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Edit Comment Close Premium member Presentation Transcript ENDOTRACHEAL INTUBATION : ENDOTRACHEAL INTUBATION Dr. PREETI GEHLAUT JNMCH, Aligarh DEFINITION: : DEFINITION: Translaryngeal placement of endotracheal tube is called as endotracheal Intubation HISTORY : : HISTORY : 1555: Andreas Vesalius: described tracheal insufflation in animals. 1778: C Kite: described oral and nasal intubation for resuscitation of apparently drowned 1858: John Snow: intubation through tracheostomy to anaesthetize animals. 1878: William Macewan: Passed a tube from mouth to trachea, using finger as guide in conscious patient for removal of carcinoma of mouth. Through this tube he gave chloroform. Previously he used it for relief of obstruction in laryngeal diphtheria. Slide 4: M. Gracia (1805-1906), a singing teacher in London, pioneered indirect laryngoscopy with a mirror. 1895: Alfred Kierstein, 1912: Gustav Killian pioneered direct laryngoscopy 1899: Chevalier Jackson: did his first bronchoscopy and popularized direct laryngoscopy. Edgar Stanley Rowbotham (1890-1979) and Ivan Whiteside Magill (1888-1986) passed tracheal tube via laryngoscope. Edgar Stanley Rowbotham: did first blind nasal intubation Slide 5: 1928: Ralph Milton Waters and Arthur E. Guedel reintroduced Inflatable cuffs. Before days of muscle relaxant, blind nasal intubation was popular as it was quicker and did not required deep inhalational anaesthesia. The use of muscle relaxants to fascilitate intubation was pioneered by Bourne 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 AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: documented H/o difficult airway with H/o previous surgery burns trauma Congenital syndromes Acquired- tumors, in and around the oral cavity, neck or cervical spine INDIVIDUAL INDICES: DIFFICULT MASK VENTILATION : INDIVIDUAL INDICES: DIFFICULT MASK VENTILATION Beard Obesity: BMI > 30 kg/m²- ↑risk of DMV. Abnormality of teeth – artificial dentures or edentulous. Snorers Elderly PHYSICAL EXAMINATION INDICES: : PHYSICAL EXAMINATION INDICES: Assessment of cervical & atlanto-occipital joint function TMJ function the mandibular space Tests for assessing the adequacy of the oropharynx for L&I , MP grading. Assessment for quality of glottic viewing during laryngoscopy AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: Interincisor gap : normal ≥ 5 cms AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: Mallampati classification: Class 3,4 - may be difficult intubation AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: grade 3,4 - ↑ risk for difficult intubation Laryngoscopic view AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: Thyromental distance > 6 cms AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: Flexion and extension of neck Sternomental distance >12 cm AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: Movement of temperomandibular joint (TMJ) Grinding GROUP INDICES: : GROUP INDICES: Wilson Scoring System. Rockes assessment of obstetrical patient. Benumofs 11 parameter analysis. Rapid airway assessment(1-2-3) EQUIPMENT PREPARATION : EQUIPMENT PREPARATION Slide 20: 1) LARYNGOSCOPE : handle & blade LARYNGOSCOPIC BLADE: : LARYNGOSCOPIC BLADE: Macintosh (curved) and Miller (straight) blade Adult : Macintosh blade small children : Miller blade Slide 22: 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 25: 3) ETT 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 27: 4) BEVEL 5) MURPHY’S EYE Slide 28: 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 30: OROPHARYNGEAL OR NASOPHARYNGEAL AIRWAY Slide 31: SUCTION: CATHETER & MACHINE Slide 32: FACE MASK & SELF INFLATING BAG MAGILL FORCEPS LOCAL ANAESTHETIC SPRAY : LOCAL ANAESTHETIC SPRAY Slide 35: Syringe Lubricating jelly Dynaplast/ tape to strap endotracheal tube Monitoring success of intubation: Stethoscope Endtidal - CO2 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 : SNIFFING 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-spineInjury : In Case of Suspected C-spineInjury Trauma chin lift Trauma jaw thrust STEPS OF OROENDOTRACHEAL INTUBATION : STEPS OF OROENDOTRACHEAL 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 b/l 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: CONTD. : PRIMARY CONFIRMATION: CONTD. 