This document discusses endrotracheal intubation including indications, anatomy, equipment, technique, and confirmation of proper tube placement. Key points include intubation is indicated for airway protection, optimizing gas exchange, decreasing metabolic demand. Proper equipment includes laryngoscope, endotracheal tubes, airways. Technique involves aligning three axes of oral, pharyngeal and laryngeal, lifting epiglottis to view cords, passing tube through cords. Placement is confirmed visually and by auscultation of breath sounds over lungs.

1. ENDOTRACHEAL INTUBATION
Dr. Ubaidur Rahaman
M.D. (Medicine), European Diploma in Intensive Care

2. INDICATION
• AIRWAY PROTECTIONA
• OPTIMIZATON OF GAS EXCHANGE
• OXYGENATION/ VENTILATIONB
• TO DECREASE METABOLIC DEMAND/
• TO REDUCE WORK OF BREATHINGC

3. INDICATION
• AIRWAY PROTECTION
• decrease LOC
• lower cranial nerve palsy
• laryngeal edema
• orofacial Injury
• Copious tracheo-bronchial secretions
A

4. INDICATION
• OPTIMIZATON OF GAS EXCHANGE:
oxygenation/ ventilation
• Hypoxic Respiratory Failure:
Pneumonea/ Pulmonary edema/
ARDS
• Hypercarbic respiratory failure:
obstructive airway disease/ OSAS/
Obesity hypoventilation syndrome
B

5. INDICATION
• TO DECREASE METABOLIC
DEMAND/ TO DECREASE WoB
• Severe septic shock/ Burn/
polytrauma
C

6. ANATOMY OF AIRWAY

7. CONGENITAL ANOMALIES
PIERRE ROBIN SYNDROME , DOWN’S SYNDROME
INFECTION IN AIRWAY
RETROPHARYNGEAL ABSCESS, EPIGLOTTITIS
TUMOR IN ORAL CAVITY OR LARYNX
ENLARGE THYROID CAUSING COMPRESSION/ DISPLACEMENT OF
TRACHEAL
CONDITION ASSOCIATED WITH DIFFICULT INTUBATION

8. Maxillofacial ,cervical or laryngeal trauma
Temperomandibular joint dysfunction
Burn scar at face and neck
Morbid obese or pregnancy
CONDITION ASSOCIATED WITH DIFFICULT INTUBATION

9. AIRWAY ASSESSMENT
INTER INCISOR DISTANCE > 3 CM

10. Soft palate
Uvula
AIRWAY ASSESSMENT
MALLAMPATI CLASSIFICATION
DIFFICULT INTUBATION

11. LARYNGOSCOPY VIEW
AIRWAY ASSESSMENT
DIFFICULT INTUBATION

12. THYRO MENTAL DISTACNE > 6 CM
AIRWAY ASSESSMENT

13. FLEXION/ EXTENSION OF NECK
AIRWAY ASSESSMENT

14. GRINDING
MOVEMENT OF TEMPEROMANDIBULAR JOINT (TMJ)
AIRWAY ASSESSMENT

15. • Laryngoscope with relevant size blades.
• Magill forceps.
• Flexible introducer.
• 10-20 ml syringe.
• Oropharangeal airways – all sizes.
• Tape or adhesive plaster.
• E.T tubes – relevant sizes.
• Bag-valve-mask with oxygen connected.
• Suction unit with Yankauer nozzle and endotracheal suction catheter.
EQUIPMENTS

16. Miller blade Macintosh blade
LARYNGOSCOPE

17. LARYNGOSCOPE

18. ENDOTRACHEAL TUBE

19. OROPHARYNGEAL/ NASOPHARYNGEAL AIRWAY

20. ENDOTRACHEAL TUBE: SIZE (mm internal diameter)
NEW BORN - 3 MONTHS
• 3 mm ID
3-9 MONTHS
• 3.5 mm ID
9-18 MONTHS
• ID 4.0 MMS
2- 6 YRS
• (AGE/3) + 3.5
> 6 YR
• (AGE/4) + 4.5
ADULT MALE = 8- 8.5 mm ID
ADULT FEMALE = 7-7.5 mm ID

21. 6) Depth of endotracheal tube :
Midtrachea or below vocal cord ~ 2
cms
 Adult -> Male = 23 cms ,Female = 21
cms
 Children
Oral endotracheal tube = (Age/2) +
12 (cm)
Nasal endotracheal tube = (Age/2) +
15 (cm)

22. TECHNIQUE OF ENDOTRACHEAL INTUBATION
THE THREE AXIS: ORAL, PHARYNGEAL AND LARYNGEAL

23. NECK FLEXION
AT LOWER CERVICAL JOINT
HEAD EXTENSION
AT ATLANTO-OCCIPETAL JOINT
SNIFFING POSITION: ALIGNING THE THREE AXIS

25. • Position the patient supine, open the airway with a head-tilt chin-lift
maneuver.(Suspected spinal injury, attempt naso-tracheal intubation, spine in neutral
position).
• Open mouth by separating the lips and pulling on upper jaw with the
index finger.
TECHNIQUE OF ENDOTRACHEAL INTUBATION

26. TECHNIQUE CONT…
• Hold laryngoscope in left hand, insert scope into mouth with blade directed to right tonsil.
• Once right tonsil is reached, sweep the blade to the midline keeping the tongue on the left.
• This brings the epiglottis into view.” DO NOT LOOSE SIGHT OF IT!”
• Advance the blade until it reaches the angle between the base of the tongue and
epiglottis(velecular space).
• Lift the laryngoscope upwards and away from the nose – towards the chest. This should
bring the vocal cords into view. It may be necessary for a colleague to press on the trachea
to improve the view of the larynx.

27. • Place the ETT in the right hand. Keep the concavity of the tube facing
the right side of the mouth.
• Insert the tube watching it enter through the cords.
• Insert the tube just so the cuff has passed the cords and then inflate the
cuff.
• Listen for air entry at both apices and both axillae to ensure correct
placement using a stethoscope.
TECHNIQUE CONT…

28. • PLACEMENT UNDER VISION
• FOUR QUADRANT AUSCULATION
• CAPNOMETRY/ CAPNOGRAPHY
• VENTILATOR GRAPHS
CONFIRMATION OF PROPER TUBE PLACEMENT

29. RULES OF INTUBATION
• Always have a suction unit available.
• An intubation attempt should never exceed 30 seconds.
• Oxygenate the patient pre and post intubation with a bag-valve-mask and monitor SpO2 continuously.
• Have sedative/ analgesic medication available.
• Always confirm tube placement by more than one methods.
• Do not attempt intubation unless you are totally skilled, rather perform bag-valve-mask ventilation.
• Always reconfirm tube placement from time to time.