Endotracheal Intubation/Extubation
Upper Airway Anatomy  (p. 158)
Visualization of Vocal Cords
Indications for Intubation <ul><li>In conditions of, or leading to resp. failure, such as; - trauma to the chest or airway...
Indications (cont’d) <ul><li>Relief of airway obstruction </li></ul><ul><li>Protection of airway (I.e. seizures) </li></ul...
Relieving Airway Obstruction <ul><li>Obstruction classified as  upper  ( above the glottis and includes the areas of the n...
Hazards of tracheal tubes & cuffs <ul><li>Infection </li></ul><ul><li>Trauma </li></ul><ul><li>Dehydration </li></ul><ul><...
Hazards (cont’d) <ul><li>Accidental intubation of the esophagus or right mainstem bronchus </li></ul><ul><li>Bronchospasm,...
Later Complications of Intubation <ul><li>Paralysis of the tongue </li></ul><ul><li>Ulcerations of the mouth </li></ul><ul...
Routes for Intubation <ul><li>Orotracheal </li></ul><ul><li>Nasotracheal </li></ul><ul><li>Tracheotomy </li></ul>
Oral Intubation
Advantages of Oral Intubation <ul><li>Larger tube can be inserted </li></ul><ul><li>Tube can be inserted usually with more...
Disadvantages of Oral Intubation <ul><li>Gagging, coughing, salivation, and irritation can be induced with intact airway r...
Nasal Intubation
Advantages of Nasal Intubation <ul><li>More comfort long term </li></ul><ul><li>Decreased gagging </li></ul><ul><li>Less s...
Disadvantages of Nasal Intub. <ul><li>Pain and discomfort </li></ul><ul><li>Nasal and paranasal complications, I.e., epist...
Intubation Equipment <ul><li>Endotracheal Tube and stylet </li></ul><ul><li>Laryngoscope </li></ul><ul><li>Sterile water-s...
Endotracheal Tube
Endotracheal Tube <ul><li>ET tube size and depth of insertion (see p. 594) </li></ul><ul><li>For children older than 2 yea...
Stylet
Light stylet (light wand)
Laryngoscope
Laryngoscope <ul><li>Blade and handle </li></ul><ul><li>Blade  - has a flange, spatula, light, and tip - curved blade (Mac...
Straight blade (Miller)
Curved blade (Macintosh)
Oral Intubation Procedure <ul><li>Assemble and check equipment - suction equipment - laryngoscope - select proper size tub...
Patient Positioning
Oral Intubation Proced. (cont’d.) <ul><li>Preoxygenate the patient - bag-valve mask - *intubation attempt should take no  ...
Oral procedure (cont’d.) <ul><li>Visualize glottis and displace epiglottis </li></ul>
Oral proced. (cont’d.) <ul><li>Insert ET tube - do not use laryngoscope blade to  guide tube - once you  see  the tube pas...
Oral proced. (cont’d) <ul><li>Inflate cuff with 5 - 10 cc of air </li></ul><ul><li>Ventilate with “bag” </li></ul><ul><li>...
Extubation <ul><li>Guidelines for extubation (see table, p. 613) </li></ul><ul><li>Cuff-leak test </li></ul>
Extubation Procedure <ul><li>Assemble Equipment - intubation equipment - in addition to intubation equipment,  O2 device a...
Extubation proced. (cont’d.) <ul><li>Place suction catheter down tube and remove ET tube as you suction </li></ul><ul><li>...
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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

  1. 1. Endotracheal Intubation/Extubation
  2. 2. Upper Airway Anatomy (p. 158)
  3. 3. Visualization of Vocal Cords
  4. 4. Indications for Intubation <ul><li>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 </li></ul>
  5. 5. Indications (cont’d) <ul><li>Relief of airway obstruction </li></ul><ul><li>Protection of airway (I.e. seizures) </li></ul><ul><li>Evacuation of secretions by tracheal aspiration </li></ul><ul><li>Prevention of aspiration </li></ul><ul><li>Facilitation of positive press. ventilation </li></ul>
  6. 6. Relieving Airway Obstruction <ul><li>Obstruction classified as upper ( above the glottis and includes the areas of the nasopharynx, oropharynx, and larynx) or lower (below the vocal cords) </li></ul><ul><li>Can also be classified as partial or complete obstruction </li></ul><ul><li>Causes include trauma, edema, tumors, changes in muscle tone or tissue support </li></ul>
  7. 7. Hazards of tracheal tubes & cuffs <ul><li>Infection </li></ul><ul><li>Trauma </li></ul><ul><li>Dehydration </li></ul><ul><li>Obstruction </li></ul><ul><li>Trauma </li></ul>
  8. 8. Hazards (cont’d) <ul><li>Accidental intubation of the esophagus or right mainstem bronchus </li></ul><ul><li>Bronchospasm, laryngospasm </li></ul><ul><li>Cardiac arrhythmias resulting from stimulation of the vagus nerve </li></ul><ul><li>Aspiration pneumonia </li></ul><ul><li>Broken or loosened teeth </li></ul>
  9. 9. Later Complications of Intubation <ul><li>Paralysis of the tongue </li></ul><ul><li>Ulcerations of the mouth </li></ul><ul><li>Paralysis of the vocal cords </li></ul><ul><li>Tissue stenosis and necrosis of the trachea </li></ul>