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 (^). NASOENDOTRACHEAL INTUBATION : NASOENDOTRACHEAL INTUBATION NASOTRACHEAL INTUBATION TECHNIQUE : NASOTRACHEAL INTUBATION TECHNIQUE Check for nasal patency Topical lidocaine or phenylephrine should be applied to the nasal passages 10 -15 min before. Generously lubricate the nares and ETT Select ETT 0.5-1.0mmID smaller than that recommended for orotracheal intubation. ETT should be advanced through the nose directly backward toward the nasopharynx NASOTRACHEAL INTUBATION TECHNIQUE : NASOTRACHEAL INTUBATION TECHNIQUE Loss of resistance marks the entrance into the oropharynx Laryngoscope and Magill forceps can be used to guide the endotracheal tube into the trachea under direct vision For awake spontaneous breathing patients, the blind technique can be used NASOTRACHEAL INTUBATION : NASOTRACHEAL INTUBATION Advantages 1) Comfortable for prolong intubation in postoperative period. 2) Suitable for oral surgery: tonsillectomy , mandible surgery. 3) Less salivation, easier to swallow. 4) Decreased gagging. 5) Less kinking and difficult to accidental extubation. 6)Improved mouth care. Disadvantages: : Disadvantages: 1) Trauma to nasal mucosa 2) Trauma to nasopharynx 3) Risk of sinusitis on prolong intubation 4) Risk for bacteremia 5) Smaller diameter and longer than oral route - difficult for suction,increased resistance and work of breathing. 6) ETT cuff can be damaged / torn CONTRAINDICATIONS: (NTI) : CONTRAINDICATIONS: (NTI) 1) Fracture base of skull 2) Coagulopathy 3) Nasal cavity obstruction 4) Nasal fracture 5) DNS COMPLICATION OF ET INTUBATION : COMPLICATION OF ET INTUBATION 1) During intubation Trauma to lip, tongue or teeth Hypertension, tachycardia or arrhythmia Pulmonary aspiration Laryngospasm Bronchospasm Arytenoid dislocation - hoarseness Increased intracranial pressure Spinal cord trauma in cervical spine injury Esophageal intubation Endobronchial intubation COMPLICATIONS OF ET INTUBATION (CON’T) : COMPLICATIONS OF ET INTUBATION (CON’T) Obstruction from klinking , secretion or over inflation of cuff Accidental extubation Endobronchial intubation Disconnection from breathing circuit Pneumothorax 2) While intubated: COMPLICATION OF ET INTUBATION(CON’T) : COMPLICATION OF ET INTUBATION(CON’T) 2) While intubated: Pulmonary aspiration Lib or nasal ulcer in case with prolong period of intubation Sinusitis or otitis in case with prolong nasoendotracheal intubation COMPLICATION OF ET INTUBATION(CON’T) : COMPLICATION OF ET INTUBATION(CON’T) 3) During extubation Laryngospasm Pulmonary aspiration Edema of upper airway COMPLICATION OF ET INTUBATION(CON’T) : COMPLICATION OF ET INTUBATION(CON’T) 4) After extubation Sore throat Hoarseness Tracheal stenosis (Prolong intubation) Laryngeal granuloma CONCERNS IN TRAUMA PATIENT : CONCERNS IN TRAUMA PATIENT CONCERNS IN PEDIATRIC PATIENTS: : CONCERNS IN PEDIATRIC PATIENTS: PEDIATRIC PTS: : PEDIATRIC PTS: Slide 77: Paediatric airway CONCERNS IN PREGNANT PATIENTS: : CONCERNS IN PREGNANT PATIENTS: PROBLEMS ENCOUNTERED: : PROBLEMS ENCOUNTERED: Weight gain Large breasts Upper airway edema & congestion Reduced FRC Increased rate of O2 consumption ↑ risk of regurgitation & aspiration- lower LES tone & ↑ intra abdominal pressure Difficult bag mask ventilation Incidence of failed intubation: General population – 1 in 2230 Obstetric pt - 1 in 280 HELPFUL MEASURES: : HELPFUL MEASURES: 1)Keep alternative airway equipment: Stubby handle or polio blade laryngoscope Detach, insert & reattach the blade of laryngoscope Always keep smaller size cuffed tubes ready (6.5mm) Keep LMA handy: proseal ,size 3 & 4 In case CVCI occurs 2)Trained assistant- Well drilled in application of sellick’s maneuver Two handed bag mask tecnique THANK YOU : THANK YOU You do not have the permission to view this presentation. 