ridges of the anterior airway. The endotracheal tube slides over the bougie and passes the vocal cords. Tracheal tube introducers may be considered for the first attempt in patients with an anticipated difficult airway.

17. After the endotracheal tube is passed through the vocal cords, the cuff is inflated using a 5 cc or 10 cc syringe filled with air.  The stylet is removed, and the proximal end of the endotracheal tube is connected to the carbon dioxide monitor and the ventilation device. Traditionally, the desired depth from the incisors to the distal tip of the endotracheal tube is 21 and 23 cm in women and men, respectively. Although the preferred distance appears to correlate more with height than gender.

18. Confirmation of Endotracheal Tube Position: After placing the endotracheal tube, it is essential to confirm its placement in the trachea and position proximal to the carina. End-tidal carbon dioxide monitor is the gold standard to confirm tracheal intubation. To rule out esophageal or hypopharyngeal intubation, an EtCO2 monitor measures the expired carbon dioxide with respiration. Extratracheal carbon dioxide waveform will read 0 mmHg while endotracheal intubation correlates reliably with the patient’s arterial partial pressure of CO2.  The physician should also auscultate for symmetric bilateral breath sounds, and the absence of breath sounds over the stomach. A post-intubation chest x-ray confirms the location of the endotracheal tube’s distal tip 2 to 4 cm proximal to the carina and rules out mainstem bronchus intubation.

19. Complications: Hypoxia (Long duration of procedure, Intubation of a bronchus ( right more common, Failure to recognize misplacement of tube, Aspiration) Pneumothorax (resulting from over ventilating with a BVM without a pressure release valve) Trauma (to the teeth, vocal cords, soft tissues of the larynx and related structures) Hypertension and tachycardia (can occur from the intense stimulation of intubation. This is potentially life-threatening in the cardiac patient)Gastric distention and regurgitating (Failure to secure the placement into esophagus). Cardiac arrhythmias (related to vagal stimulation or sympathetic nerve stimulation may occur)

20. Conti….. Tube in oesophagus Endo bronchial Intubation Trauma to lips and tooth Laryngeal and tracheal Injury Barro trauma to lungs Bleeding Tracheitis Pulmonary infection and sepsis