Endotracheal Intubation

Oleh: dr. Natalia Rasta M

Pembimbing: dr. Eko Widya, Sp. EM

Anatomy

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 Definition
• The Placement of a tube into the trachea.

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 Indication
Absolute Relative
• GCS <9 • Facial burn and
• CPR Resucitation inhalation injury
• Airway obstruction not relieved by simple
airway manoevers • Obesity
• Airway protection from esophageal soiling
during anaesthesia: gastro-esophageal
reflux, pregnancy, emergency surgery,
inadequate fasting time
• Restricted access to the patient or the
airway during sugery: prone positioning,
neurosurgery, ENT or maxillofacial shared
airway surgery
• Prolonged inttermittent positive pressure
ventilation: prolonged surgery, intensive
care, respiratory disease, lung injury or
muscular pathologies

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Contraindication

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 Preparation
1.Assess airway
Use LEMON mnemonic to predict difficulty of
airway.
• Look externally: If you sense that an airway appears
difficult, it likely is.
• Evaluate anatomy: The 3-3-2 Rule
– Thyromental distance: < 3 of the patient's finger widths is
predictive of difficult airway.
– Mouth opening: If the patient's open mouth can fit <3 of the
patient's own fingers, it is predictive of a difficult airway.
– Hyomental distance: A distance of <2 of the patient's finger
widths is predictive of a difficult airway.

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• ▶ Mallampati Score: Roughly correlates the view of
internal oropharyngeal structures with successful
intubation attempts. Graded as class I to IV.
• ▶ Obstruction: Any evidence of upper airway
obstruction heralds a difficult airway.
• ▶ Neck mobility: Neck mobility is crucial to obtaining
the optimum view of the larynx. Hindrance

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Mallampati Score
Soft palate

Uvula

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2. Instruments

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1) Laryngoscope : handle and blade

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 LARYNGOSCOPIC BLADE
 Macintosh (curved) and Miller (straight) blade
 Adult : Macintosh blade, small children : Miller blade

Miller blade Macintosh blade 13

2) Endotracheal tube

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 Instruments used...
3. Self-refilling bag-valve combination (eg,
Ambu bag) or bag-valve unit (Ayres bag),
connector, tubing, and oxygen source.

4. Tincture of benzoin and precut tape.

5. Introducer (stylets or Magill forceps).

6. Suction apparatus (tonsil tip and catheter

suction).

7. Syringe, 10-mL, to inflate the cuff.

8. Mucosal anesthetics (eg, 2% lidocaine)

9. Water-soluble sterile lubricant.

10. Gloves.

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Essentials that must be present to ensure a safe intubation: SALT
 Suction.

 Airway. the oral airway is a device that lifts the tongue off the
posterior pharynx, often making it easier to mask ventilate a
patient.

 Laryngoscope. This lighted tool is vital to placing an endotracheal

tube.

 Tube. Endotracheal tubes come in many sizes. In the average adult

a size 7.0 or 8.0 oral endotracheal tube will work just fine.

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 Tecnique:

Sniffing position

Flexion at lower cervical spine

Extension at atlanto-occipital joint

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 Topical Anesthesia: Anesthetize the
mucosa of the oropharynx, and
upper airway with lidocaine 2%, if
time permits and the patient is
awake.

Direct Laryngoscopy:

1. Place the patient in the sniffing

MADgicWand™ Mucosal Atomization Device for
atomizing topical solutions. With 5mL syringe position.

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 close at hand.

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a)
Curved blade technique
Open the patient's mouth with the
right hand, and remove any dentures.

b) Grasp the laryngoscope in the left

hand

c) Spread the patient's lips, and insert

the blade between the teeth, being
careful not to break a tooth.

d) Pass the blade to the right of the

tongue, and advance the blade into
the hypopharynx, pushing the tongue
to the left.

e) Lift the laryngoscope upward and

forward, without changing the angle
of the blade, to expose the vocal
cords.

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f) The anesthesiologist then takes the endotracheal tube, made of flexible
plastic, in the right hand and starts inserting it through the mouth
opening.
g) The tube is inserted through the cords to the point that the cuff rests
just below the cords

h) Finally, the cuff is inflated to provide a minimal leak when the bag is
squeezed
Using a stethoscope , the anesthesiologist listens for breathing sounds to
ensure correct placement of the tube

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