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Endotracheal intubation   extubation
 

Endotracheal intubation extubation

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  • Is there any evidence to support the application of negative pressure via a suction catheter in the ETT during extubation? After 14 years of practice, this is new to me.
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    Endotracheal intubation   extubation Endotracheal intubation extubation Presentation Transcript

    • Endotracheal Intubation/Extubation
    • Upper Airway Anatomy (p. 158)
    • Visualization of Vocal Cords
    • Indications for Intubation
      • In conditions of, or leading to resp. failure, such as; - trauma to the chest or airway - neurologic involvement from drugs myasthenia gravis, poisons, etc. -CV involvement leading to CNS impairment from strokes, tumors, infection, pulmonary emboli -CP arrest
    • Indications (cont’d)
      • Relief of airway obstruction
      • Protection of airway (I.e. seizures)
      • Evacuation of secretions by tracheal aspiration
      • Prevention of aspiration
      • Facilitation of positive press. ventilation
    • Relieving Airway Obstruction
      • Obstruction classified as upper ( above the glottis and includes the areas of the nasopharynx, oropharynx, and larynx) or lower (below the vocal cords)
      • Can also be classified as partial or complete obstruction
      • Causes include trauma, edema, tumors, changes in muscle tone or tissue support
    • Hazards of tracheal tubes & cuffs
      • Infection
      • Trauma
      • Dehydration
      • Obstruction
      • Trauma
    • Hazards (cont’d)
      • Accidental intubation of the esophagus or right mainstem bronchus
      • Bronchospasm, laryngospasm
      • Cardiac arrhythmias resulting from stimulation of the vagus nerve
      • Aspiration pneumonia
      • Broken or loosened teeth
    • Later Complications of Intubation
      • Paralysis of the tongue
      • Ulcerations of the mouth
      • Paralysis of the vocal cords
      • Tissue stenosis and necrosis of the trachea
    • Routes for Intubation
      • Orotracheal
      • Nasotracheal
      • Tracheotomy
    • Oral Intubation
    • Advantages of Oral Intubation
      • Larger tube can be inserted
      • Tube can be inserted usually with more speed and ease with less trauma
      • Easier suctioning
      • Less airflow resistance
      • Reduced risk of tube kinking
    • Disadvantages of Oral Intubation
      • Gagging, coughing, salivation, and irritation can be induced with intact airway reflexes
      • Tube fixation is difficult, self-extubation
      • Gastric distention from frequent swallowing of air
      • Mucosal irritation and ulcerations of mouth (change tube position)
    • Nasal Intubation
    • Advantages of Nasal Intubation
      • More comfort long term
      • Decreased gagging
      • Less salivation, easier to swallow
      • Improved mouth care
      • Better tube fixation
      • Improved communication
    • Disadvantages of Nasal Intub.
      • Pain and discomfort
      • Nasal and paranasal complications, I.e., epistaxis, sinusitis, otits
      • More difficult procedure
      • Smaller tube needed
      • Increased airflow resistance
      • Difficult suctioning
      • Bacteremia
    • Intubation Equipment
      • Endotracheal Tube and stylet
      • Laryngoscope
      • Sterile water-soluble jelly
      • Syringe to inflate cuff
      • Adhesive tape or tube fixation device
      • Bite block to prevent biting oral ET tube
      • Suction Equipment, bag- mask, O2
      • Local anesthetic
      • Stethoscope
    • Endotracheal Tube
    • Endotracheal Tube
      • ET tube size and depth of insertion (see p. 594)
      • For children older than 2 years - tube size = age/4 + 4 - depth = age/2 + 12
      • Adult - tube size female = 8.0, male = 9.0 - depth female = 19-21 and 24-26 male = 21-23 and 26-28
    • Stylet
    • Light stylet (light wand)
    • Laryngoscope
    • Laryngoscope
      • Blade and handle
      • Blade - has a flange, spatula, light, and tip - curved blade (Macintosh) - straight blade (Miller, Wisconsin)
      • Fiber optic vs. traditional laryngoscope
      • Blade size: 0 - 1 infant, 2 from 2-8 years 3 from age 10 - adult, 4 large adult
    • Straight blade (Miller)
    • Curved blade (Macintosh)
    • Oral Intubation Procedure
      • Assemble and check equipment - suction equipment - laryngoscope - select proper size tube, check tube
      • Position patient - align mouth, pharynx, larynx - “sniffing” position
    • Patient Positioning
    • Oral Intubation Proced. (cont’d.)
      • Preoxygenate the patient - bag-valve mask - *intubation attempt should take no longer than 30 sec, if unsuccessful, then ventilate again with bag and mask for 3-5 minutes
      • Insert laryngoscope - hold laryngoscope in left hand & insert in right side of mouth, displace tongue toward center
    • Oral procedure (cont’d.)
      • Visualize glottis and displace epiglottis
    • Oral proced. (cont’d.)
      • Insert ET tube - do not use laryngoscope blade to guide tube - once you see the tube pass the glottis, advance the cuff passed the cords by 2 -3 cm
      • Hold tube with right hand and remove laryngoscope & stylet - inflate cuff with 5 - 10 cc of air - ventilate with bag
    • Oral proced. (cont’d)
      • Inflate cuff with 5 - 10 cc of air
      • Ventilate with “bag”
      • Assess tube position - auscultation of chest & epigastric - cm mark at teeth - capnometry/colorimetry - light “wand”
      • Stabilize tube/Confirm placement - chest x-ray
    • Extubation
      • Guidelines for extubation (see table, p. 613)
      • Cuff-leak test
    • Extubation Procedure
      • Assemble Equipment - intubation equipment - in addition to intubation equipment, O2 device and humidity, SVN with racemic epi
      • Suction ET tube
      • Oxygenate patient
      • Unsecure tube, deflate cuff
    • Extubation proced. (cont’d.)
      • Place suction catheter down tube and remove ET tube as you suction
      • Apply appropriate O2 and humidity
      • Assess/Reassess the patient