ENDOTRACHEAL INTUBATION

Definition:
It is the placement of a tube into the trachea (windpipe) in order to maintain an open airway in
patients who are unconscious or unable to breathe on their own. Oxygen, anesthetics, or other
gaseous medications can be delivered through the tube.

Indications for Endotracheal Intubation:

Respiratory:
 Apnoea
 Acute respiratory failure ( PaO2< 50 mm and PaCO2 > 55 mm Hg)
 To control oxygen delivery( eg. Institution of positive end- expiratory pressure [ PEEP] )
 To control ventilation ( eg, to decrease work of breathing, to control PaCO2)
 Cardiopulmonary arrest
 Upper airway obstruction
 Trauma to the airway
 Burns ( concern for airway edema)

Neurologic:
 Inadequate chest wall function (eg, in patient with Guilain Barre syndrome)
 Absence of protective airway reflexes ( eg,cough, gag).
 Glassgow coma score≤ 8.

Others:
 During anaesthesia.
 Poisoning
 Anaphylactic reaction

Routes of Endotracheal Intubation

Endotracheal Intubation

Oro tracheal intubation Naso tracheal intubation

Orotracheal intubation :
In endotracheal intubation an endotracheal tube is passed through the mouth, larynx, and
vocal cords, into the trachea

Advantages of orotracheal intubation

 Tube can be inserted usually with more speed and ease with less
trauma
 Easier suctioning
 Less airflow resistance
 Reduced risk of tube kinking
Disadvantages of Oral Intubation
 Gagging, coughing, salivation, and irritation can be induced with intact airway reflexes
 Tube fixation is difficult, self-extubation
 Gastric distention from frequent swallowing of air
 Mucosal irritation and ulcerations of mouth (change tube position)

Nasotracheal intubation:
In this type of intubation a tube is passed through the nose, larynx, vocal cords, and trachea

Indications of Nasotracheal intubation:

 Obstructing mass in oral cavity
 Oral surgery
 Fracture mandible
 Inadequate mouth opening
 Neck injury
 For awake intubation ,nasal intubation is preferred over oral intubation
 When tube is to be kept for prolonged periods in intensive care units.

Contraindication of Nasotracheal intubation:

 Basal skull fractures and CSF rhinorrhea
 Bleeding disorders
 Nasal polyps
 Previous nasal surgery

Advantages of Nasal Intubation:

 More comfort long term
 Decreased gagging
 Less salivation, easier to swallow
 Improved mouth care
 Better tube fixation
 Improved communication

Disadvantages of Nasal Intubation

 Pain and discomfort
 Nasal and paranasal complications, i.e., epistaxis, sinusitis
 More difficult procedure
 Increased airflow resistance
 Difficult suctioning
 Bacteremia

Orotracheal intubation versus Nasotracheal intubation:

 Orotracheal intubation is the usual method of intubation

 Nasal intubation is performed when the oral route is difficult and impossible.
 There is increased risk of sinusitis with Nsotracheal intubation.

A study was conducted Depoix AP by to assess time for intubation, incidence of

mechanical complications, occurrence of bacteraemia caused by intubation, and postoperative
discomfort in relation to nasal and oral tracheal intubation in adult cardiac surgery in U K.The
results of study revealed that the time for placement of the tube was 2.5 times longer for nasal
intubation. Nasal bleeding was observed in 45.3% of patients intubated through the nose. In
patients in whom a naso-tracheal tube was passed, 9.4% (v. 2.3% of patients intubated via the
mouth), exhibited positive blood cultures just after intubation. Postoperative discomfort was
similar in both groups. It can be concluded that nasal tracheal intubation offers no advantage
over oral tracheal intubation in adult cardiac surgery.
Techniques of intubation:
1. Direct laryngoscopic intubation
2. Fibreoptic bronchoscopic intubation
3. Blind nasal intubation
4. Retrograde intubation
5. Rapid sequence induction

Direct laryngoscopic intubation:

 A laryngoscope is used to obtain a view of the glottis.

