endotracheal intubation basic

ENDOTRACHEAL INTUBATION: 

ENDOTRACHEAL INTUBATION By : Vonreza V. Miranda

DEFINITION:: 

DEFINITION: Translaryngeal placement of endotracheal tube is called as endotracheal Intubation

INDICATIONS:: 

INDICATIONS: Respiratory Failure: Hypoxia, Hypercapnia, tachypnea, or apnea ; ie. ARDS, asthma, pulmonary edema, infection, COPD exacerbation Inability to ventilate unconscious patient Maintenance or protection of an intact airway Cardiac Arrest Medication administration

INDICATIONS:: 

INDICATIONS: For supporting ventilation during general anesthesia Type of surgery Operative site near the airway Abdominal or thoracic surgery Prone or lateral position Long period of surgery Patient has risk of pulmonary aspiration

EQUIPMENT PREPARATION: 

EQUIPMENT PREPARATION

Slide 7: 

1) LARYNGOSCOPE : handle & blade

LARYNGOSCOPIC BLADE:: 

LARYNGOSCOPIC BLADE : Macintosh (curved) and Miller (straight) blade Adult : Macintosh blade small children : Miller blade Mc coy blade Miller Macintosh blade

Slide 9: 

2) ENDOTRACHEAL TUBE :

TYPES OF ETTs:: 

TYPES OF ETTs: 1) Portex tubes : Semirigid , with little tendency to kink. Most commonly used. 2) Rubber tubes: Soft, easily kinked. 3) Reinforced tubes : - Cuffed or non cuffed. Reinforced with wire to prevent kinking. 4) Special tubes: Double lumen ( Robertshaw

ENDOTRACHEAL TUBE: (ETT): 

ENDOTRACHEAL TUBE : (ETT) Male : ID 8.0 mms Female : ID 7.5 mms New born - 3 mths : ID 3.0 mms 3-9 months : ID 3.5 mms 9-18 months : ID 4.0 mms 2- 6 yrs : ID = ( Age/3 ) + 3.5 > 6 yrs : ID = (Age/4) + 4.5 1) Size of ETT : internal diameter (ID)

Slide 12: 

3) ETT CUFF High volume Low pressure cuff Low volume High pressure cuff 2) MATERIAL : Red rubber or PVC

ETT CUFF:: 

ETT CUFF: cuff inflating system consisting of: valve, balloon, inflating tube & cuff. Uncuffed tubes used in children to minimise pressure injury Purpose of cuff is: seal between tube & trachea Protect from aspiration of blood, mucus or vomitus .

Slide 14: 

4) BEVEL 5) MURPHY’S EYE

Slide 15: 

6) Depth of insertion : Midtrachea or below vocal cord~2 cm Adult Male ~23 cm Female ~21 cm Children Oral ETT = (Age/2) + 12 (cm) Nasal ETT = (Age/2) + 15 (cm)

OTHER EQUIPMENTS:: 

OTHER EQUIPMENTS : STYLET (malleable)

Slide 17: 

OROPHARYNGEAL OR NASOPHARYNGEAL AIRWAY Oral airway Nasal airway

Slide 18: 

FACE MASK & SELF INFLATING BAG MAGILL FORCEP S

LOCAL ANAESTHETIC SPRAY: 

LOCAL ANAESTHETIC SPRAY

OTHERS:: 

OTHERS: Suction Machine Syringe 10mL Lubricating jelly Dynaplast / tape to strap endotracheal tube Monitoring success of intubation : Stethoscope Endtidal - CO 2 Pulse oximeter

PREOXYGENATION:: 

PREOXYGENATION: ventilate with 100 % oxygen for approximately 3 min Position bed / table height: bring the patient's head to naval height

SNIFFING POSITION: 

S NIFFING POSITION Extension at atlanto-occipital joint Flexion at lower cervical spine Neck flexion is maintained by placing a few inches of padding behind the head

Sniffing position: 

Sniffing position

IN CASE OF SUSPECTED C-SPINE INJURY: 

