MHG1004-Lect 6-Assisting Dr in Definitive Airway Mx-intubation & extubation(8.8.2024).pdf

Assisting Dr in Definitive Airway Mx-intubation & extubation(8.8.2024).pdf

1. Ms Choy Kee Leong
Advanced Nursing Education
Programme (ANEP)
(9.8.2024)
MHG1004
Assisting Doctor in
Definitive Airway Management:
Intubation & Extubation
1

2. Definitive Airway
Establishing a definitive airway, defined
as a tube placed in the trachea with cuff
inflated below the vocal cords
2

3. Airway Management
Airway management includes a set of
manoeuvres and medical procedures performed
to prevent and relieve airway obstruction. This
ensures an open pathway for gas exchange
between a patient's lungs and the atmosphere.
... Airway management is commonly divided
into two categories: basic and advanced.
3

4. CRITICAL CARE I: Respiratory System
Assisting Doctor in Definitive Airway
Management:
Intubation
Extubation
4

5. Learning outcomes

At the end of lesson, students will be able to:
Define intubation and extubation
State the indications for intubation and
extubation
Assisting the intubation and extubation
procedure
Explain the complications of intubation and
extubation
Discuss nursing roles in intubation and
extubation

5

6. What is intubation?
Intubation is the placement of an
endotracheal tube in the trachea and is
the gold standard and method of choice
for establishment and maintenance of an
airway (Chethan and Hughes 2008).

6

7. What is intubation?
Intubation is defined as a technique
where a potent sedative or induction
agent is administered virtually
simultaneously with a paralyzing dose
of a neuromuscular blocking agent to
facilitate rapid tracheal intubation
by putting an artificial airway.

OBN Policy/Guidelines 2010
7

8. Endotracheal Intubation
Tube into trachea to provide ventilations
using BVM or ventilator
Sized based upon inside diameter (ID) in
mm
Lengths increase with increased ID (cm
markings along length)
Cuffed vs. Uncuffed
8

9. Endotracheal Intubation
Advantages:
Secures airway
Route for a few medications
Optimizes ventilation, oxygenation
Allows suctioning of lower airway
9

10. Endotracheal Intubation
Indications
Present or impending respiratory failure –
Worsening Respiratory Distress
Apnea / Prolonged apnoea
Unable to protect own airway
Inadequate ventilation
Worsening hypoxia, despite oxygen therapy


10

11. Indications for intubation:
Maintenance of patent airway / upper airway
obstruction

Airway obstruction: acute laryngeal edema – e.g.
inhalation burn, epiglottitis.

Anticipated loss of control of the airway:
anticipated laryngeal edema– e.g. neck trauma,
acute stridor etc.
Loss of gag/cough reflex: head injury with GCS <8
i.e. raised intracranial pressure (ICP) – to prevent
massive aspiration

11

12. Elective Intubation, i.e. following surgery,
(cardiac surgery) or prior to general anaesthesia
Trauma i.e. facial injuries
Resuscitation
12

13. Endotracheal Intubation
These are NOT Indications
Because I can intubate
Because they are unresponsive
Because I can’t show up at the hospital
without it
13

14. Endotracheal Intubation
Complications
Soft tissue trauma/bleeding
Dental injury
Laryngeal edema
Laryngospasm
Vocal cord injury
Barotrauma
Hypoxia
Aspiration
Esophageal intubation
Mainstem bronchus intubation
14

15. Endotracheal Intubation
Insertion Techniques
Orotracheal Intubation (Direct Laryngoscopy)
Blind Nasotracheal Intubation
Digital Intubation (Perform intubation
without a laryngoscope or a view of the
larynx/may be performed with or without a
bougie)



15

16. Intubation

Total time between
ventilations
should not exceed
30 seconds!