 A tube is then inserted under direct vision.
 This technique can usually only be employed if the patient isComatose (unconscious),
Under general anesthesia or Has received local or topical anesthesia to the upper airway
structures.

2. Fiberoptic Bronchoscopic Intubation:

 Fiberoptic endotracheal intubation is a useful technique in a number of situations
 Flexible fiberoptic bronchoscopy allows for indirect visualization of the larynx.  The endoscope
is introduced through the mouth or nose.  Once anatomic structures are recognized, and the
larynx or trachea are entered under direct visualization.
 It can be used when the patient's neck cannot be manipulated, as when the cervical spine is not
stable.
 It can also be used when it is not possible to visualize the vocal cords because a straight line
view cannot be established from the mouth to the larynx.
 Fiberoptic bronchoscopic intubation can be performed either awake or under general anesthesia
 It can be performed either as the initial management of a patient known to have a difficult
airway,

Indications:
 Anticipated difficult intubation (upper airway abnormality)
 Endotracheal intubation when neck extension is not desirable (cervical spine injury,
rheumatoid arthritis

Contraindications:
 Inability to oxygenate
 Major bleeding

Advantages
 Excellent airway visualization
 Minimal hemodynamic stress

Disadvantages
 Costs associated with the need for special equipment and skill

A study was conducted by Zhang Guo-hua et all to assess the effect of fiberoptic
bronchoscope compared with direct laryngoscope on hemodynamic responses to orotracheal
intubation in beijing china. The intubation time was significantly longer in the FOB group
((34.9±8.5) seconds) than in the DLS group ((27.8±10.7) seconds) (P<0.05). No significant
differences were seen in the demographic data and in the baseline values of BPs and HRs No
significant differences were in BPs at any time point in the maximal values of BPs during the
observation between the two groups. HRs at intubation and 1 minute after intubation were
significantly higher in the FOB group than in the DLS group.
3. Blind nasotracheal intubation:
 it is the passage of tube through the nose into the trachea without using a laryngoscope.
 The blind nasotracheal technic is especially valuable for intubating spontaneously breathing
patients with or without sedation, or under general anesthesia.
 It may be used in elective as well as selected emergent situations.

4. Retrograde Intubation:
 A J-tip guide wire is introduced percutaneously through the cricothyroid membrane, and
advanced into the retropharynx
 The tip is retrieved from the oral cavity, and the wire is used to guide an oral endotracheal tube
into the trachea
 The procedure is relatively safe and simple alternative if other techniques fail or not possible

5. Rapid Sequence Induction

Definition : the standard procedure of providing sedation and neuromuscular paralysis in

preparation of intubation is called rapid sequence induction. It minimizes or prevents the many of
patient’s response to noxious stimuli of intubation , such as increased ICP, It is intended for those
patients who are considered at risk of aspiration of stomach contents, the so - called “full stomach”
patients; as an effort to decrease the potential occurrence of pulmonary aspiration

Indications of Rapid sequence induction:

Any patient at risk of aspiration, this includes the following;

 Patients with full stomach (any emergent case or trauma patient)

 Pregnant patients

 Delayed gastric emptying

Contraindications of Rapid sequence induction:

 Apenic and pulseless patients

 Patient has potentially difficult airway

Medications required for rapid sequence induction:

Premedication:

1. Lidocaine

Description: Lidocaine is a local anesthetic of the amide class. It’s mechanism of action is by stabilizing
the membranes of neuronal tissue through the inhibition of sodium passage which is needed to conduct
impulses.

Indications: Local anesthesia, blunting hemodynamic response to intubation, treatment of ventricular

arrhythmias.

Precautions: Patients with heart block, severe hypovolemia, congestive heart failure.
Dosage: 1-2 mg/kg 3-5 minutes prior to intubation.

Route: Intravenous

2. Atropine

Description: it is rapid onset acetylcholine receptor antagonist . The vagolytic effect also blocks the
bradycardia caused by airway manipulation. It also reduces salivary and airway secretions.

