ET TUBE intubation and it's nursing management especially useful for BNS students (Adult)as well as for medical students.: MBBS, Staff Nurse, BDS, Lab Technician etc...

2. 7/24/2022
Prepared by:
RN Arpana Bhusal
BNS

3. CONTENT LAYOUT
• Introduction
• ET intubation
• Indication
• Contraindication
• Methods of ET intubation
• Equipment for ET intubation
• Parts of ET tube
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4. CONTENT LAYOUT…
• Functions of ET tube
• Types of ET tube
• Nursing consideration for ET intubation
• Procedure of ET intubation
• Complications
• References
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5. • The patient in the ICU often requires mechanical
assistance to maintain airway patency.
• Inserting a tube into the trachea, bypassing upper
airway and laryngeal structures, creates an artificial
airway.
• The tube is placed into the trachea via the mouth or
nose past the larynx (endotracheal [ET] intubation) or
through a stoma in the neck (tracheostomy).
• ET intubation is more common in ICU patients.
• It can be performed quickly and safely at the bedside.
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6. ⦁ Endotracheal intubation involves passing an
endotracheal tube through mouth or nose into the
trachea.
⦁ Intubation provides a patent airway when the patient
is having respiratory distress that cannot be treated
with simpler methods.
⦁ It is the method of choice in emergency care.
⦁ Endotracheal intubation is a means of providing an
airway for patients who cannot maintain an adequate
airway on their own, for patients needing mechanical
ventilation and for suctioning secretions from the
pulmonary tree.
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7. Endotracheal tube
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8. Indications for ET intubation include :
⦁ Upper airway obstruction (e.g. secondary to burn,
tumor, bleeding)
⦁ Apnea
⦁ High risk of aspiration
⦁ Ineffective clearance of secretions
⦁ Respiratory distress
⦁ Respiratory arrest.
⦁ Cardiac arrest
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9. The following are only relative contraindications to tracheal
intubation:
⦁ Severe airway trauma or obstruction that does not permit safe
passage of an endotracheal tube. Emergency cricothyrotomy is
indicated in such cases.
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⦁ Cervical spine injury, in which the need for complete
immobilization of the cervical spine makes endotracheal
intubation difficult.
⦁ Mallampati Classification of class III / IV or other
determination of potential difficult airway.

