Endotracheal
Intubation/Extubation
Upper Airway Anatomy (p. 158)
Visualization of Vocal Cords
Indications for Intubation
In conditions of, or leading to resp. failure,
such as; - trauma to the chest or
airway - neurologic involvement from
drugs myasthenia gravis, poisons, etc.
-CV involvement leading to CNS
impairment from strokes, tumors,
infection, pulmonary emboli -CP arrest
Indications (cont’d)
Relief of airway obstruction
Protection of airway (I.e. seizures)
Evacuation of secretions by tracheal
aspiration
Prevention of aspiration
Facilitation of positive press. ventilation
Relieving Airway Obstruction
Obstruction classified as upper ( above
the glottis and includes the areas of the
nasopharynx, oropharynx, and larynx) or
lower (below the vocal cords)
Can also be classified as partial or
complete obstruction
Causes include trauma, edema, tumors,
changes in muscle tone or tissue support
Hazards of tracheal tubes & cuffs
Infection
Trauma
Dehydration
Obstruction
Trauma
Hazards (cont’d)
Accidental intubation of the esophagus
or right mainstem bronchus
Bronchospasm, laryngospasm
Cardiac arrhythmias resulting from
stimulation of the vagus nerve
Aspiration pneumonia
Broken or loosened teeth
Later Complications of
Intubation
Paralysis of the tongue
Ulcerations of the mouth
Paralysis of the vocal cords
Tissue stenosis and necrosis of the
trachea
Routes for Intubation
Orotracheal
Nasotracheal
Tracheotomy
Oral Intubation
Advantages of Oral Intubation
Larger tube can be inserted
Tube can be inserted usually with more
speed and ease with less trauma
Easier suctioning
Less airflow resistance
Reduced risk of tube kinking
Disadvantages of Oral Intubation
Gagging, coughing, salivation, and
irritation can be induced with intact airway
reflexes
Tube fixation is difficult, self-extubation
Gastric distention from frequent
swallowing of air
Mucosal irritation and ulcerations of mouth
(change tube position)
Nasal Intubation
Advantages of Nasal Intubation
More comfort long term
Decreased gagging
Less salivation, easier to swallow
Improved mouth care
Better tube fixation
Improved communication
Disadvantages of Nasal Intub.
Pain and discomfort
Nasal and paranasal complications, I.e.,
epistaxis, sinusitis, otits
More difficult procedure
Smaller tube needed
Increased airflow resistance
Difficult suctioning
Bacteremia
Intubation Equipment
Endotracheal Tube and stylet
Laryngoscope
Sterile water-soluble jelly
Syringe to inflate cuff
Adhesive tape or tube fixation device
Bite block to prevent biting oral ET tube
Suction Equipment, bag- mask, O2
Local anesthetic
Stethoscope
Endotracheal Tube
Endotracheal Tube
ET tube size and depth of insertion (see
p. 594)
For children older than 2 years - tube
size = age/4 + 4 - depth = age/2 + 12
Adult - tube size female = 8.0, male =
9.0- depth female = 19-21 and 24-26
male = 21-23 and 26-28
Stylet
Light stylet (light wand)
Laryngoscope
Laryngoscope
Blade and handle
Blade - has a flange, spatula, light,
and tip - curved blade (Macintosh) -
straight blade (Miller, Wisconsin)
Fiber optic vs. traditional laryngoscope
Blade size: 0 - 1 infant, 2 from 2-8 years
3 from age 10 - adult, 4 large adult
Straight blade (Miller)
Curved blade (Macintosh)
Oral Intubation Procedure
Assemble and check equipment
- suction equipment
- laryngoscope
- select proper size tube, check tube
Position patient
- align mouth, pharynx, larynx
- “sniffing” position
Patient Positioning
Oral Intubation Proced. (cont’d.)
Preoxygenate the patient - bag-valve
mask - *intubation attempt should take no
longer than 30 sec, if unsuccessful,
then ventilate again with bag and
mask for 3-5 minutes
Insert laryngoscope - hold laryngoscope
in left hand & insert in right side of
mouth, displace tongue toward center
Oral procedure (cont’d.)
Visualize glottis and displace epiglottis
Oral proced. (cont’d.)
Insert ET tube - do not use laryngoscope
blade to guide tube - once you see
the tube pass the glottis, advance the cuff
passed the cords by 2 -3 cm
Hold tube with right hand and remove
laryngoscope & stylet - inflate cuff with 5 -
10 cc of air - ventilate with bag
Oral proced. (cont’d)
Inflate cuff with 5 - 10 cc of air
Ventilate with “bag”
Assess tube position - auscultation of
chest & epigastric - cm mark at teeth -
capnometry/colorimetry- light “wand”
Stabilize tube/Confirm placement - chest
x-ray
Extubation
Guidelines for extubation (see table, p.
613)
Cuff-leak test
Extubation Procedure
Assemble Equipment - intubation
equipment - in addition to intubation
equipment, O2 device and humidity,
SVN with racemic epi
Suction ET tube
Oxygenate patient
Unsecure tube, deflate cuff
Extubation proced. (cont’d.)
Place suction catheter down tube and
remove ET tube as you suction
Apply appropriate O2 and humidity
Assess/Reassess the patient