Endotracheal intubation

1. MRS. S.KAMALI KIRUBA
MSC (N),MEDICAL SURGICAL NURSING
ASSOCIATE PROFESSOR
GANGA COLLEGE OF NURSING
COIMBATORE

3. ANATOMY

4. INTRODUCTION
• Endotracheal intubation for the purpose of providing
anaesthesia was first described by William MacEwan in 1878
when he passed a tube from the mouth into the trachea, using
fingers as a guide in the conscious patient.
• Edgar Rowbotham and Ivan Magill gained wide experience of
endotracheal intubation during the first world war and
popularized it subsequently.

5. DEFINITION
Endotracheal intubation provides an
artificial conduit between the atmosphere
and the patient’s trachea for the purpose
of alveolar gas exchange or protection of
the lungs from extraneous substances.

6. METHODS
ET TUBES
TRACHEOSTOMY
CRICOTHYROTOMY
NASOTRACHEAL
OROTRACHEAL

7. ENDOTRACHEAL TUBE SIZE
Age Weight
(Inner) diameter
(mm)
Preterm 3 kg 2.5–3.0
0–6 months 3.5 kg 3.0–3.5
6–12 months 7 kg 3.5–4.0
1–3 years 10–12 kg 4.0–4.5
4–7 years 16–18 kg 5.0–5.5
8–10 years 24–30 kg 5.5–6.5
Adult female 7.0-7.5[
Adult male 8.0-9.0

8. AIRWAY ASSESSMENT
1. Condition that associated with difficult
intubation:
• Congenital anomalies- down syndrome
• Infection in air way-
• epiglottis, retropharyngeal abscess
• Tumor in oral cavity
• Enlarge thyroid gland
• Maxillofacial
Pierre robin syndrome

9. AIRWAY ASSESSMENT
2. Interincisor gap :normal -> more than 3 cms

10. AIRWAY ASSESSMENT
3.Mallampati classification:
Class 3,4 -> may be difficult intubation
Soft palate Uvula

11. AIRWAY ASSESSMENT
4.Laryngoscopicview:
grade 3,4 -> risk for difficult intubation

12. AIRWAY ASSESSMENT
5.Thyromental distance : more than 6cms

13. AIRWAY ASSESSMENT
6.Flexion and extension of neck

14. AIRWAY ASSESSMENT
7.Movement of temperomandibular
joint (TMJ) Grinding

15. HEAD POSITIONING FOR ENDOTRACHEAL
INTUBATIONA. Neutral position
B. Head Elevated
C. “SNIFFING” position with a
flexed neck and extended
head.(flexing the neck while
extending the head lines up
the various axes and allows
direct laryngoscopy)
D.Ramped position with
elevation of the upper part of
the back, neck, and head.

16. INDICATIONS
1. Respiratory arrest.
2. Cardiac arrest
3. Patients where complete obstruction of the
airway is imminent, i.e. respiratory burns,
anaphylaxis.
4. Inability of the conscious patient to breathe
adequately.
5. Inability of the unconscious patient to protect
their airway, i.e. overdose, ETOH, coma.

17. CONTRAINDICATIONS
The following are only relative contraindications to
tracheal intubation:
1. Severe airway trauma or obstruction that does
not permit safe passage of an endotracheal
tube. Emergency cricothyrotomy is indicated in
such cases.
2. 2. Cervical spine injury, in which the need for
complete immobilization of the cervical spine
makes endotracheal intubation difficult.
3. Mallampati Classification of class III / IV or other
determination of potential difficult airway.

18. SIDE EFFECTS
1. An endotracheal tube that is mistakenly sized
or misplaced, especially in the apneic patient,
can quickly lead to hypoxia and death.
2. Accidental intubation of the esophagus.
3. Oropharyngeal trauma.
4. Broken teeth or dentures.
5. Endobronchial intubation, ETT inserted too
far.

19. EQUIPMENT
• Laryngoscope (check size – the blade should reach between the lips
and larynx – size 3 for most patients), turn on light
• Cuffed endotracheal tube
• Syringe for cuff inflation
• Monitoring: end-tidal CO2 monitor,
• pulse oximeter,
• cardiac monitor, blood pressure
• Tape
• Suction
• Ventilation bag
• Face mask
• Oxygen supply

20. DRUGS
• Atropine
• Glycopyrrolate
• Lignocaine 1%
• Lignocaine jelly, aerosol, viscous
• Midazolam
• Propofol
• Saline
• Suxamethonium
• Thiopentone
• Non depolarizing muscle relaxant
• Morphine/ fentanyl

21. STEPS OF OROENDOTRACHEAL
INTUBATION
The “STOP MAID”mnemonic
S : Suction
T : Tools for intubation (laryngoscope blades, handle)
O : Oxygen
P : Positioning
M : Monitor s, including electrocardiography, pulseoximetry, blood pressure,
Etco2 and esophageal detectors.
A : Assistant, ambu bag with face mask, airway devices, (different size
ETs, 10 ml syringe, stylets) assessment of airway difficulty.
I : IV access
D : Drugs for pre treatment, induction, neuromuscular blockade (and any
adjuncts)

22. PROCEDURE
• Hold the laryngoscope with LEFT hand
irrespective of dominant hand.
• Open the mouth with right hand index finger
with support of thumb.
• Introduce laryngoscope from right angle of
mouth
• Shift the tongue to left and go in.
• Press over tongue.
• See epiglottis and lift it.
• Watch for vocal cord.