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12. METHODS OF ET INTUBATION
• Nasal ET intubation
• Oral ET intubation
• Tracheal ET intubation( in case of tracheostomy)
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13. ⦁ Endotracheal tube for proper size
 Average female size, 7.5-8.0mm
 Average male size, 8.5-9.0 mm
⦁ Stylet (metal wire)
⦁ Larynscope and blade
⦁ Straight blade (Miller)
⦁ Curved blade (Macintosh)
⦁ Suction
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14. CONTD…
⦁ Tonsil tip (Yankauer)
⦁ Suction kit
⦁ Syringe to inflate balloon
⦁ Topical anesthetic
⦁ Lidocaine jelly or other agent
⦁ Water soluble lubricant
⦁ Tape or device to secure tube
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15. CONTD…
⦁ Stethoscope
⦁ Bag-valve device/ manual bag With reservoir Connected to
oxygen at 15 L/min
⦁ Optional equipment
 Magill forceps
 Oropharyngeal airway
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17. An endotracheal tube :
⦁ provides a passage for gases to flow between a
patients lungs and an anaesthesia breathing system .
⦁ allows one to provide positive pressure ventilation.
⦁ protects the lung from contamination from gastric
contents and nasopharyngeal matter such as blood.
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22. Preformed endotracheal tubes
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27. Laryngoscope and blade
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28. Oropharyngeal or nasopharyngeal airway
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29. Facemask and Magill's forceps
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30. NURSING CONSIDERATION FOR ET
INTUBATION
The intubation of the trachea is the responsibility of the doctor.
However, the nurse helps him in the procedure by preparing the
patient and keeping articles ready for use.
• Explain the purpose and procedure to the patient and visitors.
• Take consent.
• Preparation of Articles:
 Endotracheal tubes of different sizes with an adaptor to connect
to the ventilator or AMBU bag.
 Syringes to inflate the cuff.
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31. CONTD…
 Laryngoscope to visualize the larynx and to depress the tongue
during the insertion.
 Flexible copper stylet – to be used as a guide during the
insertion and to give the tube greater rigidity.
 Extra syringes and needles – for medication.
 Lubricant to lubricate the tube.
 Ambu bag to ventilate the lungs.
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32. CONTD…
 Oral airway to keep in the mouth of the patient after the
intubation to prevent the patient biting on to and occluding an
endotracheal tube.
 Gauze wipes, to clean the secretions.
 Gloves to maintain asepsis.
 Adhesive plaster – to fix the endotracheal tube in place.
 Magill’s intubating forceps – to direct endotracheal tube into the
trachea.
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33. CONTD…
 Oxygen supply.
 Suction apparatus.
 Anesthetics (if required)
• Remove the dentures, if any, to prevent dislodging and
obstructing the airway.
• Never leave the patient alone.
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34. CONTD…
• Watch for complications such as laryngeal oedema, tracheal
stenosis, haemorrhage etc.
• Watch and maintain an open airway.
• Remove secretions by effective suctioning.
• Prevent displacement of the tube.
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35. CONTD…
• Provide for the humidification of the air.
• Prevent infection introduced into the lungs.
• Prevent contamination of the inhaled air.
• Maintain adequate nutrition of the patient by naso-gastric
feeding or by giving intravenous fluids. They should never be
fed on oral feeds as long as the tube is in the mouth.
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36. CONTD…
• Maintain the oral hygiene of the patient.
• Carefully watch and record the vital signs.
• Apply suction if there is much secretions.
• Give oxygen if the patient is cyanosed.
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37. PROCEDURES OF ET INTUBATION
The ET tube is passed through the mouth and vocal cords and into
the trachea with the aid of a laryngoscope or bronchoscope.
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38. BEFORE THE PROCEDURE
⦁ The patient is placed in a “sniffing” position to align the airway
structures. Placing a folded towel or bath blanket under the head
may help achieve this position.
⦁ If the procedure is performed electively, a topical anesthetic and/or
premedication with sedative or paralytic agent may be used so that
the patient better tolerates the procedure.
⦁ Before the procedure is performed, the patient is hyperoxygenated
and hyperventilated with 100% oxygen by use of a bag-valve
device with a face mask.
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39. CONTD..
⦁ The proper sized tube is chosen.
⦁ All ETTs is increase the work of breathing; however a tube that
is too small substantially increases the work of breathing and
may make ventilation and weaning difficult.
⦁ Choose the appropriate size of ET tube.
⦁ After the tube is selected, the cuff on the balloon
is inflated to check for proper functioning and/or any leaks.
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40. CONTD..
⦁ A stylet is used to stiffen the ETT and facilitate insertion.
• The ETT is lubricated with a water-soluble lubricant.
• The laryngoscope is attached to the appropriate size and type
of blade (straight or curved).
 The choice of blades varies.
 The straight blade elevates the epiglottis anteriorly to expose
the vocal cords.
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41. CONTD..
 The tip of the curved blade fits into the vallecula. When
upward traction is placed on the laryngoscope, the epiglottis is
displaced anteriorly.
DURING THE PROCEDURE
⦁ Hold the laryngoscope with left hand and irrespective of
dominant hand.
⦁ Open the mouth with right hand index finger with support of
thumb.
⦁ Introduce laryngoscope from right angle of mouth.
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42. CONTD..
⦁ Shift the tongue to the left and go in.
⦁ Press over the tongue.
⦁ See epiglottis and lift it.
⦁ Watch for the vocal cord.
⦁ Excess secretions and/or vomitus is suctioned to facilitate
visualization of the vocal cords; the tonsil suction tip is very
efficient in removing the secretion.
⦁ The ETT is inserted 5 to 6 cm beyond the vocal cords, and the
cuff is inflated.
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43. CONTD..
• The procedure should be performed within 30 seconds.
• Connect the source to the tube.
• Confirm the position of the tube by:-
 Auscultation
 Chest expansion
 Bag movement
• Fix the tube with adhesive tape.
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44. CONTD..
• Connection to ventilate with
 AMBU bag
 Anesthesia machine
 Ventilator
AFTER THE PROCEDURE
• Place the patient in lateral position.
• Arrange for chest X-ray in order to check placement of ET
Tube.
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45. CONTD..
• Apply ET tube suctioning as needed.
• Watch for the chest movement, ET tube kinking, obstruction,
leakage of tube cuff and over inflation of cuff.
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46. Several complications may occur as a result of oral
endotracheal or nasotracheal intubation. Complications
include:-
⦁ trauma to airway structures
⦁ hypoxia
⦁ dysrhythmias
⦁ aspiration
⦁ accidental intubation of esophagus
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47. ⦁ laryngospasm
⦁ bronchospasm
⦁ intubation of the right mainstem bronchus
⦁ an endotracheal tube that is mistakenly sized or misplaced,
especially in the apneic patient, can quickly lead to hypoxia
and death
⦁ Broken teeth or dentures
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48. ET EXTUBATION
• Assemble equipment.
 Intubation equipment
 In addition to intubation equipment, O2 devices and humidity,
• Suction ET tube
• Oxygenate patient
• Unsecure tube, deflate cuff.
• Ask patient to deep breathe and remove the ET tube.
• Apply appropriate O2 and humidity.
• Assess/reassess the patient condition.
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50. REFERENCES
2019. Mayo Foundation of Medical Foundation and
Research. ET intubation.
https://www.mayoclinic.org@2021/06/25at 2pm.
October 23, 2018. Endotracheal tube intubation.
https://www.slideshare.net@2021/06/25 at 2pm.
https://www.canestar.com/endotrachealintubationemer
gency-nursing-care..html @2021/07/5 at 1pm.
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