Intubation part 1.

special presentation for slide share customers

1. ENDOTRACHEAL INTUBATION -Dr Nisar Ahmed Arain Assistant Professor Anesthesia/Critical care/ER

2. -FEATURES --1- They are made of:-Polyvinyl chloride (PVC) that are disposable (The most common) or red rubber that are Re – useable and auto – claveable (obsolete) --2- A side hole just above and opposite the bevel called the Murphy Eye is present to enable ventilation and decreases the risk of complete tube occlusion by secretions, Blood or the wall of the trachea. --3- The size of the endotracheal tube is usually designated in millimeters of internal diameter for less commonly In the French scale which is the external circumference of the tube in millimeters --4- Most adult endotracheal tubes have a cuff inflation system consisting of a valve, Pilot balloon, inflating tube and cuff --5- The valve prevents air loss after cuff inflation --6- The pilot balloon provides a gross indication of cuff inflation --7- The cuff creates a seal allowing positive pressure ventilation and decreases the risk of Aspiration --8- Uncuffed tubes are usually used in children (upto 6 to 8 years old) to decrease the risk of pressure injury and post intubation croup (edema) --9- The cuff is not required because the Larynx of pediatric patients is FUNNEL shaped with the narrowest part at the cricoid cartilage (in adults, the vocal cords are the narrowest part. In addition to the loose submucosa in pediatrics which make the edema very likely to occur

3. -FEATURES OF ENDOTRACHEAL TUBE

4. - FEATURES OF ENDOTRACHEAL TUBE

5. -TYPES OF CUFFS HIGH PRESSURE (LOW VOLUME) CUFF --It is present mainly in the Red rubber tubes and produces better seal but the cuff produces more severe ischemic damage to the tracheal mucosa as the pressure inside the cuff exceeds that of the capillaries in the tracheal mucosa. Therefore it is less suitable for long operations or long stay in the intensive care LOW PRESSURE (HIGH VOLUME) CUFF --It is present mainly in the disposable PVC tubes and produces more sore throat (as there is a larger mucosal contact area) --Spontaneous extubation and difficult insertion (due to floppy cuff) but it produces less severe ischemic damage to the tracheal mucosa. --Therefore it is more recommended especially for long operations or long stay in the intensive care --It is used most commonly

6. - CUFF PRESSURE DEPENDS ON - 1- Inflation volume. -2- The diameter of the cuff in relation to the trachea. -3- Tracheal and cuff compliance. -4- Intrathoracic pressure (as cuff pressure increases with coughing). -5- N20 diffusion from the tracheal mucosa into the cuff which causes an increase of cuff pressure; therefore, it is recommended to readjust cuff volume after 10-15 min or fill the cuff with Oz/N20 mixture

7. -SIZE --The ‘size’ of a tracheal tube refers to its internal diameter which is marked on the outside of the tube in millimeters. --Narrower tubes increase the resistance to gas flow, therefore the largest possible internal diameter should be used. --This is especially important during spontaneous ventilation where the patient’s own respiratory effort must overcome the tube’s resistance. --A size 4-mm tracheal tube has 16 times more resistance to gas flow than a size 8-mm tube. Usually, a size 8.5–9-mm internal diameter tube is selected for an average size adult male and a size 7.5–8-mm internal diameter tube for an average size adult female. --Paediatric sizes are determined on the basis of age and weight. --Tracheal tubes have both internal diameter (ID) and outside diameter (OD) markings.

8. -SIZE contd --There are various methods or formulae used to determine the size of paediatric tracheal tubes. A commonly used formula is: Internal diameter in mm = age in years/4 +4 --The length (taken from the tip of the tube) is marked in centimeters on the outside of the tube. --Black intubation depth markers located 3 cm proximal to the cuff can be seen in some designs. These assist the accurate placement of the tracheal tube tip within the trachea. --The vocal cords should be at the black mark in tubes with one mark, or should be between marks if there are two such marks. However, these are only rough estimates and correct tracheal tube position depth should always be confirmed by auscultation.