Dosage: 0.02 mg/kg and a maximum dose of 0.4mg/ kg .I/v

3. Fentanyl

Description: Fentanyl is a highly potent opioid analgesic compound in the same family as morphine. It is
100 times more potent than morphine. Fentanyl has a rapid onset and short duration of action. It is
cardiovascularly stable and tends to support blood pressure. Respiratory depression is common and dose
dependent. It too, is accentuated by the presence of other depressants. Fentanyl possess some sedating
properties. It’s effects can be reversed with naloxone.

Indications: Analgesia/sedation, premedication prior to intubation

Precautions: Elderly, hypovolemic, or patients with other sedatives should have reduced dosages.

Dosage: 3-5 mcg/kg 3-5 minutes prior to intubation.

Route: Intravenous

Induction Agents

1. Sodium Thiopental

Description: Sodium thiopental (STP) is in the barbiturate class of agents. It is ultrashort - acting, has a
rapid onset with the induction of hypnosis and amnesia. Cardiac depression and vasodilatation with
hypotension can be severe. It is a potent respiratory depressant. STP is primarily used for the induction
of anesthesia.

Indications: Induction agent, Anticonvulsant, Sedative, Intracranial pressure control

Contraindications: Presence of porphyria

Precautions: STP will cause hypotension from cardiac depression and therefore should be used with
caution or in reduced doses in patients who are or are at risk of hypovolemia and/or hypotensive,
hypertensive, cardiac history, elderly patients.

Dosage: 3-5mg/kg

Route: Intravenously

2. Etomidate

Description: Etomidate is a nonbarbiturate induction agent that lacks analgesic properties as well. It has
minimal cardiovascular effects and maintains blood pressure. It too, is a potent respiratory depressant.
Etomidate has been reported to decrease adrenal steroid response. Myoclonus (jerky, muscular
contractions) may be seen after administration. It has a rapid onset with a short duration of action.

Indications: As induction agent, particularly useful in patient at risk of hypovolemia, with history of
cardiac disease, or hypertension.

Precautions: Patients with hypertension, hypovolemia, or elderly may need decreased dosages.

Dosage: 0.1 - 0.4 mg/kg

Route: Intravenous

3. Ketamine

Description: Ketamine is a phencyclidine (PCP) derivative that is rapid acting in producing a

“dissociative” anesthesia in which the patient is detached from their nervous system. It has minimal
cardiac depression and may increase heart rate and blood pressure by central sympathetic stimulation.
Ketamine is a bronchodilator and has minimal respiratory depression with respiratory stimulation seen
frequently. There is a characteristic increase in salivary secretions after administration. Unlike the other
agents, ketamine has potent analgesic properties as well.

Indications: Induction agent, analgesia.

Contraindications: Patients with increased intracranial pressure

Precautions: Hypotension may be seen in patients who are relying on their sympathetic drive; use
caution in patients with hypertension or cardiac disease; hallucinations and emergence reactions are
common.

Dosage: 1 - 2 mg/kg

Route: Intravenous

4. Propofol

Description: Propofol is a white, milky, alcohol emulsion that produces a rapid onset of anesthesia with
no analgesic effects. It is rapidly metabolized and redistributed to give a short duration of action. It is a
potent vasodilator and cardiac depressant with hypotension seen after administration. It is a potent
respiratory depressant.

Indications: Induction agent, sedative.

Contraindications: Patients with soybean or egg allergies.

Precautions: Elderly patients, hypovolemic patients, hypertensive patients, reduced dosages are needed;
may cause vascular irritation if given in small vein; emulsion supports growth of bacteria and is intended
for single use.

Dosage: 2 mg/kg

Route: Intravenous

5. Midazolam
Description: Midazolam is a benzodiaezepine in the same family as diazepam. It is short acting and has
a fairly rapid onset. It is possesses antianxiety, amnesic, anticonvulsant, and sedating properties for
which it is commonly used for. It has no analgesic properties. It has the potential to decrease blood
pressure, and is a respiratory depressant as well, which is increased if another depressant is already
present (alcohol, narcotics). May be reversed by antagonist flumazenil.