16

17. Intubation
Death occurs from failure to Ventilate,
not failure to Intubate
17

18. Rapid Sequence Intubation
(RSI)
Know the 7 P’s of RSI:
Preparation
Pre-oxygenation
Pre-treatment
Paralysis and Induction
Protection
Placement of the Tube
Post-intubation Management

18

19. Equipment and Materials
Laryngoscope and blade (appropriate size for
patient)
Proper size endotracheal tubes (include a
smaller endotracheal tube than previously in
place due to the possibility of laryngeal/tracheal
edema)
Syringe
Tape or tube fixation device

19

20. Intubation Equipment
Equipment
Laryngoscope Handle
(lighted) & Blades
Stylet / Bougie
Syringe
Magills Forceps
Lubricant
Suction (Yankauer
suction tip)
Bag Valve Mask (BVM)
Beck Airway Airflow
Monitor (BAAM -Blind
Nasal)
Selection
Typical Adult ET Tube
Sizes
Male - 8.0, 8.5, 9.0
Female - 7.0, 7.5, 8.0
Blade
Mac - 3 or 4
Miller - 3
Tube Depth
Usually 20 - 22 cm at
the teeth
20

21. Beck Airway Airflow Monitor –
For Nasotracheal Intubation
In order for blind nasotracheal intubation to be
successful it requires patient respiratory effort and air
exchange so that you can listen for air movement
from the end of the endotracheal tube.
BAAM - A device which when attached to a 15 mm
endotracheal tube adapter, magnifies airway-airflow
sounds, producing a whistling sound which greatly
aids in correct endotracheal tube placement.
BAAM device is only used in the Tube-before-Scope
approach.
21

22. Beck Airway Airflow Monitor

22
BAAM-
Bottom
BAAM-
Top
BAAM attached to the
15mm adaptor of an
endotracheal tube.

23. Equipment and Materials
Stylet/Bougie
Xylocaine jelly
Forceps
Scissors
Sterile gloves (2)
Suction
Suction catheters
Manual resuscitator and appropriately sized mask
Oxygen to be administered post extubation via mask/
nebulizer system
Racemic epinephrine

23

24. 24

25. Water Circuit for Ventilation
25

26. 26

27. Equipment: ETT (Adult)
27

28. 28

29. 29

30. Test the Function of ETT Cuff
30

31. Test the Function Of ETT
31

32. 32

33. 33

34. Murphy’s Eye
34

35. 35

36. Stylet/Bougie
36

37. Equipment: ETT (Pediatric)
37

38. Pediatric ET Intubation
Pediatric Equipment
Differences
Uncuffed tube < 8 years
old
Miller blade preferred
Tube Size
Premie: 2.0, 2.5
Newborn: 3.0, 3.5
1 year: 4
Then: (age/4)+4
Pediatric Differences
Anatomic Differences
Depth (cm)
Tube ID x 3
12 + (age/2)
easily dislodged
Intubation vs BVM
38

39. Positioning
Patient Positioning
Goal
Align 3 planes of view, so
Vocal cords are most
visible
T - trachea
P - Pharynx
O - Oropharynx
39

40. 40
Klchoy/Lect 7/Intubation &
Extubation/8.8.2018

41. 41

42. Assessment Acronym
M Mandible
O Opening
U Uvula
T Teeth / Tongue size
H Head/ Cervical spine
S Silhouette
42

43. Mallampati Score
Evaluates ability to visualize glottic
opening
Patient seated with neck extended
Open mouth as wide as possible
Protrude tongue as far as possible
Look at posterior pharynx
Grade based on visual field
Grades 1,2 have low intubation failure rates
Grades 3,4 have higher intubation failure rates
43

44. Mallampati Grades
 Difficulty 
Class I Class II Class III Class IV
44

45. Obstruction
Know or suspected
Foreign bodies
Tumors
Abscess
Epiglottitis
Hematoma
Trauma
45

46. 46

47. Glottic Opening
Cormack-Lehane
laryngoscopy grading
system

Grade 1 & 2 low
failure rates

Grade 3 & 4 high
failure rates


47

48. Tube Placement
From TRIPP, CPEM
48

49. Traditional Methods
Observation of ETT passing through
vocal cords.
Presence of breath sounds
Absence of epigastric sounds
Symmetric rise and fall of chest
Condensation in ETT
Chest Radiograph

49

50. Additional Methods
Pulse Oximetry
Aspiration Techniques
End Tidal CO
2
50

51. Pharmacologic Assisted
Intubation
Sedation
Reduce anxiety
Induce amnesia
Depress gag reflex, spontaneous breathing
Used for
induction
anxious, agitated patient
Contraindications
hypersensitivity
hypotension
51

