Endotracheal tubes are used to intubate patients and enable ventilation. They are typically made of PVC or rubber and have features like a Murphy eye, size designations, and a pilot balloon-connected inflation system to create a seal in the trachea. Complications can occur during or after intubation and extubation, like trauma, aspiration, or laryngospasm. Nasotracheal intubation has advantages like patient comfort but risks like trauma or sinusitis. Proper preparation, techniques, and monitoring are important for safe endotracheal intubation.

1. ENDOTRACHEAL
INTUBATION
-Dr Nisar Ahmed Arain
Assistant Professor
Anesthesia/Critical care/ER

2. -FEATURES
--1-They are made of:-Polyvinyl chloride (PVC) that are disposable (The most common) or red rubber
that are Re – useable and auto – claveable (obsolete)
--2-A side hole just above and opposite the bevel called the Murphy Eye is present to enable ventilation
and decreases the risk of complete tube occlusion by secretions, Blood or the wall of the trachea.
--3-The size of the endotracheal tube is usually designated in millimeters of internal diameter for less
commonly In the French scale which is the external circumference of the tube in millimeters
--4-Most adult endotracheal tubes have a cuff inflation system consisting of a valve, Pilot balloon,
inflating tube and cuff
--5-The valve prevents air loss after cuff inflation
--6-The pilot balloon provides a gross indication of cuff inflation
--7-The cuff creates a seal allowing positive pressure ventilation and decreases the risk of Aspiration
--8-Uncuffed tubes are usually used in children (upto 6 to 8 years old) to decrease the risk of pressure
injury and post intubation croup (edema)
--9-The cuff is not required because the Larynx of pediatric patients is FUNNEL shaped with the
narrowest part at the cricoid cartilage (in adults, the vocal cords are the narrowest part. In addition
to the loose submucosa in pediatrics which make the edema very likely to occur

3. -FEATURES OF ENDOTRACHEAL TUBE

4. -FEATURES OF
ENDOTRACHEAL TUBE

5. -TYPES OF CUFFS
HIGH PRESSURE (LOW VOLUME) CUFF
--It is present mainly in the Red rubber tubes and produces better seal
but the cuff produces more severe ischemic damage to the tracheal
mucosa as the pressure inside the cuff exceeds that of the capillaries in
the tracheal mucosa. Therefore it is less suitable for long operations or
long stay in the intensive care
LOW PRESSURE (HIGH VOLUME) CUFF
--It is present mainly in the disposable PVC tubes and produces more sore
throat (as there is a larger mucosal contact area)
--Spontaneous extubation and difficult insertion (due to floppy cuff) but it
produces less severe ischemic damage to the tracheal mucosa.
--Therefore it is more recommended especially for long operations or long
stay in the intensive care
--It is used most commonly

6. -CUFF PRESSURE
DEPENDS ON
-1- Inflation volume.
-2- The diameter of the cuff in relation to the
trachea.
-3- Tracheal and cuff compliance.
-4- Intrathoracic pressure (as cuff pressure increases
with coughing).
-5- N20 diffusion from the tracheal mucosa into the
cuff which causes an increase of cuff pressure;
therefore, it is recommended to readjust cuff
volume after 10-15 min or fill the cuff with
Oz/N20 mixture

7. -SIZE
--The ‘size’ of a tracheal tube refers to its internal diameter
which is marked on the outside of the tube in millimeters.
--Narrower tubes increase the resistance to gas flow,
therefore the largest possible internal diameter should
be used.
--This is especially important during spontaneous ventilation
where the patient’s own respiratory effort must overcome
the tube’s resistance.
--A size 4-mm tracheal tube has 16 times more resistance to
gas flow than a size 8-mm tube. Usually, a size 8.5–9-mm
internal diameter tube is selected for an average size adult
male and a size 7.5–8-mm internal diameter tube for an
average size adult female.
--Paediatric sizes are determined on the basis of age and
weight.
--Tracheal tubes have both internal diameter (ID) and outside
diameter (OD) markings.

8. -SIZE contd
--There are various methods or formulae used to
determine the size of paediatric tracheal tubes.
A commonly used formula is: Internal diameter
in mm = age in years/4 +4
--The length (taken from the tip of the tube) is marked
in centimeters on the outside of the tube.
--Black intubation depth markers located 3 cm
proximal to the cuff can be seen in some designs.
These assist the accurate placement of the tracheal
tube tip within the trachea.
--The vocal cords should be at the black mark in tubes
with one mark, or should be between marks if there
are two such marks. However, these are only rough
estimates and correct tracheal tube position depth
should always be confirmed by auscultation.

