This document discusses endotracheal intubation. It begins by describing airway anatomy and then covers indications, contraindications, and preparation for rapid sequence intubation. The seven Ps of rapid sequence intubation are outlined. Preparation, equipment, patient positioning, laryngoscopy technique, tube placement confirmation, and post-intubation management are described in detail. Complications are briefly mentioned. Alternative intubation techniques like delayed sequence intubation and awake oral intubation are also summarized.

1. ENDOTRACHEAL
INTUBATION
ENDOTRACHEAL
INTUBATION
Dr Shanif Muhammed
Departement Of Emergency Medicine
ASTER MIMS Kottakkal

2. AIRWAY ANATOMY
● Pharynx: Nasopharynx, Oropharynx, Hypopharynx
● Piriform sinus/recess/fossa
● Larynx
● Laryngeal inlet
● Arytenoid cartilage
● Glottis
● Vallecula
● Hyoepiglottic ligament

4. RAPID-SEQUENCE INTUBATION
Sequential administration of an induction agent and neuromuscular
blocking agent to facilitate endotracheal intubation

5. INDICATIONS
● Relief of airway obstruction
Epiglotittis, Facial burns, Smoke inhalation, Vocal cord edema
● Protection of the airway
Prevent aspiration, Absence of coordinated swallowing
● Support Ventilation
Respiratory arrest, Post anaesthesia recovery

6. CONTRAINDICATIONS
● Absolute
Total upper airway obstruction
Total loss of facial/ oropharyngeal landmarks
● Relative
Anticipated difficult airways
The crash airway

7. The Seven Ps of Rapid Sequence Intubation
1. Preparation
2. Preoxygenation
3. Pretreatment
4. Paralysis with induction
5. Positioning
6. Placement of tube
7. Postintubation management

8. 1. PREPARATION
• Oxygen source and tubing
• Ambu bag
• Mask with valve, various sizes and shapes
• Oropharyngeal And Nasopharyngeal airways
• Suction catheters,nasogastric suction
connections & Suction source
• Pulse oximetry
• Carbon dioxide detector
• Endotracheal tubes
• Laryngoscopes
• Syringes
• Magill forceps
• Stylets and gum elastic bougie
• Water-soluble lubricant or anesthetic jelly
• Rescue devices: VLS, LMA, ILMA, i-gel®
• Surgical cricothyroidotomy kit
• Medications for topical airway anesthesia,
sedation, and rapid-sequence intubation

9. Preintubation Checklists
PRE-ARRIVAL
1. Bag mask ventilation setup with oxygen running at >15 L/min
2. Suction connected and running
3. Laryngoscope functioning and ready
4. Ready an endotracheal tube
5. Back-up devices such as laryngeal mask airway available and ready
6. Cricothyrotomy set
7. End-tidal CO2 detector ready

10. PRE-INTUBATION
1. Assess the airway: open mouth, examine neck mobility, palpate anterior neck
2. Decide best approach: awake, sedated, or RSI
3. Communicate intubation medication orders to nurses,
including post-intubation medications
4. Optimally position patient
5. Preoxygenate patient (usually with face mask oxygen at 60 L/min)
6. Apply nasal cannula at 10–15 L/min in preparation for apneic oxygenation
7. Discuss airway plan with entire team
8. Ensure functioning pulse oximeter
9. Ensure patient intravenous catheter
10.Ensure assistants are ready (nurses, respiratory therapists)

11. ET TUBE
The endotracheal tubes size (“give me a 6.0 tube”) refers to its internal diameter in
millimeters (mm). The ETT will typically list both the inner diameter and outer diameter
on the tube (for example, a 6.0 endotracheal tube will list both the internal diameter, ID
6.0, and outer diameter, OD 8.8).
The narrower the tube, the greater resistance to gas flow.
After successfully intubating the patient the depth of the endotracheal tube ending at the
teeth or lips should be noted. This depth provides a baseline measurement to ensure the
tube has not traveled out of the trachea or deeper into the trachea

12. Ideally, the distal tip of the ETT is 4 cm (+/- 2 cm) above the carina on chest x-ray in adults
the patient typically needs to be intubated with at least 7.5-8.0 size ETT
The typical depth of the endotracheal tube is 23 cm for men and 21 cm for women, measured at the central incisors.
The average size of the tube for an adult male is 8.0, and an adult female is 7.0, though this is somewhat an
institution dependent practice.
Pediatric tubes are sized using the equation: size = ((age/4) +4) for uncuffed ETTs, with cuffed tubes being one-half
size smaller
Typically a pediatric ETT is taped at a depth of 3 x the tube size in a child (i.e., a 4.0 ETT commonly gets taped at
around 12cm depth).

13. Direct Laryngoscope

14. ASSESSING FOR A DIFFICULT AIRWAY
The American Society of Anesthesiology Difficult Airway Guidelines state that “in
patients with no gross upper airway pathology or anatomic anomaly, there is
insufficient published evidence to evaluate the effect of a physical examination on
predicting the presence of a difficult airway“
The Mallampati classification predicts intubation difficulty based on the visibility of
intraoral structures. Classes III and IV predict difficult intubation.
A short thyromental distance (less than 6 cm or 3 fingerbreadths) when the head is
extended predicts difficult intubation.

