ENDOTRACHEAL INTUBATION ,INDICATION, PROCEDURE
- 1. ENDOTRACHEAL INTUBATION INTRODUCTION: Endotracheal intubation (ETI) is an advanced airway procedure where an orotracheal tube is placed under direct vision through the larynx into the trachea. It has the advantage of providing a protected airway whilst enabling ventilation, a route for oxygenation andsuctioning. Intubation is the process of inserting a breathing tube (endotracheal tube) into the windpipe (trachea) either through mouth or nose for administration of oxygen, for mechanical ventilation support or for general anesthesia. Anaesthesia is usually administered to reduce discomfort during the procedure. Occasionally, endotracheal tube is inserted with the assistance of a device called bronchoscope while the patient is kept awake. In this situation local anaesthetic is administered to patient’s nasal or oral passage before insertion of the bronchoscope and endotracheal tube into the trachea. 1
- 2. INDICATIONS FOR INTUBATION: 1. Inadequate oxygenation (decreased arterial PO2) that is not corrected by supplemental oxygen via mask/nasal. 2. Inadequate ventilation (increased arterial PCO2). 3. Need to control and remove pulmonary secretions. 4. Any patient in cardiac arrest. 5. Ant patient in deep coma who cannot protect his airway.(Gag reflex absent.). 6. Any patient in imminent danger of upper airway obstruction (e.g. Burns of the upper airways). 7. Any patient with decreased L.O.C, GCS <= 8. 8. Severe head and facial injuries with compromised airway. 9. Any patient in respiratory arrest 10. Respiratory failure 1. Hypoventilation/Hypercarbia A. Paco2 > 55mmhg 2. Arterial hypoxemia Refractory to O2 A. Paco2 < 70 on 100% O2 CONTRAINDICATIONS FOR INTUBATION 1. Patients with an intact gag reflex. 2. Patients likely to react with laryngospasm to an intubation attempt. e.g. Children with epiglottitis. 3. Basilar skull fracture – avoid naso-tracheal intubation and nasogastric/pharyngeal tube. COMPLICATIONS ASSOCIATED WITH INTUBATION: 1. Trauma of the teeth, cords, arytenoid cartilages, larynx and related structures. 2
- 3. 2. Nasotracheal tubes can damage the turbinates, cause epistaxis, and even perforate the nasopharyngeal mucosa. 3. Hypertension and tachycardia can occur from the intense stimulation of intubation; This is potentially dangerous in the patient with coronary heart disease. 4. Transient cardiac arrhythmias related to vagal stimulation or sympathetic nerve traffic may occur. 5. Damage to the endotracheal tube cuff, resulting in a cuff leak and poor seal. 6. Intubation of the esophagus, resulting in gastric distention and regurgitation upon attempting ventilation. 7. Baro-trauma resulting from over ventilating with a bag without a pressure release valve (phneumothorax). 8. Over stimulation of the larynx resulting in laryngospasm, causing a complete airway obstruction. 9. Inserting the tube to deep resulting in unilateral intubation (right bronchus). 10. Tube obstruction due to foreign material, dried respiratory secretion and/or blood. EQUIPMENT SALT: suction, airway, laryngoscope, tube 1. Self-refilling bag-valve combination (Ambu bag), connector, tubing and oxygen source 2. Laryngoscope with curved (Macintosh) and straight (Miller)*3.ET-T (several different sizes) 4. Oral airways 5. Tincture of benzoin and precut tape 6. Introducer (stylets or Magill forceps) 7. Suction apparatus 3
- 4. 8. Syringe 10 ml. to inflate the cuff 9. Mucosal anesthetics (lidocaine spray) 10. Water-soluble sterile lubricant (K-Y jelly) RULES OF INTUBATION: 1. Always have a suction unit available. 2. An intubation attempt should never exceed 30 seconds. 3. Oxygenate the patient pre and post intubation with a bag-valve-mask.(100% O2). 4. Have sedative medication available if needed. (e.g. Midazolam 15mg/3ml) 5. Always recheck tube placement manually guided by oxygen saturation readings.(Spo2) TUBE SIZES 1. Newborn – to 4 kg - 2.5 mm (uncuffed). 2. 1-6 months 4-6 kg – 3.5 mm (uncuffed). 3. 7-12 months 6-9 kg – 4.0 mm (uncuffed). 4. 1 year 9 kg – 4.5 mm (uncuffed). 5. 2 years 11 kg – 5.0 mm (uncuffed). 6. 3-4 years 14–16 kg - 5.5 mm (uncuffed). 7. 5-6 years 18–21 kg – 6.0 mm (uncuffed). 8. 7-8 years 22-27 kg – 6.5 mm ( uncuffed). 9. 9-11 years 28-36 kg – 7.0 mm (cuffed). 10. 14 to adults 46+ kg – 7.0 – 80 mm (cuffed). 11. Adult female 7.0 – 8.0mm (cuffed). 12. Adult male 7.5 – 8.5 mm (cuffed). 13. The size of the tube may also be determined by the size of the patients little finger. 4