52. Pharmacologic Assisted
Intubation
Common Medications for Sedation
Benzodiazepines (diazepam, midazolam)
Narcotics/opioid (fentanyl)
Anesthesia Induction Agents
Etomidate
Ketamine
Propofol (Diprivan
®
)

52

53. Pharmacologic Assisted
Intubation
Neuromuscular Blockade
Temporary skeletal muscle paralysis
Indications
When intubation required in patient
who:
•is awake,
•has gag reflex, or
•is agitated, combative
53

54. Pharmacologic Assisted
Intubation
Neuromuscular Blockade
Advantages:
Enables provider to intubate patients who
otherwise would be difficult, impossible to
intubate
Minimizes patient resistance to intubation
Reduces risk of laryngospasm
54

55. Pharmacologic Assisted
Intubation
Disadvantages:
Does not provide sedation, amnesia
Aspiration during procedure
Difficult to detect motor seizure activity
Side effects, adverse effects of specific drugs
55

56. Pharmacologic Assisted
Intubation
Common Used NMB Agents
Suxamethonium/succinylcholine
(Anectine
®
)
Vecuronium (Norcuron
®
)
Rocuronium (Zemuron
®
)
Pancuronium (Pavulon
®
)
56

57. Assist in ETT Intubation
57

58. Nursing Skills
Competent in intubation procedure, equipments,
mechanical ventilation, BLS/ACLS
Assessment and monitoring patient receiving the
medications
Dosing, indications, and use, actions, side effects
and contraindications of drug administered
Recognizing potential emergency situation and
appropriate nursing interventions



58

59. Nursing Skills
The procedure is performed and the
patient is monitored according to
accepted standards of practice
Emergency equipment and medications that
must be available immediately to the patient
receiving any medication
Closed monitoring and documentation


59

60. Procedure
 Pull bed out from wall to allow access.
 Ensure adequate lighting.
 Ensure continuous cardiac and oxygen
saturation monitoring.
 Patient is positioned supine with one pillow
under the head and is pre-oxygenated with
100% oxygen.
60

61. Procedure
Attach 20 ml syringe to pilot balloon cuff of ETT
and inflate cuff to check for leaks or faults,
deflate cuff fully. Avoid contaminating tube.
Fully insert connector, check for tight fit.

Check Dr’s preference re-lubrication. If so,
lubricate tube lightly and place it back in its bag
for Dr use. Take care that lubricant doesn’t
block the lumen of the tube.
61

62. Procedure
As drugs are being administered, watch monitor
for alteration in heart rate and observe pulse
oximeter for decreases in oxygen saturation.
Apply cricoid pressure if requested. Maintain
this pressure until asked to release.
Act as time-keeper once Dr. ceases oxygenation
and attempts to intubate. Warn at 60 seconds
if tube is not successfully positioned.
62

63. Procedure
Once tube is in place, inflate cuff and hand
ventilate patient whilst the Dr. checks air entry.
Release cricoid pressure as instructed.
Secure ETT by tying it with white cotton tape (or
adhesive tape - hyperfix)
Record ETT position/marking at lips (in
appropriate section of the flow chart)
Connect the ETT to the humidifier and ventilator.
Assess chest wall movement and auscultate for air
entry.
63

64. Intubation
64

65. Placement of Laryngoscope
65

66. Intubation Procedure
66

67. 67

68. 68

69. 69

70. 70

71. 71

72. Removal Of Stylet/Bougie Post
Insertion of ETT
72

73. 73

74. 74

75. Apply Cricoid Pressure
75

76. 76

77. Inflate the ETT Cuff
77

78. Inflate the ETT Cuff
78

79. Inflate the ETT Cuff
79

80. Cuff Pressure Manometer
80

81. Cuff Pressure Manometer
81

82. Secure ETT
82

83. Techniques in Securing ETT
83

84. Techniques in Securing ETT
84

85. Techniques in Securing ETT
85

86. 86

87. Assess the Position of ETT Marking
87

88. Techniques in Securing ETT
88

89. Connection of ETT to Ventilator Circuits
89

90. Nasotracheal ETT Intubation
90

91. Bronchoscopic Intubation
91

92. IMMEDIATE NURSING
INTERVENTIONS
Secure ETT firmly.

Inflate the ETT pilot cuff till the air leak sound
diminishes (cuff pressure of not > 20 cm H
2O).

