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Endotracheal intubation
- 1. ENDOTRACHEAL TUBES and INTUBATION Dr NisarAhmed Arain Assistant Professor Anesthesia/Critical Care/ER
- 2. -INDICATIONS --A =Airway Protection =Optimizationof gas exchange --B =Oxygenation / Ventilation =To Decrease Metabolic Demand --C =To Reduce work of breathing
- 3. -INDICATIONS =Airway protection =Decrease LOC =Lowercranial nerve palsy A =Laryngeal edema =Orofacial injury =Copious trachea-bronchial secretions
- 4. -INDICATIONS =Optimization of Gasexchange Oxygenation / Ventilation B =Hypoxic Respiratory Failure Pneumonia / Pulmonary edema/ARDS =Hyperbaric respiratory failure Obstructive airway disease/ OSAS Obesity hypoventilation syndrome
- 5. -INDICATIONS =To decrease metabolicdemand/ To decrease WoB -C =Severe septic shock / Burn / polytrauma
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- 7. -Conditions associated withdifficult intubation -Congenital anomalies Pierre Robin Syndrome, Down’s Syndrome -Infection in airway Retropharyngeal abscess, epiglottis -Tumor in oral cavity or Larynx -Enlarge thyroid causing compression / displacement of trachea
- 8. -Conditions associated withdifficult intubation --Maxillofacial cervical of laryngeal trauma --Temporomandibular joint dysfunction --Burn scar at Face and Neck --Morbidly obese or pregnancy
- 9. -Airway assesment -Inter Incisordistance > 3 cm
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- 12. -Airway assesment -Thyro mentaldistance > 6 cm -Difficult Intubation
- 13. -Airway assesment -Flexion /Extension of Neck
- 14. -Airway Assesment -Movement ofTemporomandibular joint (TMJ) -GRINDING
- 15. -EQUIPMENTS --Laryngoscope with relevantsize blade --Magill's Forceps --Flexible Introducer --10 to 20 ml syringe --Oropharyngeal airways –All sizes --Tape or adhesive Plaster --E.T tubes--relevant sizes --Bag—Valve—Mask with oxygen connected --Suction unit with Yankauer nozzle and endotracheal suction catheter
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- 20. -Endotracheal Tube: Size(mm Internal Diameter) --New Born—3 Months = 3.0 mm ID --3 to 9 Months = 3.5 mm ID --9 to 18 Months = 4.0 mm ID --2 Years to 6 Years = (Age/3) + 3.5 -- >6 Years = (Age/4) + 4.5 --Adult Male = 8 to 8.5 mm ID --Adult Female =7.0 to 7.5 mm ID
- 21. -Depth of endotrachealtube : should be placed at Mid trachea or below vocal cords = 2 cms --Adult -> Male = 23 cms --Adult -> Female = 21 cms --Children a- Oral endotracheal tube = (Age/2) + 12 cms b- Nasal endotracheal tube = (Age/2) + 15 cms
- 22. -Technique of endotrachealIntubation The three Axis : Oral, Pharyngeal and Laryngeal
- 23. -Sniffing Position :Aligning the three Axis
- 25. -Technique of endotrachealIntubation --Position the patient supine, open the airway with a head- tilt-chin-lift maneuver. (suspected spinal injury, attempt Nasotracheal intubation spine in neutral position --Open mouth by separating the lips and pulling on upper jaw with the index finger
- 26. -Technique of endotrachealIntubation --Hold laryngoscope in the left hand, insert scope into the mouth with blade directed to right tonsil. --Once right tonsil is reached, sweep the blade to the midline keeping the tongue on the left. --This brings the Epiglottis into view. “DO NOT LOOSE SITE OF IT “ --Advance the blade until it reaches the angle between the base of the tongue and epiglottis (Vallecular space) --Lift the laryngoscope upwards and away from the Nose – towards the chest. This should bring the vocal cords into view. It may be necessary for a colleague to press on the trachea to improve the view of the larynx
- 27. -Technique of endotrachealIntubation cont. --Place the ETT in the right hand. Keep the concavity of the tube facing the right side of the mouth --Insert the tube watching it enter through the cords. --Insert the tube just so the cuff has passed the cords and then inflate the cuff --Listen for air entry at both apices and both axillae to ensure correct placement using stethoscope
- 28. -CONFIRMATION OF PROPERTUBE PLACEMENT --PLACEMENT UNDER VISION --FOUR QUADRANT AUSCULTATION --CAPNOMETERY / CAPNOGRAPHY --VENTILATOR GRAPHS
- 29. --GOLDEN RULES OF INTUBATION --Alwayshave a suction unit available --An intubation attempt should never exceed 30 seconds --Oxygenate the patient Pre and Post intubation with a Bag-valve-Mask and monitor SpO2 continuously --Have sedative / analgesic medicines available --Always confirm tube placement by more then one methods --Do not attempt intubation unless you are totally skilled, rather perform Bag-Valve-Mask Ventilation --Always confirm tube placement from time to time