Indications: Sedation

Precautions: Respiratory depression may worsen intracranial pressure. Use reduced dosages in elderly,
hypovolemic, or patients with other depressants present.

Dosage: 0.5 - 1mg dosages; titrated to effect

Route: Intravenous

Neuromuscular Blockers

1. Succinylcholine

Description: Succinylcholine is a depolarizing muscle relaxant. Cardiovascular effects are minimal

however, bradycardia and arrhythmias may be seen.). This, as all paralyzing agents, have no sedative or
analgesic properties.

Indication: Rapid skeletal muscle relaxation

Contraindications: patients with deficiencies of pseudocholinesterase; history or family history of

malignant hyperthermia; penetrating eye injuries.

Precautions: Use with caution, if at all, in any patients suspected of having a difficult airwayDosage: 1-2
mg/kg

Route: Intravenous

2.Rocuronium

Description: Rocuronium is is a competitive, non - depolarizing muscle relaxant. It binds to the

receptors and competes for the sites with acetylcholine. it has a rapid onset, ( 60 seconds) and a
decreased duration of action. Both onset and duration are dose dependent. Generally lasts 15 - 20
minutes. Cardiovascular effects are minimal, may see tachycardia. Rocuronium’s favorable onset has
made it the drug of choice in RSI when there is a contraindication or concern with the use of
succinylcholine.

Indications: Muscle relaxation.

Precautions: Same as vecuronium.

Dosage: Intubating (RSI) - 1mg/kg; Maintenance - 0.1mg/kg

Route: Intravenous.

Procedure OF RSI

 All equipment is available and functional (laryngoscopes, ETT, suction, # 11 scalpel, pulse
oximeter/end tidal CO2 monitor, ECG and BP monitor).
  IV access is established.

 Preoxygenation with non -rebreather mask or AMBU bag - valve assisted ventilations with the
application of cricoid pressure.

 Premedications, if any, are administered.

 The induction agent is administered.

 The paralytic agent is given immediately following induction

 .Laryngoscopy and intubation is performed

 .Endotracheal tube placement is confirmed (listening for bilateral equal breath sounds, absence
of breath sounds over the stomach, esophageal detector, presence of end tidal CO2, observing
symmetrical chest expansion).

 Cricoid pressure is then released

 Tube is secured.

 Patient is ventilated with additional paralysis and sedation as needed.

Complications of RSI

 Cardiac collapse
 Exacerbation of an elevated ICP may occur if an inappropriate RSI is used.

EQUIPMENTS REQUIRED FOR ENDOTRACHEAL INTUBATION:

1. Laryngoscope with relevant size blades:: it is used for visualising glottis to facilitate intubation.
It consists of handle and blade with a bulb.
 Macintosh (curved) and Miller (straight) blade
 Macintosh blade: it is commonly used type. It is a curved blade and is available in 4 sizes
smallest for children and largest for adult with long neck. It is mainly used for adults.
 Miller blade: it is a straight blade with curve at a tip only. It is also available in different
sizes

Pediatric laryngoscope blade sizes

Weight size/ type

0-3 months 0 (straight)

3months- 1.0(straight)
3years
3yr-12yr 2.0(straight or curved)

12-18yr 3.0( straight or curved)

2. Endotracheal tube: The types of endotracheal tubes are
 Cuffed endotracheal tubes
 Uncuffed endotracheal tubes

Cuffed endotracheal tubes:

An endotracheal tube with a balloon at one end that may be inflated to tighten the fit in the lumen
of the airway . The balloon forms a cuff that prevents gastric contents from passing into the lungs and
gas from leaking back from the lungs. Both high-pressure and low-pressure cuffs are used. Over
inflation of the cuff can cause contusion, hemorrhage, mucosal sloughing, or stenosis. these tubes have
Pilot balloon with integral one-way valve .Size of tube also clearly marked on the pilot balloon The cuff
is optimally designed for routine intubation Pilot balloon indicates intracuff pressure and is clearly
marked with tube size for immediate identification

Types of cuffs:

High pressure low volume cuff: high pressure, low volume cuff operates by distending a rubber
balloon around the tip of the tube, thus sealing the trachea. This carries the risk that the pressure within
the cuff can cause trauma to or necrosis of the tracheal wall.