IN CASE OF SUSPECTED C-SPINE INJURY Trauma chin lift Trauma jaw thrust

STEPS OF ENDOTRACHEAL INTUBATION: 

STEPS OF ENDOTRACHEAL INTUBATION

BAG MASK VENTILATION: 

BAG MASK VENTILATION Thumb and index finger of left hand in the shape of a “C” press down The other 3 fingers at the inferior ramus of the mandible and lift the mandible up (jaw thrust) “E” C E

HOLDING A LARYNGOSCOPE: 

HOLDING A LARYNGOSCOPE Hold the handle of the laryngoscope with your left hand

OPEN MOUTH TECHNIQUES: 

OPEN MOUTH TECHNIQUES Hyper-extension technique (no touch technique) Cross fingers techniques

INTUBATION TECHNIQUE: 

INTUBATION TECHNIQUE introduce the blade into the right side of the patient's mouth move the blade posteriorly and toward the midline, sweeping the tongue to the left and keeping it away from the visual path with the flange of the blade ensure the lower lip is not being pinched by the lower incisors and laryngoscope blade advance the laryngoscope until the epiglottis is in view

INSERTING THE BLADE: 

INSERTING THE BLADE

INTUBATION TECHNIQUE: 

INTUBATION TECHNIQUE lift the laryngoscope upward and forward insert the ETT from the right angle of mouth with its concave curve facing downward and to the right side of the patient maneuver the endotracheal tube into the larynx, midway between the cricoid cartilage and the sternal angle

LIFTING UP A LARYNGOSCOPE:: 

LIFTING UP A LARYNGOSCOPE: Pull the blade forward and upward using firm but Steady pressure without rotating the wrist Avoid leaning on the upper teeth with the blade

EXPOSURE OF THE LARYNX:: 

EXPOSURE OF THE LARYNX: In most situations vocal cords should become visible If not, exert gentle pressure over the cricoid area to help bring them into view

BURP Maneuver:: 

BURP Maneuver: ON THYROID CARTILAGE Backward: against the cervical Vertebrae Upward Right: lateral pressure to the right

ROLE OF AN ASSISTANT : 

ROLE OF AN ASSISTANT To provide the endotracheal tube to the operator’s right hand To apply circoid pressure Facilitates intubation using BURP maneuver

INTUBATION TECHNIQUE: 

INTUBATION TECHNIQUE inflate the cuff and apply positive pressure ventilation while the assistant auscultates secure the endotracheal tube in position after bilateral equal air entry is confirmed

HOW TO CONFIRM THE CORRECT PLACEMENT OF ETT?: 

HOW TO CONFIRM THE CORRECT PLACEMENT OF ETT? Primary Confirmation Secondary Confirmation

PRIMARY CONFIRMATION : BY PHYSICAL EXAM: 

PRIMARY CONFIRMATION : BY PHYSICAL EXAM Confirm tube placement immediately Listen over the epigastrium and observe the chest wall for movement If stomach gurgling and no chest wall expansion – esophagus intubated: deflate the cuff and remove ET tube Reattempt intubation after re -oxygenation

PRIMARY CONFIRMATION:: 

PRIMARY CONFIRMATION: If chest wall rises and stomach not gurgling, perform 5-point auscultation If still doubt, use laryngoscope to see the tube passing through the vocal cords (best) Secure the tube Look for moisture condensation on the inside of the tracheal tube (not 100%: false +ve with esophageal intubations)

SECONDARY CONFIRMATION : 

SECONDARY CONFIRMATION End-Tidal CO2 Detectors Commercial device that reacts with a color change to CO2 exhaled from the lungs: Qualitative detection device indicates exhaled CO2 indicates proper tracheal tube placement Absence of CO2 (unless prolonged CPR), indicates esophageal intubation False +ve: Distended stomach, carbonated beverages False - ve: Low or no blood flow states

Endotracheal tube(ET) trachea, endotracheal tube (arrows) and location of carina (^). : 

Endotracheal tube(ET) trachea, endotracheal tube (arrows) and location of carina (^).

Slide 42: 

THANK YOU