INTUBATION REVIEW

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INTUBATIONREVIEW

• SFC HILL

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Advantages/Complications of Tracheal Intubation
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Advantages of tracheal intubations

• Airway patency
• Protects the airway
• Maintains patency during positioning
• Control of ventilation
• ventilation over a long period of time without
  intubation can lead to gastric distention and
  regurgitation

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Advantages of tracheal intubations

• Route for inhalation anesthesia and emergency
  medications
• N - Narcan
• A - Atropine
• L - Lidocaine
• E - Epinephrine

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Complications of tracheal intubation

• Trauma to the lips, teeth, and soft tissues of
  the airway.
• Awareness
• meticulous technique
• Bronchial intubation
• frequent complication
• auscultation of the chest bilaterally

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Complications of tracheal intubations

• Laryngospasm
• common when extubation is done when the patient
  is in a semiconscious state
• extubation should be done in a relatively deep
  anesthesia or when the protective laryngeal
  reflex has returned
• Postintubation hoarseness and sore throat
• due to mechanical presence of the tracheal tube

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Preparation of Equipment

• Assemble pharyngeal airways in assorted sizes
• Nasopharyngeal
• Oropharyngeal
• Inspect laryngoscope for serviceability
• Batteries
• Light bulb
• Blades curved/straight (Macintosh or Miller)

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Selection of laryngoscope blade (preference)

• Macintosh is a curved blade whose tip is inserted
  into the vallecula (the space between the base of
  the tongue and the pharyngeal surface of the
  epiglottis). Most adults require a Macintosh
  number 3 or 4 blade.

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Selection of laryngoscope blade (preference)

• Miller is a straight blade that is passed so that
  the tip of the blade lies beneath the laryngeal
  surface of the epiglottis. The epiglottis is
  then lifted to expose the vocal cords. Most
  adults require a Miller number 3 blade.

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Preparation of Equipment -Inspect endotracheal
tubes

• Tube size
• adult male 8 mm to 9 mm tube
• adult female 7 mm to 8 mm tube
• Tube length- extend from the lower incisor to a
  point midway between the cricoid cartilage and
  Louis's angle (the sternal angle) on the patient
• Endotracheal tube cuff

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Preparation of Equipment

• Malleable stylet (should not extend past Murphy's
  eye)
• Lubrication
• Laryngeal sprays

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Inspect resuscitator (AMBU bag) for serviceability

• Bag
• Mask
• Intake valve
• Valve body with relief valve

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Inspect stethoscope

• Diaphragm
• Earpieces
• Tubing

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Gather and prepare all equipment necessary for an
emergency Airway

• Scalpel handle
• Surgical blades
• Curved hemostats
• Endotracheal tube
• Syringe

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Intubation Technique

• ventilate with 100 percent oxygen for
  approximately 1 min
• Position bed height to bring the patient's head
  to a mid-abdominal height
• Flex the cervical spine and extend the head at
  the atlanto-occipital joint
• Long axis of the oral cavity, pharynx, and
  trachea lie almost in a straight line

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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

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Intubation Technique

• lift the laryngoscope upward and forward
• insert the endotracheal tube from the right 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

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Intubation Technique

• inflate the cuff and apply positive pressure
  ventilation while the assistant auscultates
• secure the endotracheal tube in position

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Curved Blade Technique

• The curved blade technique is essentially
  similar. The only difference being when the
  epiglottis is in view, advance the tip of the
  laryngoscope blade into the vallecula, formed by
  the base of the tongue and the epiglottis lift
  upward and forward.

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Nasotracheal intubation technique

• topical lidocaine or phenylephrine should be
  applied to the nasal passages
• 0.5-1.0 Neosynephrine and 4 Lidocaine, mixed
  11 should also give satisfactory results
• generously lubricate the nares and endotracheal
  tube
• ET tube should be advanced through the nose
  directly backward toward the nasopharynx

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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

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Confirmation of tracheal intubation

• Direct visualization of the ET tube passing
  through the vocal cords
• CO2 in exhaled gases
• Bilateral breath sounds
• Absence of air movement during epigastric
  auscultation

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Confirmation of tracheal intubation

• Condensation (fogging) of water vapor in the tube
  on exhalation
• Refilling of reservoir bag during exhalation
• Maintenance of arterial oxygenation
• Chest X-ray the tip of the ET tube should be
  between the carina and thoracic arc or
  approximately at the level of the aortic arch

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Extubation

• ensure that the patient is recovering is
  breathing spontaneously with adequate volumes
• evaluate the patient's ability to protect his
  airway by observing whether the patient responds
  appropriately to verbal commands

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Extubation steps

• Oxygenate patient with 100 percent high flow O2
  for 2 to 3 minutes
• if secretions are suspected in the
  tracheobronchial tree, remove them with a suction
  catheter through the lumen of the endotracheal
  tube
• ensure that the patient is not in a semiconscious
  state

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Extubation steps

• turn the patient onto his side if he is still
  unconscious
• unsecure the endotracheal tube from the patient's
  face
• deflate the cuff and remove the endotracheal tube
  quickly and smoothly during inspiration
• continue to give the patient O2 as required