  10. 10. Routes for Intubation <ul><li>Orotracheal </li></ul><ul><li>Nasotracheal </li></ul><ul><li>Tracheotomy </li></ul>
  11. 11. Oral Intubation
  12. 12. Advantages of Oral Intubation <ul><li>Larger tube can be inserted </li></ul><ul><li>Tube can be inserted usually with more speed and ease with less trauma </li></ul><ul><li>Easier suctioning </li></ul><ul><li>Less airflow resistance </li></ul><ul><li>Reduced risk of tube kinking </li></ul>
  13. 13. Disadvantages of Oral Intubation <ul><li>Gagging, coughing, salivation, and irritation can be induced with intact airway reflexes </li></ul><ul><li>Tube fixation is difficult, self-extubation </li></ul><ul><li>Gastric distention from frequent swallowing of air </li></ul><ul><li>Mucosal irritation and ulcerations of mouth (change tube position) </li></ul>
  14. 14. Nasal Intubation
  15. 15. Advantages of Nasal Intubation <ul><li>More comfort long term </li></ul><ul><li>Decreased gagging </li></ul><ul><li>Less salivation, easier to swallow </li></ul><ul><li>Improved mouth care </li></ul><ul><li>Better tube fixation </li></ul><ul><li>Improved communication </li></ul>
  16. 16. Disadvantages of Nasal Intub. <ul><li>Pain and discomfort </li></ul><ul><li>Nasal and paranasal complications, I.e., epistaxis, sinusitis, otits </li></ul><ul><li>More difficult procedure </li></ul><ul><li>Smaller tube needed </li></ul><ul><li>Increased airflow resistance </li></ul><ul><li>Difficult suctioning </li></ul><ul><li>Bacteremia </li></ul>
  17. 17. Intubation Equipment <ul><li>Endotracheal Tube and stylet </li></ul><ul><li>Laryngoscope </li></ul><ul><li>Sterile water-soluble jelly </li></ul><ul><li>Syringe to inflate cuff </li></ul><ul><li>Adhesive tape or tube fixation device </li></ul><ul><li>Bite block to prevent biting oral ET tube </li></ul><ul><li>Suction Equipment, bag- mask, O2 </li></ul><ul><li>Local anesthetic </li></ul><ul><li>Stethoscope </li></ul>
  18. 18. Endotracheal Tube
  19. 19. Endotracheal Tube <ul><li>ET tube size and depth of insertion (see p. 594) </li></ul><ul><li>For children older than 2 years - tube size = age/4 + 4 - depth = age/2 + 12 </li></ul><ul><li>Adult - tube size female = 8.0, male = 9.0 - depth female = 19-21 and 24-26 male = 21-23 and 26-28 </li></ul>
  20. 20. Stylet
  21. 21. Light stylet (light wand)
  22. 22. Laryngoscope
  23. 23. Laryngoscope <ul><li>Blade and handle </li></ul><ul><li>Blade - has a flange, spatula, light, and tip - curved blade (Macintosh) - straight blade (Miller, Wisconsin) </li></ul><ul><li>Fiber optic vs. traditional laryngoscope </li></ul><ul><li>Blade size: 0 - 1 infant, 2 from 2-8 years 3 from age 10 - adult, 4 large adult </li></ul>
  24. 24. Straight blade (Miller)
  25. 25. Curved blade (Macintosh)
  26. 26. Oral Intubation Procedure <ul><li>Assemble and check equipment - suction equipment - laryngoscope - select proper size tube, check tube </li></ul><ul><li>Position patient - align mouth, pharynx, larynx - “sniffing” position </li></ul>
  27. 27. Patient Positioning
  28. 28. Oral Intubation Proced. (cont’d.) <ul><li>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 </li></ul><ul><li>Insert laryngoscope - hold laryngoscope in left hand & insert in right side of mouth, displace tongue toward center </li></ul>
  29. 29. Oral procedure (cont’d.) <ul><li>Visualize glottis and displace epiglottis </li></ul>
  30. 30. Oral proced. (cont’d.) <ul><li>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 </li></ul><ul><li>Hold tube with right hand and remove laryngoscope & stylet - inflate cuff with 5 - 10 cc of air - ventilate with bag </li></ul>
  31. 31. Oral proced. (cont’d) <ul><li>Inflate cuff with 5 - 10 cc of air </li></ul><ul><li>Ventilate with “bag” </li></ul><ul><li>Assess tube position - auscultation of chest & epigastric - cm mark at teeth - capnometry/colorimetry - light “wand” </li></ul><ul><li>Stabilize tube/Confirm placement - chest x-ray </li></ul>
  32. 32. Extubation <ul><li>Guidelines for extubation (see table, p. 613) </li></ul><ul><li>Cuff-leak test </li></ul>
  33. 33. Extubation Procedure <ul><li>Assemble Equipment - intubation equipment - in addition to intubation equipment, O2 device and humidity, SVN with racemic epi </li></ul><ul><li>Suction ET tube </li></ul><ul><li>Oxygenate patient </li></ul><ul><li>Unsecure tube, deflate cuff </li></ul>
  34. 34. Extubation proced. (cont’d.) <ul><li>Place suction catheter down tube and remove ET tube as you suction </li></ul><ul><li>Apply appropriate O2 and humidity </li></ul><ul><li>Assess/Reassess the patient </li></ul>
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