23. Con…

24. Con…
• Take the tube in right hand
• Introduce under vision.
• Confirm placement by auscultation.
• It tube is cuffed inflate the cuff.
• Connect the source to tube.
• Confirm the position of tube
by auscultation
by chest expansion
by bag movement
o Fix the tube with adhesive.

25. STABILIZING ET TUBE

26. Con..
• Connection to ventilate with
* ambu bag
* anesthesia machine
*ventilator.

27. NURSES ROLE
• oxygenate the patient using a bag valve mask.
• Attach the patient to a pulse oximeter for
monitoring.
• Delegate tasks immediately (E.g. medication nurse,
nurse who will assist the physician and prepare the
laryngoscope, nurse who will assess the condition of
the patient and checks vital signs, and etc.)
• Ensure that the emergency cart is accessible to the
room or the area of the patient.
• If the patient has no intravenous access, immediately
insert a line.

28. NURSES ROLE
• Position the patient and the height of the bed comfortable
to the physician who will insert the tube.
• Align the patient’s head in a neutral position.
Hyperextended the head to a comfortable degree.
• Consider premedication, optional for most patients-usually
given 2-3 minutes prior to induction. Prepare and
administer the sedative medication as ordered by the
physician.
• Prepare the laryngoscope and blades. Assist the physician
during insertion.
• inflate the cuff to the desired cuff pressure using a syringe.
• Check the tube position and the level in the lip line (e.g. 20
cm, 21 cm, 22 cm, and 23 cm)

29. NURSES ROLE
• Fix the tube in place partially using tape or tie, to ensure that
the tube is steady.
• Continue to oxygenate the patient using bag-valve or the
manual resuscitator.
• Verify the tube position immediately. Auscultate both lung
fields. Assess if both chests are rising equally.
• Check also the pulse oximeter to assess a patient’s
oxygenation.
• If the endotracheal tube is correctly placed, secure tube in
position using either a leukoplast, an ET holder, or ET ties.
• Suction patient’s secretions as needed.
• Attach patient to a mechanical ventilator. Check the
physician’s orders for the mechanical ventilator settings.

30. NURSING DIAGNOSIS
• Ineffective Airway Clearance related to: Retained secretions;
secretions in the bronchi; exudate in the alveoli; excessive
mucus; airway spasm; foreign body in airway; presence of
artificial airway/Infection
• Ineffective Breathing Pattern related to: Anxiety; [panic
attacks]/Pain/Perception/cognitive impairment/Fatigue;
[deconditioning]; respiratory muscle fatigue/Hyperventilation;
hypoventilation syndrome [alteration of client’s normal O2:CO2
ratio (e.g., lung diseases, pulmonary hypertension, airway
obstruction, O2 therapy in COPD)]
• Pain, Acute related to: Physical agents, e.g. suctioning,
manipulated endotracheal tube/Psychological manifestations,
e.g. anxiety, fear

31. COMPLICATION
1. DURING INTUBATION
2. DURING REMAINED INTUBATION
3. DURING EXTUBATION
4. AFTER EXTUBATION

32. COMPLICATION
1.DURING INTUBATION:
Trauma to lip, tongue or teeth
Hypertension and tachycardia
or arrhythmia
Laryngeal edema
Arytenoid dislocation -> hoarseness
Increased intracranial pressure
Spinal cord trauma in cervical spine injury
Esophageal intubation

33. COMPLICATION
2.DURING REMAINED INTUBATION
Obstruction from klinking,
secretion or overinflation of cuff
Accidental extubation or
endobronchial intubation
Disconnection from breathing circuit
Pulmonary aspiration
Lib or nasal ulcer in case with
prolong period of intubation
Sinusitis or otitis in case with prolong
nasoendotracheal intubation

34. COMPLICATION
3) During extubation
Laryngospasm
Pulmonary aspiration
Edema of upper airway
Complication of endotracheal intubation

35. COMPLICATION
4) After extubation
Sore throat
Hoarseness
 Tracheal stenosis
(Prolong intubation)
Laryngeal granuloma
TRACHEAL STENOSIS

36. CONCLUSION
As a nurse, it comes in handy if you are well
aware of the basic interventions or management
during an emergency, most especially when it
concerns airway management.
Time is always of the essence.