Connect the ETT to bag-valve-mask and
perform hand ventilation.

R: Allow doctor to auscultate of ETT placement.

92

93. IMMEDIATE NURSING
INTERVENTIONS
Release cricoid pressure as ordered.

Connect ETT to the ventilator circuit tubing.

Confirm the ETT placement by:

Assess chest wall movement (symmetrical,
adequate rise & fall)

Auscultate for equal air entry into the lungs
(to rule out esophagus intubation)
93

94. IMMEDIATE NURSING
INTERVENTIONS
Watch for misting of the ETT.

Check the ETT marking at patient’s lip / teeth
level.

Monitor hemodynamic status - BP, HR, &
respiratory status (RR, pattern, SpO
2, EtCO
2).

Obtain ABG sampling at least 30 minutes after
intubation / any changes made on the ventilator
settings.
94

95. IMMEDIATE NURSING
INTERVENTIONS
Assess for signs of pulmonary pathology, e.g.,
pneumothorax / hypotension secondary to high
thoracic volume/pressure.

Perform ETT suctioning when indicated.

Obtain chest X-ray for confirmation of the depth
and ETT placement as ordered.

Document date of ETT insertion, ETT size and
marking, and ventilator settings.

95

96. Post intubation care
Auscultation of chest is performed to
check for equal air entry.

Clinical observation of chest movement:
 symmetrical
- adequate rise and fall
96

97. Post Intubation Care
ETT position is checked on CXR. Tube should
be below larynx and 2-4 cm above carina
(approximately level with the middle of the aortic
arch).

Once position confirmed, record level of tube at
lips on flowchart and in patient’ notes. Also
record date of ETT insertion.
97

98. Checked x-ray
98

99. Post intubation care
Use a cuff pressure gauge to check cuff pressure
each shift and PRN. The cuff should be inflated to
the extent that a seal in the trachea is achieved.
The pressure should be <25 cm H
2O to prevent
tracheal ischaemia.

Check tube is taped securely.

Ensure documentation of tube size and type.
99

100. 100

101. What Is Extubation?

Extubation is described as the
discontinuation of an artificial airway.

National Institute of Health
101

102. When To Extubate?
 Based on pulmonary assessment:
RR < 25/min
Spontaneous tidal volume greater than 5
ml/kg
Inspiratory force of at least –20 cm H
2O
Vital capacity at least 10 ml/kg

102

103. When To Extubate?
The patient has sustained arterial blood
gas values which have demonstrated a
consistent
PaO
2 greater than 60 mm Hg
FiO
2 of less than 0.5
PaCO
2 in the “normal” range
pH greater then 7.35.


103

104. When to extubate?
The patient has demonstrated
cardiovascular stability.

The patient has demonstrated an
appropriate mental status and ability to
protect his/her airway.


104

105. When to extubate?



SIMV Protocol
Switch to SIMV from assist mode or decrease RR
Begin with RR 8/min decrease SIMV rate by two
breaths per hour unless clinical deterioration
if assume to fail, increase SIMV rate to previous level,
until stable
if stable at least 1 hour of rate 0/ min extubate
in patient without respiratory disorders, decrease rate
with half an hour interval, 2 hr extubate
105

106. Precautions
Extubation should take place during a period of
the day when adequate physician, nursing and
therapist staffs are readily available.

Monitoring and continuous evaluation of the
patient are necessary as well as the presence of
skilled personnel who can reintubate the patient
is necessary.

106

107. Precautions
Prior to extubation, all of the equipment
necessary for reintubation should be available at
the bedside in case of acute decompensation.

Racemic epinephrine should be available for
aerosolization in case of acute airway edema
after extubation.

