Endotracheal intubation

1. Prepared by: Sultanat khan
Discipline: Emergency care
Submitted To: Lec Abdur-Raheem
07-Jan-17 Sultanat khan 1

2. 
 ET intubation is a procedure in which ET tube is placed
inside the trachea through the mouth or nostrils.
 ET intubation is much simpler than tracheotomy surgical
procedure that creates an airway opening by cutting into
the trachea.
 In spite of many advantages
of a tracheostomy tube,
ET intubation is preferred
as the initial means of
establishing an artificial airway.
Introduction
Two adult endotracheal tubes (8.0 mm ID). Note that
one’s cuff is inflated and the other’s is not. Also note
the markings visible on the tubes.
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3. 
 In general, if the patient requires an artificial airway for a
brief period (e.g., 10 days or less) and full recovery is
expected, an ET tube is used.
 Relief of airway obstruction:
─Epiglottitis
─Facial burns and smoke inhalation
─Vocal cord edema.
 Protection of the airway:
─Prevention of aspiration
─Absence of coordinated swallow.
Indications
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4. 
 Facilitation of suctioning:
─Excessive secretions
─Inadequate cough
 Support of ventilation
─Ventilatory failure / respiratory arrest
─Chest trauma
─Postanesthesia recovery
─Hyperventilation to ↓ intracranial pressure
Indications
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5. 
 An ET tube may be inserted orally (oral intubation)
or nasally (nasal intubation) through the larynx into
the trachea.
 Intubation through the mouth is the preferred
method of establishing an artificial airway. An oral
route provides quick access to the lungs in
emergency situations and it allows the passage of a
larger ET tube than the nasal route.
Indications
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6. 
 Prior to intubation, the patient must be assessed to rule
out any potential contraindications to include head injury,
cervical spine injury, airway burns, and facial trauma.
 The degree of difficulty in intubation due to anatomical
structures can be evaluated by using the Mallampati
classification method:
─Class 1 (easiest)
─Class 2 (Difficult)
─ Class 3 (more difficult)
─Class 4 (most difficult)
Initial Intubation procedure
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7. 
 Equipment's needed for ET intubation include:
(1) laryngoscope handle,
(2) blade, (3) ET tube, (4) 10-mL syringe, (5) water-
soluble lubricant, (6) tape, and
(7) stethoscope.
 Optional supplies for ET intubation include (8)
stylet, (9) topical
anesthetic, and (10) Magill forceps.
Equipment's
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8. 
 The size refers to the internal diameter (ID) of the tube in
millimeters (mm).
 Neonate (, 1000 grams) 2.5 mm ID
 Neonate (1000 to 2000 grams) 3.0 mm ID
 Neonate (2000 to 3000 grams) 3.5 mm ID
 Neonate (. 3000 grams) 4.0 mm ID
 Child (1 to 2 years) 4.5 mm ID
 Child (2 to 12 years) 4.5+(age/4) mm ID
 Adult female 7.0 or 7.5 mm ID
 Adult male 7.5 or 8.0 mm ID
ETT Sizes Estimation
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9. 
 Neonates 6 + weight
 >2 years age/2 + 12
 Adult:
 Male : 21----24cm
 Female : 18----21cm
Length──cm
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10. 
 1. Assemble and test supplies (e.g., check light source
and ET tube cuff for air leak).
 2. Lubricate the deflated cuff with a water-soluble
lubricant.
 3. Inform or explain procedure to patient.
 4. Bag-mask ventilate and preoxygenate patient with
100% oxygen.
 5. Tilt the head back and place in the sniffing
position (tilting the forehead back slightly and moving the mandible
anteriorly to the patient.)
Procedure for Oral Intubation
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11. 
 6. Open mouth, apply anesthetic spray.
 7. Hold laryngoscope handle with left hand and
insert blade into the right side of the opened mouth.
 8. Slide blade to the base of tongue and sweep blade
to the left.
 9. Maneuver the tip of straight blade underneath the
epiglottis (or the tip of curved blade at the vallecula).
 10. Lift handle and blade up anteriorly to displace
the tongue and attached soft tissues.
Cont…
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12. 
 11. Locate the epiglottis (only with curve blade), larynx,
and vocal cords.
 12. Insert ET tube through the vocal cords under direct
vision.
 13. For adults, the centimeter marking on the ET tube
should initially be placed at the lips or incisors at 21 to 23
cm.
 14. Inflate cuff and confirm endotracheal tube placement
(e.g., loss of phonation, rising SpO2, presence of bilateral
breath sounds and expired CO2).
 15. Verify proper depth of ET tube placement (1.5 inch
above carina) with chest radiograph.
Cont…
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13. 
1) During intubation:
 Trauma to lip, tongue or teeth
 Hypertension and tachycardia or arrhythmia
 Pulmonary aspiration
 Laryngospasm
 Bronchospasm
 Esophageal intubation
Complications
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14. 
2) During remained intubation:
 Obstruction from klinking , secretion or overinflation
of cuff
 Accidental extubation or endobronchial intubation
 Disconnection from breathing circuit
 Pulmonary aspiration
Complications
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15. 
3) During extubation
 Laryngospasm
 Pulmonary aspiration
 Edema of upper airway
Complications
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16. 
4) After extubation
 Sore throat
 Hoarseness
 Tracheal stenosis (Prolong intubation)
 Laryngeal granuloma
Complications
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17. 
THANKS
07-Jan-17 Sultanat khan 17