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
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.
8. 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
9. 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
10.
11. 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.
12. 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
13. 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).
14. 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
15. 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
16. “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
17. “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
18. 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
