This document summarizes the indications, procedures, equipment, and complications related to endotracheal intubation and extubation. It describes the anatomy of the upper airway and indications for intubation such as respiratory failure, airway obstruction, or the need for positive pressure ventilation. The document outlines the procedures and equipment used for oral and nasal intubation, including laryngoscopes, endotracheal tubes, and positioning. Potential complications of intubation and extubation are also summarized such as infection, trauma, aspiration, and laryngeal injury.

1. Endotracheal Intubation/Extubation

2. Upper Airway Anatomy (p. 158)

3. Visualization of Vocal Cords

4. 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

5. 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

6. 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

7. Hazards of tracheal tubes & cuffs Infection Trauma Dehydration Obstruction Trauma

8. 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

9. Later Complications of Intubation Paralysis of the tongue Ulcerations of the mouth Paralysis of the vocal cords Tissue stenosis and necrosis of the trachea

10. Routes for Intubation Orotracheal Nasotracheal Tracheotomy

11. Oral Intubation

12. 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

13. 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)

14. Nasal Intubation

15. Advantages of Nasal Intubation More comfort long term Decreased gagging Less salivation, easier to swallow Improved mouth care Better tube fixation Improved communication

16. 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

17. 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

18. Endotracheal Tube

19. 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

20. Stylet

21. Light stylet (light wand)

22. Laryngoscope

23. 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

24. Straight blade (Miller)

25. Curved blade (Macintosh)

26. Oral Intubation Procedure Assemble and check equipment - suction equipment - laryngoscope - select proper size tube, check tube Position patient - align mouth, pharynx, larynx - “sniffing” position

27. Patient Positioning

28. 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

29. Oral procedure (cont’d.) Visualize glottis and displace epiglottis

30. 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

31. 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

32. Extubation Guidelines for extubation (see table, p. 613) Cuff-leak test

33. 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

34. 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