9. -ENDOTRACHEAL INTUBATION
--Orotracheal
--Nasotracheal
INDICATIONS
-1-For supporting ventilation in patient
with pathological disease
a-Upper airway obstruction
b-Respiratory Failure
c-Loss of consciousness
-2-For supporting ventilation during General Anesthesia
d-Type of surgery
1- near the airway
2-Thoracic or abdominal surgery
3-Prone or Lateral surgery
4-Long period of surgery
e-Patient has risk of pulmonary aspiration
f-Difficult Mask ventilation

10. -PREPARING FOR THE PROCEDURE
INTUBATION
--1-SUCTION:-This is extremely important. Often patients will have material in
the pharynx making visualization of the vocal cords difficult
--2-AIRWAY:-The oral airway is a device that lifts the tongue off the posterior
pharynx often making it easier to mask ventilate a patient
--3-AMBU BAG:-A source of oxygen with a delivery mechanism
(ambu – bag – Mask) must be available
--4-LARYNGOSCOPE:-This lighted tool is very vital for placing an endotracheal
tube
--5-TUBE:-Endotracheal tubes come in many sizes. One has to prepare proper
size

11. -INSTRUMENTS USED
--1-Self - Refilling bag – valve combination
(e.g Ambu bag) or Bag – Valve unit
(Ayres bag) connector, tubing and
oxygen source assemble all items
before attempting intubation
--2-Tincture of Benzoin and pre – cut tape
--3-Introducer (Stylets or Magill's forceps)
--4-Suction apparatus and catheter suction
--5-Syringe 10 ml to inflate the cuff
--6-Mucosal Anesthetics (e.g 2% lidocaine)
--7-Water soluble sterile lubricant
--8-Gloves

12. -TECHNIQUE
-TPICAL ANESTHESIA:-Anesthetize the mucosa of the oropharynx
and upper airway with lidocaine 2%
If time permits and patient is awake
-DIRECT LARYNGOSCOPY
--1-Place the patient in the sniffing position
(Flexion at the lower cervical spine and Extension at the Atlanto – occipital joint)
--2-Check the Laryngoscope and blade for proper fit and make sure that the light works
--3-Make sure that all materials are assembled and are close at hand
--4-Open the patient’s mouth with the right hand, and remove any dentures
--5-Grasp the Laryngoscope in the left hand
--6-Spread the patient’s lips, and insert the blade between the teeth, being careful not to
break a tooth
--7-Pass the blade to the right of the tongue, and advance the blade into the Hypopharynx
pushing the the tongue to the left
--8-Lift the Laryngoscope upward and forward, without changing the angle of the blade to
expose the vocal cords

13. -SNIFFING POSITION

14. -SNIFFING POSITION contd.

15. -COMPLICATIONS OF
ENDOTRACHEAL INTUBATION
-DURING INTUBATION
--1-Trauma to Lip, Tongue or Teeth
--2-Hypertension, Tachycardia or Arrythmia
--3-Pulmonary Aspiration
--4-Larynospasm
--5-Bronchospasm
--6-Laryngeal edema
--7-Arytenoid dislocation ?? Hoarseness
--8-Increased intracranial pressure
--9-Spinal cord Trauma in spinal cord injury
--10-Esophageal intubation

16. -COMPLICATIONS OF
ENDOTRACHEAL INTUBATION
--During remained intubation
--1-Obstruction from kinking, secretion or over inflation of cuff
--2-Accidental Extubation or Endobronchial intubation
--3-Disconnection from breathing circuit
--4-Pulmonary Aspiration
--5-Lip or Nasal Ulcer in case of prolonged period of intubation
--6-Sinusitis or Otitis in case with prolong Naso – Endo – Tracheal
intubation

17. -COMPLICATIONS OF
ENDOTRACHEAL EXTUBATION
-DURING EXTUBATION
--1-Laryngospasm
--2-Pulmonary Aspiration
--3-Edema of upper airway
-AFTER EXTUBATION
--1-Sore throat
--2-Hoarseness
--3-Tracheal stenosis
--4-Laryngeal granuloma

18. -NASOTRACHEAL INTUBATION
ADVANTAGES
--1-Comfortable for prolong intubation in
postoperative period
--2-Suitable for
a- oral surgery
b-Tonsillectomy
c-Mandible surgery
--3-For Blind Nasal intubation
--4-Can take oral feeding
--5-Resist for kinking and difficult to accidental
extubation
DISADVANTAGES
--1-Trauma to Nasal mucosa
--2-Risk for sinusitis in prolonged
intubation
--3-Risk for Bacteremia
--4-Smaller diameter then oral
route ? Difficult for suction

19. -CONTRAINDICATIONS OF
NASOTRACHEAL INTUBATION
--1-Fracture base of skull
--2-Coagulopathy
--3-Nasal cavity obstruction
--4-Retropharyngeal Abscess