Low pressure, high volume cuff: it has a much greater volume than the traditional cuff, and so
requires a lower inflation pressure to produce a seal. There is, therefore, less risk of trauma to the
trachea. However, there is a danger that, if the cuff is over-inflated, rupture of the trachea can occur. It is
important that only very low pressures should be used to inflate these cuffs.

Uncuffed endotracheal tubes:

These tubes are used in children under the age of 12. This is because the paediatric airway is
narrowest in the sub glottic area, and it is essential that the fit is not too tight or else there will be
necrosis of the mucosal lining. When intubating a child there must always be an audible leak.

Age Internal Distance between Type of ET tube

diameter(mm) lips and location in
mid trachea of
distal end(cm)
Premature 2.5 ` Wt in kg + 6cm uncuffed
Full term 3.0 Wt in kg + 6cm uncuffed
1-6 months 3.5 12- 13 uncuffed
6-18 months 3.5-4.0 13-14 uncuffed
18m -3 years 4.0- 4.5 13.5-14.5 uncuffed
3-5 years 4.5 14.5-15.5 uncuffed
5-6 years 5.0 15.5-17 uncuffed
6-8 years 5.5-6.0 17-19 uncuffed
8-10 years 5.5-6.0 19-20 cuffed
10-12 years 6.0-6.5 20-21 cuffed
12-14 years 6.5-7.0 21-22 Cuffed
14-16 years 7.0-8.0 22-23 cuffed
Formula for calculating the size of ET tube

 Predicted Size Uncuffed Tube = (Age / 4) + 4

 Predicted Size Cuffed Tube = (Age / 4) + 3
 A prospective randomized controlled multi-centre trial of cuffed or uncuffed endotracheal tubes in
small children was conducted in Zurich, Switzerland The aim of this study was to compare post-
extubation morbidity and TT exchange rates when using cuffed vs uncuffed tubes in small children.
Methods for study: Patients aged from birth to 5 yr requiring general anaesthesia with TT intubation
were included in 24 European paediatric anaesthesia centres. Patients were prospectively randomized
into a cuffed TT group (Microcuff® PET) and an uncuffed TT group (Mallinckrodt®, Portex®,
Rüsch®, Sheridan®). Endpoints were incidence of post-extubation stridor and the number of TT
exchanges to find an appropriate-sized tube. For cuffed TTs, minimal cuff pressure required to seal the
airway was noted; maximal cuff pressure was limited at 20 cm H2O with a pressure release valve.

Results of the study:

 A total of 2246 children were studied (1119/1127 cuffed/uncuffed).
 The age was 1.93 (1.48) yr in the cuffed and 1.87 (1.45) yr in the uncuffed groups.
 Post-extubation stridor was noted in 4.4% of patients with cuffed and in 4.7% with uncuffed TTs
(P=0.543).
 TT exchange rate was 2.1% in the cuffed and 30.8% in the uncuffed groups (P<0.0001).
Minimal cuff pressure required to seal the trachea was 10.6 (4.3) cm H2O.
Conclusions of the study: The use of cuffed TTs in small children provides a reliably sealed airway
at cuff pressures of 20 cm H2O, reduces the need for TT exchanges, and does not increase the risk
for post-extubation stridor compared with uncuffed TTs.

3. Oropharangeal airways – all sizes.

4. Magill forceps
5. Stylet
6. Self inflating Bag with mask
7. Suction unit with nozzle
8. Suction cathetar
9. Tongue blade
10. Bite block
11. 10 – 20 ml syringe
12. Stethoscope
13. Gloves
14. Mask

PROCEDURE OF INTUBATION:

Preparation of Patient:
 Obtain consent
 Assessment of airway: assess for
1.Condition that associated with difficult intubation
 Maxillofacial ,cervical or laryngeal trauma
 Infection in airway: Retropharyngeal abscess, Epiglottitis
 Tumor in oral cavity or larynx
 Enlarge thyroid gland
 Burn scar at face and neck

2.Interincisor gap : it is the distance between the upper and lower incisors. normal -> more than 3
cms. It is assessed to see to opening of mouth for inserting the laryngoscope.

