An endotracheal tube is inserted into the trachea to mechanically ventilate a patient or breathe for them using a machine. It has a proximal end that connects to a ventilator, a distal end with an opening, and a radio-opaque marker to visualize placement via x-ray. Endotracheal tubes can be cuffed or uncuffed. Intubation requires laryngoscopy to visualize the vocal cords and guide the tube past them into the trachea, which is then confirmed using end-tidal carbon dioxide monitoring and chest auscultation. Complications can include hypoxia, bronchial intubation, trauma, and infection if not performed correctly.

1. Endotracheal tubes
krishnakumarm D
AVMC&H

3. Introduction:
• The word intubation means to insert a tube. Usually, the word intubation is
used in reference to the insertion of an endotracheal tube.
• Patients may need an endotracheal tube for one of several reasons.
• An endotracheal tube is needed to mechanically ventilate a patient (or breathe
for them by a machine).
• Each breath is pushed into the endotracheal tube and into the lung.

4. THE ETTUBE HASTHE FOLLOWING
COMPONENTS :
•
• PROXIMAL END – 15mm adapter (connector) which fits to ventilator or
AMBU bag
• CENTRAL PORTION:A vocal cord guide (black line ) which should be
placed at the level of the opening of the vocal cords so that the tip of the
ET tube is positioned above the bifurcation if the trachea.

5. • The distance indicator (marked in centimetres) which facilitates placement of ET tube.
• A radio-opaque marker which is essential for accurate visualization of the position of the ET tube within the
trachea by means of an X-ray
• A cuff- in case of cuff ET tube DISTAL END – has Murphy’s eye (opening in the lateral wall ) which prevents
complete blockage of ET tube in case the distal end is impacted with secretion , blood , etc

7. TYPES:
• ET tubes can be : - cuffed - uncuffed • Cuffed ET tubes are used in children > 8 years.
• The cuff when inflated maintains the ET tube in proper position and prevents aspiration of contents from GI
tract into respiratory tract.
• In children < 8 uncuffed ET tubes are used because the narrow subglottic area performs the function of a cuff
and prevents the ET tube from slipping.

8. Laryngoscopy:

9. Indication Endotracheal Intubation:
1. Respiratory Failure: Hypoxia, Hypercapnia, tachypnoea,
or apnoea ; ie. ARDS, asthma, pulmonary oedema,
infection,
2. COPD exacerbation Inability to ventilate,
3. unconscious patient Maintenance or protection of an
intact airway,
4. Cardiac Arrest,
5. Medication administration.

10. Contraindication:
1. Inability of patient to extend head
2. Moderate to severe trauma to the cervical spine or anterior neck
3. Infection in the epiglottal area
4. Mandibular fracture or trismus
5. Mild hypoxia
6. Uncontrolled oropharyngeal haemorrhage
7. Intact tracheostomy
8. Basilar skull fracture (during nasal intubation)

11. Difficult to intubation: (MOANS)
1. Mask Seal : Small Hands, Wrong Mask Size, Oddly Shaped
Face, Bushy Beard, Blood/Vomit, and Facial Trauma Obesity
or
2. Obstruction: Heavy chest, Abdominal contents inhibit
movement of the diaphragm, Increased supra glottic airway
resistance, Billowing cheeks, Difficult mask seal, Quicker
desaturation
3. Age > 55: Associated with BVM difficulty, possibly due to
loss of tone in the upper airway
4. No Teeth: Face tends to cave in Consider leaving dentures in
for BVM and remove for intubation.
5. Stiff : Refers to Poor Compliance, Reactive Airway Disease,
COPD, Pulmonary Edema/Advance Pneumonia, History of
Snoring/Sleep Apnea, Also predicts a higher Mallam Patti
score.

12. Difficult to Laryngoscopy and
intubation:
• LEMONS:
• Look Externally : Beards or facial hair, Short, fat neck,
• Morbidly obese patients,
• Facial or neck trauma, Broken teeth (can lacerate
balloons), Dentures (should be removed), Large teeth,
Protruding tongue,
• A narrow or abnormally shaped face.
• Evaluate : Bottom of Jaw/Chin to Neck > 3 fingers,
Jaw/Palate > 3 fingers wide, Mouth opens > 2 fingers
wide.