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Endotracheal Intubation preetigehlaut Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: (To copy code, click on the text box) Embed: URL: Thumbnail: WordPress Embed Customize Embed The presentation is successfully added In Your Favorites. Views: 3053 Category: Science & Tech.. License: All Rights Reserved Like it (5) Dislike it (1) Added: August 20, 2010 This Presentation is Public Favorites: 2 Presentation Description No description available. Comments Posting comment... By: anceline (7 month(s) ago) Respected Sir kindly send me thisETintubation ppt to my email. Thank you sranceline@hotmail.com Saving..... Post Reply Close Saving..... Edit Comment Close By: dhammdeepkadam (9 month(s) ago) Good one mam Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript ENDOTRACHEAL INTUBATION : ENDOTRACHEAL INTUBATION Dr. PREETI GEHLAUT JNMCH, Aligarh DEFINITION: : DEFINITION: Translaryngeal placement of endotracheal tube is called as endotracheal Intubation HISTORY : : HISTORY : 1555: Andreas Vesalius: described tracheal insufflation in animals. 1778: C Kite: described oral and nasal intubation for resuscitation of apparently drowned 1858: John Snow: intubation through tracheostomy to anaesthetize animals. 1878: William Macewan: Passed a tube from mouth to trachea, using finger as guide in conscious patient for removal of carcinoma of mouth. Through this tube he gave chloroform. Previously he used it for relief of obstruction in laryngeal diphtheria. Slide 4: M. Gracia (1805-1906), a singing teacher in London, pioneered indirect laryngoscopy with a mirror. 1895: Alfred Kierstein, 1912: Gustav Killian pioneered direct laryngoscopy 1899: Chevalier Jackson: did his first bronchoscopy and popularized direct laryngoscopy. Edgar Stanley Rowbotham (1890-1979) and Ivan Whiteside Magill (1888-1986) passed tracheal tube via laryngoscope. Edgar Stanley Rowbotham: did first blind nasal intubation Slide 5: 1928: Ralph Milton Waters and Arthur E. Guedel reintroduced Inflatable cuffs. Before days of muscle relaxant, blind nasal intubation was popular as it was quicker and did not required deep inhalational anaesthesia. The use of muscle relaxants to fascilitate intubation was pioneered by Bourne 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 AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: documented H/o difficult airway with H/o previous surgery burns trauma Congenital syndromes Acquired- tumors, in and around the oral cavity, neck or cervical spine INDIVIDUAL INDICES: DIFFICULT MASK VENTILATION : INDIVIDUAL INDICES: DIFFICULT MASK VENTILATION Beard Obesity: BMI > 30 kg/m²- ↑risk of DMV. Abnormality of teeth – artificial dentures or edentulous. Snorers Elderly PHYSICAL EXAMINATION INDICES: : PHYSICAL EXAMINATION INDICES: Assessment of cervical & atlanto-occipital joint function TMJ function the mandibular space Tests for assessing the adequacy of the oropharynx for L&I , MP grading. Assessment for quality of glottic viewing during laryngoscopy AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: Interincisor gap : normal ≥ 5 cms AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: Mallampati classification: Class 3,4 - may be difficult intubation AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: grade 3,4 - ↑ risk for difficult intubation Laryngoscopic view AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: Thyromental distance > 6 cms AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: Flexion and extension of neck Sternomental distance >12 cm AIRWAY ASSESSMENT: : AIRWAY ASSESSMENT: Movement of temperomandibular joint (TMJ) Grinding GROUP INDICES: : GROUP INDICES: Wilson Scoring System. Rockes assessment of obstetrical patient. Benumofs 11 parameter analysis. Rapid airway assessment(1-2-3) EQUIPMENT PREPARATION : EQUIPMENT PREPARATION Slide 20: 1) LARYNGOSCOPE : handle & blade LARYNGOSCOPIC BLADE: : LARYNGOSCOPIC BLADE: Macintosh (curved) and Miller (straight) blade Adult : Macintosh blade small children : Miller blade Slide 22: 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 25: 3) ETT 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 27: 4) BEVEL 5) MURPHY’S EYE Slide 28: 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 30: OROPHARYNGEAL OR NASOPHARYNGEAL AIRWAY Slide 31: SUCTION: CATHETER & MACHINE Slide 32: FACE MASK & SELF INFLATING BAG MAGILL FORCEPS LOCAL ANAESTHETIC SPRAY : LOCAL ANAESTHETIC SPRAY Slide 35: Syringe Lubricating jelly Dynaplast/ tape to strap endotracheal tube Monitoring success of intubation: Stethoscope Endtidal - CO2 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 : SNIFFING 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-spineInjury : In Case of Suspected C-spineInjury Trauma chin lift Trauma jaw thrust STEPS OF OROENDOTRACHEAL INTUBATION : STEPS OF OROENDOTRACHEAL 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 b/l 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: CONTD. : PRIMARY CONFIRMATION: CONTD. 