Endotracheal intubation is used to secure an airway in patients with airway issues, respiratory deficiencies, circulatory problems, neurological issues, or muscle weakness. The document outlines the proper procedure for intubating a patient including positioning them in sniffing position, using a curved blade laryngoscope to visualize the vocal cords, and carefully sliding the endotracheal tube between the cords. Placement must be verified and potential complications addressed. Difficult intubations may require alternate techniques if the cords cannot be initially seen such as pushing the laryngoscope further in or adjusting the patient's head position.

1. ENDOTRACHEAL
INTUBATION
DR DEEPAK SINGLA

2. Indications of Endotracheal
Intubation
 Airway problems: external pressures on the airway, vocal cord paralysis,
tumor, infection, and laryngospasm.
 Respiratory deficiencies: patients with poor general condition,
hypoxemic/hypercapnic respiratory insufficiency (respiratory rate less than
8 or more than 30 per minute, PO2 in blood gas less than 55 mmHg,
PCO2above 55 mmHg).
 Inadequate circulation: cardiac arrest in hypothermic and hypotensive
cases.
 Central nervous system problems: head injury, stroke, unconscious
patients, altered sensorium, raised intracranial pressure.
 Muscle weakness: (Guillain-Barre, amyotrophic lateral sclerosis,
myasthenia gravis, muscular dystrophy, acid-maltase insufficiency, phrenic
nerve injury, botulism, polymyositis, spinal cord injury, brainstem infarction,
etc.).
 Patients at risk of aspiration of the stomach contents, blood, mucus, or
secretion.
 For general anaesthesia

3. What is this?

4. Suggested items to be ready for
Intubation
 Equipment :
 Personal protective equipment
 Direct Laryngoscope with blades
 Endotracheal tubes
 Magill forceps
 Stylets
 Intravenous catheters
 Syringes( 5ml, 10ml)
 Nasal/ Oral airways
 Suction
 Tape
 Tube exchanger

5. Method of Endotracheal Intubation
Step 1 Check the equipment
Step 2 Assemble all materials close at hand
Step 3 Position of the patient:

6. Patient Positioning
Sniffing position
Lower neck flexion
Upper neck extension
Important in obesity
Unless contraindicated – ie. Trauma.

7.  Step 4 Curved blade technique:
 Open the patient’s mouth with the right hand, and remove any
dentures.
 Grasp the laryngoscope in the left hand.
 Spread the patient’s lips, and insert the blade between the teeth,
being careful not to break a tooth.
 Pass the blade to the right of the tongue, and advance the blade
into the hypo-pharynx, pushing the tongue to the left.
 Lift the laryngoscope upward and forward, without changing
the angle of the blade, to expose the vocal cords.

9.  Look for epiglottis
 If initially not found insert laryngoscope further
 If this maneuver does not work slowly pull laryngoscope
back
 Once epiglottis visualized, push laryngoscope into vallecula
and apply traction at 45 degree angle to “push” epiglottis up
and out of the way
www.int-med.uiowa.edu/Research/TLIRP/Bronchos

10.  Look for vocal cords or arytenoid cartilages and try to
optimize view
 (i.e. lift head, apply more traction at 45 degree
angle if necessary)
 Do not move once view is optimized!
 Insert ETT into far right aspect of mouth
 Insert ETT above and between arytenoids and through
vocal cords
 Try to visualize the ETT passing between the vocal cords

12. Verify Tube Placement
 Visualize tube passing through the cords.
 Misting of the tube with respirations (not always reliable).
 Movement of the chest with respirations.
 Auscultation of the chest (You should hear breath sounds on both sides
of the chest).
 Auscultation of the stomach (You shouldn’t hear gurgles here when
bagging).
 Wave form CO2 with numeric reading
 Esophageal detector device.
 Rising or stable O2 saturation.
 Clinical improvement of the patient.

13. COMPLICATIONS OF INTUBATION
(At the time of intubation)
 Failed intubation
 Trauma to lips, teeth, tongue and nose
 Laryngeal trauma, Cord avulsions, fractures and dislocation of
arytenoids
 Airway perforation
 Laryngospasm Bronchospasm
 Spinal cord and vertebral column injury
 Tension pneumothorax
 Pulmonary aspiration
 Hypertension, tachycardia, bradycardia and arrhythmia

14. COMPLICATIONS OF INTUBATION
(After intubation)
 Reasons for acute deterioration of the intubated patient:
Think DOPE
 Displacement of the tube.
 Obstruction of the tube (mucous plug, biting).
 Pneumothorax, PE, pulselessness (cardiac arrest or shock).
 Equipment failure (No oxygen, failure of the ventilator,
disconnected tubing).

15. DIFFICULT INTUBATION
An intubation is called difficult if a normally trained
anesthesiologist needs more than 3 attempts or more
than 10 min for a successful endotracheal intubation

16. Common problems
“I can’t see anything!”
Make sure tongue is swept to the left
You are probably too shallow or too deep. Even with
difficult intubations the epiglottis can be visualized
Insert laryngoscope in further looking for epiglottis
Pull laryngoscope back if this fails

17. “I can see the cords. But I can’t get the tube there!”
You may not be giving yourself adequate room in the oral
cavity
Push up and to the left with the laryngoscope to make sure
the mouth is still fully opened and the tongue adequately
swept away
Slide the ETT in the mouth all the way to the right side,
perhaps even sideways

18. “I can’t see the cords!”
Epiglottis is visualized, vocal cords are not
Removing the epiglottis partly from view is
necessary to visualize the vocal cords below
Push the end of the laryngoscope blade further
into the vallecula and “toe up”
Lifting the patient’s head with your other hand may
may improve the sniffing position and bring the
vocal cords into view

19. Direct laryngoscopy – Cormack & Lehane grading :
Gr I – Visualization of entire vocal cords
Gr II – Visualization of post. part of laryngeal aperture
IIa – post part of vocal cords visible
IIb – arytenoids only
Gr III – Visualization of epiglottis
IIIa – liftable
IIIb – adherent
Gr IV – No glottic structures seen
Gr I Gr II Gr III Gr IV

24. Rescue techniques (front of
neck access)
 Cannula cricothyroidotomy
 Surgical cricothyroidotomy
 Tracheostomy

25. Thank you