Power point on Endotracheal Intubation 02-04-23.ppt
- 2. Endotracheal Intubation Endotracheal Intubation Indications How to select and prepare equipment needed How to use laryngoscope How to determine tube is in trachea How to use ET tube to suction trachea How to use ET tube to administer PPV
- 3. Indications Indications Prolonged PPV required Bag & mask ineffective: Inadequate chest expansion If chest compressions required: Intubation facilitates coordination and efficiency of ventilation Tracheal suction required Diaphragmatic Hernia Use of Drugs through ET tube
- 4. Prerequisites for Intubation Prerequisites for Intubation Pre oxygenate before intubation PPV with 100% oxygen Deliver Free Flow oxygen during intubation Not more than 30 sec per attempt : Not more than 3 attempts Ventilate with Bag and mask with 100% oxygen in between attempts
- 6. What kind of ET are best to use? What kind of ET are best to use? ET tubes are supplied in sterile packages & should be handled with clean technique ET tubes with uniform diameter throughout the length of the tube should be used Use non cuffed ET tube for neonatal resuscitation Most ET tubes made for neonates come with centimeter markings along the tube, identifying the distance from the tip of the tube
- 7. How to prepare the ET tube for use? How to prepare the ET tube for use? Weight (g) Gestational age (wks) Tube size (mm) Internal diameter ET tube suction catheter size <1000 <28 2.5 5-6 1000-2000 28-34 3.0 5-6 2000-3000 34-38 3.5 6-8 3000-4000 >38 4.0 6-8 ET tube sizes for babies of different weight/gestations ET tubes for babies of various sizes should available before initiation of resuscitation in high risk deliveries
- 8. Consider cutting the tube to a shorter length Some prefer to cut the ET tube beforehand to about 13 to 15 cm to ease handling & lessen the chances of inserting it too far Following insertion of tube remove the connector & cut the tube diagonally to ease reinsertion the connector Ensure that the connector & tube properly aligned to avoid kinking of the tube
- 9. How to know Tip of tube is in How to know Tip of tube is in right location right location NTL(naso tragus length) +1 is a rough estimate of depth of insertion Gestational age chart is most accurate
- 10. Preparation of laryngoscope & additional Preparation of laryngoscope & additional supplies supplies First , select the appropriate sized blade & attach to laryngoscope handle (No.0 for PT & No. 1 for term) Turn on the light by clicking the blade into the ‘open’ position to determine if batteries & bulb are working Prepare suction equipment Adjust the suction source to 100mm Hg by ↑/↓ the level of suction while occluding the end of the suction tubing
- 11. Connect a 10 F (or larger) suction catheter to suction tubing to suction secretions from mouth & nose Small suction catheters (5F,6F or 8F, depending on the size of the ET tube) should be available for suctioning the tube ET tube size Catheter size 2.5 5F or 6F 3.0 6F or 8F 3.5 8F 4.0 8F or 10F
- 12. Prepare device for administering positive Prepare device for administering positive pressure pressure A resuscitation bag & mask or T- piece resuscitator capable of providing 90-100% oxygen should be available (to ventilate the baby between intubation attempts , unsuccessful intubation & to ventilate the baby after intubation) Turn on oxygen : oxygen tubing should be connected to oxygen source to deliver 100% free flow oxygen @ 5 to 10 L/min.
- 13. Positioning of the neonate & holding Positioning of the neonate & holding the laryngoscope the laryngoscope Same as for bag & mask ventilation Place a shoulder roll to maintain in a sniffing position to align the trachea for optimal view Avoid excessive flexion or extension of neck Laryngoscope should be held in left hand only between thumb & 1st two or three fingerswith blade pointing away Rest of the fingers can provide stability to face
- 15. Anatomy required to visualise prior to Anatomy required to visualise prior to insertion of ET tube insertion of ET tube Epiglottis –lid like structure overhanging the entrance to trachea Valeculla –a pouch formed by the base of the tongue & epiglottis Esophagus Cricoid cartilage Glottis- opening of the larynx leading to trachea, flanked by the vocal cords
- 16. Vocal cords- mucous membrane covered ligaments on both sides of the glottis Trachea Main bronchi Carina- where the trachea branches into two main bronchi
- 18. Steps for Endotracheal Intubation Steps for Endotracheal Intubation Stabilize the head with right hand to maintain sniffing position, a second person may be helpful . Free flow oxygen to be delivered throughout the procedure Slide the blade over the right side of the tongue, pushing it to left & advance the blade until the tip lies in valeculla Lift the blade slightly to raise the entire blade by pulling up in the direction the handle is pointing, to expose the pharyngeal area
- 21. Rocking rather than elevating the tip of the blade will not produce view of the glottis but put excessive pressure on the alveolar ridge Visualise the land marks : When blade is correctly positioned in the valeculla, epiglottis should be at the top with glottic opening below with vocal cords appearing as vertical strips or inverted ‘V’ Inadequate visualisation of vocal cords is most common reason for unsuccessful intubation & can be improved by suction, applying pressure over cricoid,
- 24. Holding the tube in right hand, introduce it into the right side of the mouth with curve lying in horizontal plane. With keeping glottis in view, insert the tube when cords are apart with vocal cord guide positioned at the level of vocal cords Stabilise the tube with one hand & remove laryngoscope with other .With right hand held against face, hold the tube at the lips& / or use finger to hold the tube against baby’s hard palate
- 25. Minimizing hypoxia during Minimizing hypoxia during intubation intubation Providing free-flow oxygen (Assistant’s responsibility) Limiting each intubation attempt to 30 seconds
- 26. How to check whether tube is in How to check whether tube is in trachea? trachea? Improvement in heart rate and colour. Breath sounds over both lung fields but decreased or absent over the stomach. No gastric distention with ventilation Vapor condensing on the inside of the tube during exhalation. Symmetrical movement of chest with each breath
- 28. Positioning of ET tube Positioning of ET tube use the NTL+1 measurement to estimate if the tube has been inserted to the correct distance Listen to breath sounds on both the axillas & see if it is equal NO YES Pull back the tube untill breath sound heard to be equal note of the centimeter marking that appears at the upper lip & fix carefully maintaining the position
- 29. Complication Possible Causes Prevention or Corrective Action to be Considered Hypoxia Taking too long to intubate Incorrect placement of tube Pre-oxygenate with bag and mask. Provide free-flow oxygen during procedure. Halt intubation attempt after 30 seconds. Reposition tube Bradycardia/apnea Hypoxia Vagal response from laryngoscope or suction or catheter Pre-oxygenate with bag and mask Provide free-flow oxygen during procedure. Oxygenate after intubation with bag and tube. Pneumothorax Overventilation of one lung due to tube in right main bronchus or excessive ventilation pressures Place tube correctly Use appropriate ventilating pressures Consider transillumination or needle aspiration if suspected Contusions or lacerations of tongue, gums or airway Rough handling of laryngoscope or tube, Inappropriate “rocking” rather than lifting of laryngoscope Laryngoscope blade too long or Obtain additional practice/ skill Select appropriate equipment
- 30. Complication Possible Causes Prevention or Corrective Action to be Considered Perforation of trachea or esophagus Too vigorous insertion of tube Stylet protrudes beyond end of tube Handle tube gently. Place stylet properly Obstructed endotracheal tube Kink in tube or tube obstructed Try to suction tube with catheter Infection Introduction of organisms via hands or equipment Pay careful attention to clean/sterile technique