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 (^). NASOENDOTRACHEAL INTUBATION : NASOENDOTRACHEAL INTUBATION NASOTRACHEAL INTUBATION TECHNIQUE : NASOTRACHEAL INTUBATION TECHNIQUE Check for nasal patency Topical lidocaine or phenylephrine should be applied to the nasal passages 10 -15 min before. Generously lubricate the nares and ETT Select ETT 0.5-1.0mmID smaller than that recommended for orotracheal intubation. ETT should be advanced through the nose directly backward toward the nasopharynx NASOTRACHEAL INTUBATION TECHNIQUE : NASOTRACHEAL INTUBATION TECHNIQUE Loss of resistance marks the entrance into the oropharynx Laryngoscope and Magill forceps can be used to guide the endotracheal tube into the trachea under direct vision For awake spontaneous breathing patients, the blind technique can be used NASOTRACHEAL INTUBATION : NASOTRACHEAL INTUBATION Advantages 1) Comfortable for prolong intubation in postoperative period. 2) Suitable for oral surgery: tonsillectomy , mandible surgery. 3) Less salivation, easier to swallow. 4) Decreased gagging. 5) Less kinking and difficult to accidental extubation. 6)Improved mouth care. Disadvantages: : Disadvantages: 1) Trauma to nasal mucosa 2) Trauma to nasopharynx 3) Risk of sinusitis on prolong intubation 4) Risk for bacteremia 5) Smaller diameter and longer than oral route - difficult for suction,increased resistance and work of breathing. 6) ETT cuff can be damaged / torn CONTRAINDICATIONS: (NTI) : CONTRAINDICATIONS: (NTI) 1) Fracture base of skull 2) Coagulopathy 3) Nasal cavity obstruction 4) Nasal fracture 5) DNS COMPLICATION OF ET INTUBATION : COMPLICATION OF ET INTUBATION 1) During intubation Trauma to lip, tongue or teeth Hypertension, tachycardia or arrhythmia Pulmonary aspiration Laryngospasm Bronchospasm Arytenoid dislocation - hoarseness Increased intracranial pressure Spinal cord trauma in cervical spine injury Esophageal intubation Endobronchial intubation COMPLICATIONS OF ET INTUBATION (CON’T) : COMPLICATIONS OF ET INTUBATION (CON’T) Obstruction from klinking , secretion or over inflation of cuff Accidental extubation Endobronchial intubation Disconnection from breathing circuit Pneumothorax 2) While intubated: COMPLICATION OF ET INTUBATION(CON’T) : COMPLICATION OF ET INTUBATION(CON’T) 2) While intubated: Pulmonary aspiration Lib or nasal ulcer in case with prolong period of intubation Sinusitis or otitis in case with prolong nasoendotracheal intubation COMPLICATION OF ET INTUBATION(CON’T) : COMPLICATION OF ET INTUBATION(CON’T) 3) During extubation Laryngospasm Pulmonary aspiration Edema of upper airway COMPLICATION OF ET INTUBATION(CON’T) : COMPLICATION OF ET INTUBATION(CON’T) 4) After extubation Sore throat Hoarseness Tracheal stenosis (Prolong intubation) Laryngeal granuloma CONCERNS IN TRAUMA PATIENT : CONCERNS IN TRAUMA PATIENT CONCERNS IN PEDIATRIC PATIENTS: : CONCERNS IN PEDIATRIC PATIENTS: PEDIATRIC PTS: : PEDIATRIC PTS: Slide 77: Paediatric airway CONCERNS IN PREGNANT PATIENTS: : CONCERNS IN PREGNANT PATIENTS: PROBLEMS ENCOUNTERED: : PROBLEMS ENCOUNTERED: Weight gain Large breasts Upper airway edema & congestion Reduced FRC Increased rate of O2 consumption ↑ risk of regurgitation & aspiration- lower LES tone & ↑ intra abdominal pressure Difficult bag mask ventilation Incidence of failed intubation: General population – 1 in 2230 Obstetric pt - 1 in 280 HELPFUL MEASURES: : HELPFUL MEASURES: 1)Keep alternative airway equipment: Stubby handle or polio blade laryngoscope Detach, insert & reattach the blade of laryngoscope Always keep smaller size cuffed tubes ready (6.5mm) Keep LMA handy: proseal ,size 3 & 4 In case CVCI occurs 2)Trained assistant- Well drilled in application of sellick’s maneuver Two handed bag mask tecnique THANK YOU : THANK YOU