15. LEMON- ASSESSMENT OF AIRWAY

18. IDENTIFY…….

20. Difficult Bag & mask ventilation
MOANS
Mask seal
Obstruction or obesity
Aged
No teeth
Stiffness (resistance to
ventilation)
Difficult SGA Placement
RODS
Restricted mouth opening
Obstruction or obesity
Distorted anatomy
Stiffness (resistance to ventilation)

22. 2. PREOXYGENATION
preoxygenation increases safe apnea time from 1 to 8 minutes
Administer 100% oxygen for at least 3 minutes using a NRBM (60-70% O2)
Higher oxygen delivery is possible by increasing the oxygen regulator to its
maximum “flush” rate(90% to 97% O2)

24. IF unable to achieve oxygen saturation >95% with spontaneous breathing,
consider the use of bag-valve-mask ventilation OR BiPAP
In obese patients, safe apnoea time can be improved by preoxygenating the
patient in head up position and continuing oxygenation through nasal cannula

25. 3. PRETREATMENT
Decrease adverse physiologic response to laryngoscopy and RSI
Fentanyl can decrease the reflex sympathetic response to airway
manipulation. Used in patients in whom a rise BP & HR could be detrimental
as in hypertensive emergency,
Reactive airway disease: Albuterol, 2.5 mg, by nebulizer. If time does not
permit albuterol nebulizer, give lidocaine 1.5 mg/kg IV.

27. INDUCTION AGENTS
Etomidate - short duration of action, protects from myocardial and cerebral
ischemia, causes minimal histamine release, and causes little hemodynamic
depression.
Propofol - rapid onset and shorter duration of action than etomidate. It has
anticonvulsant and antiemetic properties, and may lower ICP without triggering
histamine release.
Ketamine- analgesia and amnesia. Ketamine preserves the respiratory drive,
hence ideal for awake intubation. Ketamine increases bp and heart rate, which
may be useful in hypovolemic or hypotensive state

29. Neuromuscular blockade eliminates protective airway reflexes.
Neuromuscular blockade can facilitate tracheal intubation, improve mechanical
ventilation, and help control ICP
Neuromuscular blockers include depolarizing (Ach-) and nondepolarizing
agents(Ach+)
4. PARALYSIS

30. Succinylcholine
A depolarizing agent
rapid onset after IV dosing and a
shorter duration of action than
nondepolarising agents
After brief fasciculation, complete
relaxation occurs at 60 seconds, with
maximal paralysis at 2 to 3 minutes.
Effective respirations resume in 8 to
12 minutes

31. Rocuronium is an intermediate-duration( nondepolarizing)that is an excellent
alternative to succinylcholine for RSI due to its shorter duration of action.
Vecuronium bromide is an intermediate- to long-acting( non depolarizing) .
Has no cardiac effects. Hypersensitivity reactions are rare, doses are only
minimally cumulative, and excretion is biliary.
Atracurium is a non-depolarizing neuromuscular blocking drug. is a
competitive antagonist atneuromuscular junction. It competes with
acetylcholine for binding sites.

32. Sugammadex is a reversal agent that reverses blockade from rocuronium or
vecuronium by encapsulating the molecules of the nondepolarizing agents
circulating in plasma. The dose is 2 to 4 milligrams/kg.
Neostigmine, a cholinesterase inhibitor, may be used to reverse
neuromuscular blockade, but it has undesirable cardiac and cholinergic side
effects.

33. It is usual to wait 45 seconds from when the succinylcholine is given and 60 seconds from when rocuronium is
given to allow sufficient paralysis to occur.

34. 5. PATIENT POSITIONING

37. Protecting the airway against aspiration prior to intubation
Flex the lower neck and extend the atlanto occipital joint (sniffing
position) to align the oropharyngeal laryngeal axis for direct view of
larynx
Best when ear is horizontally alligned with sternal notch

46. Sellick or Cricoid maneuver
Direct pressure overthe cricoid ring

47. PROCEDURE
1. Clear the oropharynx.
Remove dentures and any obscuring blood, secretions, or vomitus. Suction
airway clear.
2. Hold laryngoscope in left hand. Hold the laryngoscope at the base, where the
blade inserts to the handle.
3. Use right hand to: Open the mouth. Operate suction catheter.
Manipulate larynx to enhance visualization.
Insert the ETT.

48. 4. Insert blade into the right cor ner of the patient’s mouth. Carefully advance blade
into oropharynx. Lift and hyperextend the head. Use the vertical flange of the curved
Macintosh blade to push the tongue toward the left side of the oropharynx.
5. Visualize and lift the epiglottis. Lift the epiglottis directly with the straight blade
(Miller) or indirectly with the curved blade (Macintosh).
6. Visualize vocal cords (arytenoids).
Look for the arytenoid cartilages to avoid overly deep insertion of the blade, which is a
common error. BURP maneuver may improve visualization.

49. 7. Advance ETT. Visualize tube and cuff passing through vocal cords. Correct tube
placement is a minimum of 2 cm above the carina
8. Inflate balloon. Use 5–7 mL of air. Check cuff pressure to avoid tracheal injury
from pressure
9. Confirm ETT placement.
Listen for bilateral breath sounds and the absence of epigastric sounds.
Confirm placement with capnography or colori- metric carbon dioxide detector.
10. Secure ETT.
Use commercial tube holder, adhesive tape, or umbilical tape.

50. 6. PLACEMENT OF TUBE- CONFIRMATION

52. Pocus

53. Pocus

54. POST INTUBATION MANAGEMENT

56. COMPLICATIONS

58. Delayed Sequence Intubation
maximize preoxygenation in preparation for intubation
dissociative doses of ketamine (1.0 mg/kg IV)

59. Awake Oral Intubation
sedative and topical anesthetic agents are administered to permit management
of a difficult airway without neuromuscular blockade.
ketamine, is often the best choice
Aliquots of ketamine at a dose of 0.5 mg/kg IV, titrated to the desired level of
sedation and procedural tolerance, is an effective method

60. THANK YOU