9. -ENDOTRACHEAL INTUBATION --Orotracheal --Nasotracheal INDICATIONS -1-For supporting ventilation in patient with pathological disease a-Upper airway obstruction b-Respiratory Failure c-Loss of consciousness -2-For supporting ventilation during General Anesthesia d-Type of surgery 1- near the airway 2-Thoracic or abdominal surgery 3-Prone or Lateral surgery 4-Long period of surgery e-Patient has risk of pulmonary aspiration f-Difficult Mask ventilation

10. -PREPARING FOR THE PROCEDURE INTUBATION --1-SUCTION:- This is extremely important. Often patients will have material in the pharynx making visualization of the vocal cords difficult --2-AIRWAY:- The oral airway is a device that lifts the tongue off the posterior pharynx often making it easier to mask ventilate a patient --3-AMBU BAG:- A source of oxygen with a delivery mechanism ( ambu – bag – Mask) must be available --4-LARYNGOSCOPE:- This lighted tool is very vital for placing an endotracheal tube --5-TUBE:- Endotracheal tubes come in many sizes. One has to prepare proper size

11. -INSTRUMENTS USED --1-Self - Refilling bag – valve combination (e.g Ambu bag) or Bag – Valve unit (Ayres bag) connector, tubing and oxygen source assemble all items before attempting intubation --2-Tincture of Benzoin and pre – cut tape --3-Introducer (Stylets or Magill's forceps) --4-Suction apparatus and catheter suction --5-Syringe 10 ml to inflate the cuff --6-Mucosal Anesthetics (e.g 2% lidocaine) --7-Water soluble sterile lubricant --8-Gloves

12. -TECHNIQUE -TPICAL ANESTHESIA:-Anesthetize the mucosa of the oropharynx and upper airway with lidocaine 2% If time permits and patient is awake -DIRECT LARYNGOSCOPY --1-Place the patient in the sniffing position (Flexion at the lower cervical spine and Extension at the Atlanto – occipital joint) --2-Check the Laryngoscope and blade for proper fit and make sure that the light works --3-Make sure that all materials are assembled and are close at hand --4-Open the patient’s mouth with the right hand, and remove any dentures --5-Grasp the Laryngoscope in the left hand --6-Spread the patient’s lips, and insert the blade between the teeth, being careful not to break a tooth --7-Pass the blade to the right of the tongue, and advance the blade into the Hypopharynx pushing the the tongue to the left --8-Lift the Laryngoscope upward and forward, without changing the angle of the blade to expose the vocal cords

13. -SNIFFING POSITION

14. - SNIFFING POSITION contd.

15. -COMPLICATIONS OF ENDOTRACHEAL INTUBATION -DURING INTUBATION --1-Trauma to Lip, Tongue or Teeth --2-Hypertension , Tachycardia or Arrythmia --3-Pulmonary Aspiration --4-Larynospasm --5-Bronchospasm --6-Laryngeal edema --7-Arytenoid dislocation ?? Hoarseness --8-Increased intracranial pressure --9-Spinal cord Trauma in spinal cord injury --10-Esophageal intubation

16. - COMPLICATIONS OF ENDOTRACHEAL INTUBATION --During remained intubation --1- Obstruction from kinking, secretion or over inflation of cuff --2- Accidental Extubation or Endobronchial intubation --3- Disconnection from breathing circuit --4- Pulmonary Aspiration --5- Lip or Nasal Ulcer in case of prolonged period of intubation --6- Sinusitis or Otitis in case with prolong Naso – Endo – Tracheal intubation

17. - COMPLICATIONS OF ENDOTRACHEAL EXTUBATION -DURING EXTUBATION --1-Laryngospasm --2-Pulmonary Aspiration --3-Edema of upper airway -AFTER EXTUBATION --1-Sore throat --2-Hoarseness --3-Tracheal stenosis --4-Laryngeal granuloma

18. -NASOTRACHEAL INTUBATION ADVANTAGES --1-Comfortable for prolong intubation in postoperative period --2-Suitable for a- oral surgery b-Tonsillectomy c-Mandible surgery --3-For Blind Nasal intubation --4-Can take oral feeding --5-Resist for kinking and difficult to accidental extubation DISADVANTAGES --1-Trauma to Nasal mucosa --2-Risk for sinusitis in prolonged intubation --3-Risk for Bacteremia --4-Smaller diameter then oral route ? Difficult for suction

19. -CONTRAINDICATIONS OF NASOTRACHEAL INTUBATION --1- Fracture base of skull --2- Coagulopathy --3- Nasal cavity obstruction --4- Retropharyngeal Abscess