- 5. 4 RULES OF SUCTIONING: 1. Never suction further than you can see. 2. Always suction on the way out. 3. Never suction for longer than15 seconds. 4. Always oxygenate the patient before and after suctioning. STEPS FOR TRACHEAL INTUBATION: STEP 1: Check the equipment (laryngoscope, curved (Macintosh type) and straight (Miller type) blades of an appropriate size for the patient and assure that the light works, check ETT cuff for leaks). STEP 2:Assemble all materials close at hand (laryngoscope handle, blades, assorted ET tube sizes, 10cc syringe, water-soluble lubricant, securing device, BVM, suction equipment, stethoscope). STEP 3: Position of the patient: Unless contraindicated – ie. Trauma. Elevating the patient’s head about 10cm with pads under the occiput and extension of the head into the sniffing position serve to align the oral, pharyngeal and laryngeal axis, so that the passage from the lips to the glottic opening is almost a straight line. This position permits better visualization of the glottis and vocal cords and allows easier passage of the endotracheal tube. STEP 4: Curved blade technique: 5
- 6. a) Hyper-oxygenate the patient with 100% oxygen for 2 minutes. b) Open the patient’s mouth with the right hand, and remove any dentures. c) Grasp the laryngoscope in the left hand. d) Spread the patient’s lips, and insert the blade between the teeth, being careful not to break a tooth. e) Pass the blade to the right of the tongue, and advance the blade into the hypopharynx, pushing the tongue to the left. f) Lift the laryngoscope upward and forward, without changing the angle of the blade, to expose the vocal cords. The Sellick Maneuver is used to lower the trachea to facilitate tube passage and to compress the epiglottis and prevent aspiration. A crewmember should apply gentle downward pressure on the Cricoid cartilage, start off slowly and then gradually increase the downward force. g) Pass the tube through the vocal cords. STEP 5: Straight blade technique: Follow the steps outlined above, but advance the blade down the hypopharynx, and lift the epiglottis with the tip of the blade to expose the vocal cords. 6
- 7. STEP 6: Withdraw the stylet. STEP 7: Connect the bag-valve mask and begin ventilation with 100% oxygen. STEP 8: Verify tube placement. Bolded are mandatory. 1. Visualize tube passing through the cords. 2. Misting of the tube with respirations (not always reliable). 3. Movement of the chest with respirations. 4. Auscultation of the chest (You should hear breath sounds on both sides of the chest). 5. Auscultation of the stomach (You shouldn’t hear gurgles here). 6. Capnometer or CO2 colormetric device. 7. Esophageal detector device. 8. Rising or stable O2 saturation. 9. Clinical improvement of the patient. Reasons for acute deterioration of the intubated patient: Think DOPE • Displacement of the tube (It isn’t where it should be). • Obstruction of the tube (mucous plug, biting). • Pneumothorax, PE, pulselessness (cardiac arrest or shock). • Equipment failure (No oxygen, failure of the ventilator, disconnected tubing). STEP 9: Secure the tube in place with tape or a commercial device. AFTER THE PROCEDURE: 1. Patient is usually given sedation and pain-killer to relieve the associated discomfort. They may lose some of their consciousness or even become unconscious. 2. A bite block may be placed in mouth to prevent patient from biting onto the tube and occluding the airway. 3. Frequent suctioning through the tube and physiotherapy may be necessary to maintain airway clearance and to improve lung expansion. 4. Patient may be restrained if they have the intention to pull out the tube by themselves. Relatives will be informed if this happens. 7
- 8. 5. Eating and drinking is not allowed. Mouth care is provided to maintain mouth hygiene. FOLLOW UP: 1. The breathing tube may be removed when condition improves and ventilation support is no longer required. 2. If patient does not improve and requires ventilation for a long period (more than 2 weeks), a breathing tube (tracheostomy tube), inserted through a surgical opening in neck, may be recommended to replace the endotracheal tube. 3. Always oxygenate patient before and after intubation. 4. Do not attempt intubation unless you are totally skilled, rather perform bag-valve-mask ventilation. 5. Always monitor the spo2 readings. 6. Always reconfirm tube placement from time to time. 8