Airway Management - Intubation

Topics For Discussion

 Basic anatomy and  Technique of

physiology. endotracheal intubation.
 Advantages of  Rules of endotracheal
endotracheal intubation. intubation.
 Indications of  Tube sizes.
intubation.  Rules and principals of
 Contraindications of suctioning.
intubation.  Other airway adjuncts.
 Complications of  Conclusion.
intubation.  Difficult intubations.
 Equipment required for
intubation.
 Anatomy and Physiology

The airways can be divided in to parts

namely:
 The upper airway.
 The lower airway.
The Upper Airway
The Lower Airway
 Advantages of Endotracheal
Intubation
 Cuffed E.T tubes protect the airway from
aspiration.
 E.T tube provides access to the
tracheobronchial tree for suctioning of
secretions.
 E.T tube does not cause gastric distention and
associated danger of regurgitation.
 E.T tube maintains a patent airway and assists in
avoiding further obstruction.
 E.T tube enables delivery of aerosolized
medication.
 Indications for Intubation
 Inadequate oxygenation(decreased arterial
PO2) that is not corrected by supplemental
oxygen via mask/nasal.
 Inadequate ventilation (increased arterial
PCO2).
 Need to control and remove pulmonary
secretions.
 Any patient in cardiac arrest.
 Indications for Intubation
 Ant patient in deep coma who cannot protect his
airway.(Gag reflex absent.).
 Any patient in imminent danger of upper airway
obstruction (e.g. Burns of the upper airways).
 Any patient with decreased L.O.C, GCS <= 8.
 Severe head and facial injuries with
compromised airway.
 Indications Cont…
 Any patient in respiratory arrest
 Respiratory failure
1.
Hypoventilation/Hypercarbia
A. Paco2 > 55mmhg
2. Arterial hypoxemia
refractory to O2
A. Paco2 < 70 on 100% O2
 Contraindications for Intubation

 Patients with an intact gag reflex.

 Patients likely to react with laryngospasm
to an intubation attempt. e.g. Children
with epiglottitis.
 Basilar skull fracture – avoid naso-
tracheal intubation and
nasogastric/pharyngeal tube.
 Complications Associated With
Intubation
 Trauma of the teeth, cords, arytenoid cartilages, larynx
and related structures.
 Nasotracheal tubes can damage the turbinates, cause
epistaxis, and even perforate the nasopharyngeal
mucosa.
 Hypertension and tachycardia can occur from the
intense stimulation of intubation; This is potentially
dangerous in the patient with coronary heart disease.
 Transient cardiac arrhythmias related to vagal
stimulation or sympathetic nerve traffic may occur .
 Complications Continued…
 Damage to the endotracheal tube cuff, resulting
in a cuff leak and poor seal.
 Intubation of the esophagus, resulting in
gastric distention and regurgitation upon
attempting ventilation.
 Baro-trauma resulting from over ventilating with
a bag without a pressure release valve(
phneumothorax).
 Complications Continued…
 Over stimulation of the larynx resulting in
laryngospasm, causing a complete airway
obstruction.
 Inserting the tube to deep resulting in
unilateral intubation (right bronchus).
 Tube obstruction due to foreign material, dried
respiratory secretion and/or blood.
Laryngoscope : handle and blade
Endotracheal tube
Equipment Required for Successful
Intubation
 Equipment Cont…
 Laryngoscope with relevant size blades.
 Magill forceps.
 Flexible introducer.
 10-20 ml syringe.
 Oropharangeal 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.
Technique of Endotracheal Intubation
(in a ideal setting)
 Technique Cont…
 Position the patient supine, open the airway with
a head-tilt chin-lift maneuver.(Suspected spinal
injury, attempt naso-tracheal intubation, spine
in neutral position.).
 Open mouth by separating the lips and pulling on
upper jaw with the index finger.
 Hold laryngoscope in left hand, insert scope into
mouth with blade directed to right tonsil.
 Once right tonsil is reached, sweep the blade to
the midline keeping the tongue on the left.
 Technique Cont…
 This brings the epiglottis into view.” DO NOT LOOSE
SIGHT OF IT!”
 Advance the blade until it reaches the angle between
the base of the tongue and epiglottis.( volecular 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.
 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.
 Technique Cont…
 Insert the tube just so the cuff has passed the
cords and then inflate the cuff.
 Listed for air entry at both apices and both
axillae to ensure correct placement using a
stethoscope.
 Rules of Intubation
 Always have a suction unit available.
 An intubation attempt should never exceed 30
seconds.
 Oxygenate the patient pre and post
intubation with a bag-valve-mask.(100% O2).
 Have sedative medication available if needed.
(e.g. Midazolam 15mg/3ml)
 Always recheck tube placement manually
guided by oxygen saturation readings.(Spo2).
 Tube sizes
 Newborn – to 4 kg - 2.5 mm (uncuffed).
 1-6 months 4-6 kg – 3.5 mm (uncuffed).
 7-12 months 6-9 kg – 4.0 mm (uncuffed).
 1 year 9 kg – 4.5 mm (uncuffed).
 2 years 11 kg – 5.0 mm (uncuffed).
 3-4 years 14–16 kg - 5.5 mm (uncuffed).
 5-6 years 18–21 kg – 6.0 mm (uncuffed).
 7-8 years 22-27 kg – 6.5 mm ( uncuffed).
 Tube Sizes
 9-11 years 28-36 kg – 7.0 mm(cuffed).
 14 to adults 46+ kg – 7.0 – 80 mm (cuffed).
 Adult female 7.0 – 8.0mm (cuffed).
 Adult male 7.5 – 8.5 mm (cuffed).
 The size of the tube may also be determined by
the size of the patients little finger.
N.B patients below the age of 8 require uncuffed
ETT due to damage caused by the cuff in
younger patients. Always monitor the ECG
activity during intubation.
 4 Rules of Suctioning

 Never suction further than you can see.

 Always suction on the way out.
 Never suction for longer than15 seconds.
 Always oxygenate the patient before and
after suctioning.
 Other Airway Adjuncts

 Kombi-tube.
 Oropharangeal airways/tubes.
 Nasopharyngeal airways/tubes.
 Oro-tracheal tubes.
 Naso-tracheal tubes.
 Conclusion
 Always oxygenate patient before and
after intubation.
 Do not attempt intubation unless you are
totally skilled, rather perform bag-valve-
mask ventilation.
 Always monitor the spo2 readings.
 Always reconfirm tube placement from
time to time.