13. Equipment Endotracheal Intubation:
•
Laryngoscope Blades: curved (MacIntosh) and straight
(Miller)
• Endotracheal tubes of various sizes: Neonates and full
term infants: no. 0 and 1,Adult women: 7.0 mm i.d.,Adult
men: 7.0 to 8.5 mm i.d. Pediatric size: (age in years/4) +
4 or width of fingernail of the fifth digit

14. Lubricant, Malleable stylet:
• 10-ml syringe (to inflate ET cuff)
• Oxygen and manual bag valve mask
• Suction apparatus
• Stethoscope
• Sterile gloves and
• Goggles
• Oropharyngeal airway
• CO2 Detector
• ETT,
• Stylet, and
• syringe

15. Emergency drugs:
• Atropine
• Glycopyrrolate
• Lignocaine 1%
• Lignocaine jelly,
• aerosol,
• Midazolam
• Propofol
• Saline
• Suxamethonium
• Thiopentone
• Non depolarizing muscle relaxant Morphine/fentanyl

16. Technique:
• Appropriate preparation and positioning of the patient are essential to
successful intubation.
• The operator should confirm that the light source of the laryngoscope
is functioning, and the blade is locked in place.
• The laryngoscope is held on the operator’s left hand.
• the operator slides the laryngoscope into the right side of the patient’s
mouth and advances inward while applying upward pressure at a 45-
degree angle against the tongue.

18. • the curved laryngoscope is used to lift the epiglottis and expose the
vocal cords.
• Once the glottis is visualized, the operator will ask the respiratory
assistant to place the endotracheal tube with the malleable stylet on the
operator’s right hand.
• The operator then inserts the endotracheal tube to the right of the
laryngoscope blade and visualizes passage through the vocal cords.
• Some brands of endotracheal tubes have a marking proximal to the
cuff that indicates the relative level of insertion through the vocal
cords.

19. • the first intubation attempt is unsuccessful, operators must be ready to
change their approach and method on subsequent attempts.
• A tracheal tube introducer, also called bougie, can be used if the initial
attempt is unsuccessful.
• The bougie is a flexible device with an anteriorly angulated tip that is
introduced in the airway when vocal cord visualization is poor.
• The introduction of the bougie allows for indirect identification of the
cartilaginous ridges of the anterior airway.
• The endotracheal tube slides over the bougie and passes the vocal cords.
Tracheal tube introducers may be considered for the first attempt in patients
with an anticipated difficult airway.

20. • After the endotracheal tube is passed through the vocal cords, the cuff
is inflated using a 5 cc or 10 cc syringe filled with air.
• The stylet is removed, and the proximal end of the endotracheal tube is
connected to the carbon dioxide monitor and the ventilation device.
Traditionally, the desired depth from the incisors to the distal tip of the
endotracheal tube is 21 and 23 cm in women and men, respectively.
• Although the preferred distance appears to correlate more with height
than gender.

21. Confirmation of Endotracheal Tube Position:
• After placing the endotracheal tube, it is essential to confirm its placement in the
trachea and position proximal to the carina.
• End-tidal carbon dioxide monitor is the gold standard to confirm tracheal
intubation.
• To rule out esophageal or hypopharyngeal intubation, an EtCO2 monitor measures
the expired carbon dioxide with respiration.
• Extratracheal carbon dioxide waveform will read 0 mmHg while endotracheal
intubation correlates reliably with the patient’s arterial partial pressure of CO2.
• The physician should also auscultate for symmetric bilateral breath sounds, and
the absence of breath sounds over the stomach.
• A post-intubation chest x-ray confirms the location of the endotracheal tube’s
distal tip 2 to 4 cm proximal to the carina and rules out mainstem bronchus
intubation.

22. Complications:
• Hypoxia (Long duration of procedure,
• Intubation of a bronchus ( right more common, Failure to recognize misplacement of tube,
Aspiration)
• Pneumothorax (resulting from over ventilating with a BVM without a pressure release valve)
• Trauma (to the teeth, vocal cords, soft tissues of the larynx and related structures)
• Hypertension and tachycardia (can occur from the intense stimulation of intubation.
• This is potentially life-threatening in the cardiac patient)Gastric distention and regurgitating (Failure
to secure the placement into esophagus).
• Cardiac arrhythmias (related to vagal stimulation or sympathetic nerve stimulation may occur)

23. Conti…..
• Tube in oesophagus
• Endo bronchial Intubation
• Trauma to lips and tooth
• Laryngeal and tracheal Injury
• Barro trauma to lungs
• Bleeding
• Tracheitis
• Pulmonary infection and sepsis