107

108. Don’t extubate too soon
Patients who are re-intubated increased
mortality over those who are not reintubated
Difficulty intubating trachea
Aspiration pneumonia
Laryngeal injury
Ischemia
108

109. Don’t extubate too late
Risk of nosocomial pneumonia is proportional
to number of days on ventilator
Tracheal injury from endotracheal tube cuff
Muscle weakening/atrophy
Unnecessary expense
109

110. What Did We Do Before We
Extubated Our Patient?
Ensured proper equipment needed for
reintubation
Monitoring BP, HR, SP02, RR
Turned off the propofol sedation
110

111. What Did We Do Before We
Extubated Our Patient?
We did not quantitatively evaluate his
tidal volume, thoracic compliance, pH,
breathing trial, etc…
We qualitatively evaluated several things
1. Stable hemodynamics
2. Able to protect airway
3. Able to exchange gases
111

112. 112

113. 113

114. 114

115. 115

116. Equipment and Materials
Laryngoscope and blades (appropriate size for
patient)
Proper size endotracheal tubes (include a
smaller endotracheal tube than previously in
place due to the possibility of laryngeal/tracheal
edema)
Syringe
Tape or tube fixation device

116

117. Equipment and Materials
Stylet
Xylocaine jelly
 Forceps
 Scissors
Sterile gloves (2)
 Suction
Suction catheters
Manual resuscitator and appropriately sized mask
Oxygen to be administered post extubation via mask/nebulizer
system
Racemic epinephrine

117

118. Procedure
There should be communication between
nursing and physician staff in order to
plan an appropriate time for extubation:

In optimal situations, two individuals will
extubate the patient-one with sterile gloves
suctioning the patient and the second person
hyperventilating the patient and removing the
endotracheal tube.

118

119. Procedure
Assemble the equipment listed in
Equipment/Materials.

Explain the procedure to the patient.

Place the patient in intermediate or high
Fowler’s position.

Wash hands thoroughly and don gloves and
mask.

119

120. Procedure
Prepare equipment:
Adjust the vacuum pressure so that it is
appropriate for the patient.

Select the appropriate suction catheter size
for the patient’s airway.

Obtain sterile gloves, syringe, and scissors.



120

121. Procedure
Hyperoxygenate the patient with 100% O2 prior
to extubation.

Remove tape or Tube Fixation System which
secures the endotracheal tube.

Suction the endotracheal tube adequately with
pre and post hyperoxygenation and then suction
the pharynx above the endotracheal tube cuff.

121

122. Procedure
Insert a new catheter into the trachea via the
endotracheal tube and instruct the patient to
breathe slowly and deeply.

Deflate the cuff or cut the pilot balloon.

Ask the patient to take a deep breath and to
cough, apply vacuum, and at the peak of
inspiratory effort, rapidly remove the tube.

122

123. Procedure
Administer humidified oxygen therapy.

Continue to evaluate the patient post
extubation for signs of respiratory
compromise.

123

124. Complications

Aspiration
Pneumothorax
Atelectasis
Respiratory failure related to
premature extubation. Anticipate
re-intubation
124

125. Extubation Failure
Defined as reintubation within 24-72h.
Incidence varies between 6-47% depending on
site, patient population.
Reintubated patients
Longer duration of ventilation
Higher mortality rate (30-40%)

higher odds ratio for nosocomial
pneumonia

125

126. Extubation Failure:
Pathophysiology
Upper airway oedema
Deconditioned Respiratory Muscles
Poor Nutrition
Decreased LOC
Inability to clear/copious airway
secretions
On-going critical illness
126

127. Extubation Failure Risk
Factors
Medical, Multidisciplinary, Paediatric Patient
Age >70
Continuous IV Sedation
Anemia (Hb<100, Hct<0.300)
Duration of ventilation
Positive Fluid Balance
Neurological Impairment
Self Extubation
127

128. Post Extubation Care

Record date and time of extubation

Continue to monitor & record vitals

Monitor for complication

Ascertain phonation (cords intact, the voice
will be rough)

Osculate breath sounds and document
findings as a base line

128

129. Post Extubation Care
Obtain ABG 30 minutes post extubation

Dr may request a chest X-ray

Encourage patient to deep breath and cough to
prevent atelectasis

After approximately 2 hrs dispose of tubing into
contaminated waste and return ventilator for
cleaning

129

130. Documentation
Document the suctioning and extubation
procedures
Patient toleration
Monitoring
ABG, vital signs

130

131. Summary:
Assisting ETT Intubation
131

132. Summary:
Assisting ETT Intubation
132

133. 133

134. 134

135. 135

136. 136

137. Questions?
137

138. Thank You
138