3. Mallampati classification: This system is a method for quantifying the degree of difficulty of
endotracheal intubation based on amount of posterior pharynx that can be visualized.this
method gives an indirect means of evaluating the relative proportionality of the base of the
tongue and oropharynx. If the base of the tongue is proportional to the oropharynx then the
exposure of glottic inlet is will not be difficult. On the other hand , a disproportionately large
 base of the tongue overshadows the larynx and perhaps makes the angle between the two more
acute preventing easy exposure of the larynx
Class 1- soft palate, fauces, entire uvula, tonsillor pillars are visible
Class 2- soft palate, fauces, part of uvula
Class 3- soft palate, base of uvula
Class4 – soft palate not visible at all

4.Laryngoscopic view:
Grade 1- most of the glottis visible
Grade 2- Only the posterior of the glottis visible
Grade 3- No parts of the glottis visible
Grade 4- not even glottis is visible
In grade 3 and 4 there is risk for difficult intubation.

5. Thyromental distance : Measure from upper edge of thyroid cartilage to chin with the head fully
extended. A short thyromental distance equates with an anterior larynx that is at a more acute angle and
also results in less space for the tongue to be compressed into by the laryngoscope blade.Thyromental
distance less than 6 cm may predict a difficult intubation

6. Flexion and extension of neck: it assess the feasibility to make sniffing position for intubation i.e
alignment of oral, pharyngeal and laryngeal axis into an arbitary straight line.

7. Movement of temperomandibular joint (TMJ): this is assessed for introduction of laryngoscope

 Positioning of the patient:Sniffing position is given. This position is given by flexion at lower
cervical spine and extension at atlanto occipital joint
 Positionning In children: A sniffing position without hyperextension of
the neck is usually appropriate for infants and children .It is helpful to
place the towel under the child’s shoulder.

Prior to intubation:
 Check the intubation equipment before beginning.
 Attach the blade to the handle and be sure that the bulb illuminates
 Attach suction to suction machine and be sure that suction is turned on.
 If using a stylet, insert it into endotracheal tube
 The tip of the stylet should be 1-2 cm proximal to distal end of endotracheal tube ,ensuring that
the stylet does not go through murphy eye
 Prepare to monitor the patient’s heart rate, oxygen saturation levels and blood pressure

Steps of procedure:
 Hand washing
 Preoxygenate with 100% oxygen
 Administer 0.01 – 0.02 mg/kg IV of atropine
 Wear gloves
 Laryngoscope handle is held with the left hand
 Insert the laryngoscope blade in the patients right side of the mouth and sweep to the center of
the mouth
 When a curved blade/ straight blade is used, the tip of the blade is advanced into the vallecula.
 When a straight blade is used, the tip of the blade is inserted under the epiglottis
  Apply sellick’s maneuver
 Lift the laryngoscope blade in an upward motion
 The handle must not be used with a prying motion, and the upper teeth must not be used as a
fulcrum
 Visualize the vocal cords
 Using the right hand, insert the endotracheal tube until you see the cuff pass through the vocal
cords. Advance the tube an additional ½ to 1 inch for proper placement.
 Remove the laryngoscope carefully from the patients mouth
 Remove the stylet from the endotracheal tube
 Ventilate the patient
 Check for proper placement
Observational methods to confirm correct tube placement:
- Direct visualization of the tube passing through the vocal
cords
- Clear and equal bilateral breath sounds on auscultation of the
chest
- Absent sounds on auscultation of the epigastrium
- Inflate the endotracheal tube’s cuff with 10 cc’s of air
- Equal bilateral chest rise with ventilation
- Fogging of the tube
- An absence of stomach contents in the tube

Instruments to confirm correct tube placement:

- Colorimetric end tidal CO2 detector
- Waveform capnography
- Self inflating esophageal bulb
- Pulse oximetry (patients with a pulse) - delay in fall of
saturation, especially if pre-oxygenated
- Oesophageal Detection Device (ODD)

 Tape endotracheal tube securely in place

 Continue to ventilate patient and suction as necessary

COMPLICATIONS:
At the time of intubation:
 Failed intubation
 Laryngospasm
 Oesophageal intubation
 Bronchial intubation
 Airway perforation
 Nasal , pharyngeal, laryngeal, uvular ,tracheal trauma

During remained intubation

 Obstruction from kinking , secretions or overinflation of cuff
 Accidental extubation or endobronchial intubation
 Disconnection from breathing circuit
 Pulmonary aspiration
 Lip or nasal ulcer in case with prolong period of intubation
 Sinusitis or otitis in case with prolong nasoendotracheal intubation

During extubation:
 Difficult extubation
 Aspiration of oral or gastric contents
After extubation:
 Sore throat
 Laryngeal oedema
 Hoarseness
 Superficial laryngeal ulcers
 Laryngeal granuloma
 Vocal cord paralysis
 Tracheal stenosis

NURSING CARE OF A PATIENT WITH ENDOTRACHEAL INTUBTION:

Assessment:
 The nurse has a vital role in assessing the patient’s status
 Physical assessment includes systematic assessment of all body systems, with and indepth focus
on respiratory system
 Respiratory assessment includes respiratory rate and pattern, breath sounds, potential evidence
for hypoxia
 Auscultate breath sounds of anterior and lateral chest bilaterally
 Monitor for sign and symptoms of aspiration.

1. Nursing diagnosis
 Risk for ineffective airway clearance related to increased secretions secondary to endototracheal
intubation or displacement of endotracheal tube
Goal:
 Maintainance of patent airway

Nursing interventions:
 Assess for the presence of secretions by lung auscultation at least every 2-4 hours
 Clear the airway by suctioning. Frequency of suctioning should be determined by patient’s
assessment
 Chest physiotherapy should be done
 Position should be changed frequently
 Nurse must monitor for the proper placement of ET Tube at least every 2 – 4 hours

2.Nursing diagnosis:
 Risk for trauma and infection related to endotracheal intubation

Goal:
 Prevention of trauma and infection

Nursing interventions:
 The nurse must ensure that there is minimal pulling or distortion of tube in the trachea ; this
reduces the risk of trauma to the trachea.
 Cuff pressure is monitored every 8 hourly to maintain the pressure at less than 25 cm of water
 The nurse evaluates the for the presence of cuff leak
 The nurse administer 0ral care frequently
 The endotracheal tube should be retaped or secured every 24 hours and as needed
 If the patient is nasally intubated, the nurse should remove the old tape or ties and clean the skin
around the ET tube with saline soaked gauze or cotton swab
 If the patient is orally intubated, the nurse should remove the bite block ( if present) and the old
tape and ties and replace with the other one.
3. Nursing diagnosis:
 Impaired verbal communication related to inability to produce speech secondary to endotracheal
intubation

Goal:
 Fostering adjustment to nonverbal methods of communication

Nursing interventions :
 The nurse assesses the patient’s communication abilities to evaluate for limitations
 The nurse offers several appropriate communication approaches like writing pad and pencil or
magic slate, gesturing etc.
 The nurse should make sure that the patient’s eyeglasses, hearing aids are available to enhance
the patient’s ability to communicate
 The patient should be assisted to find the most suitable communication methods.

4. Nursing diagnosis:
 Impaired mobility related to ventilator dependency

Goal:
 Attainment of optimal mobility

Nursing interventions:
 As muscle activity and mobility are beneficial as they stimulate respirations and improve morale
 The nurse provide active and passive range of motion exercises every 6-8 hrly
 The nurse assist the patient whose condition has become stable to get out of bed and to a chair
as soon as possible.
 Conclusion
Endotracheal intubation is a boon for maintenance of patent airway in order to save the life
of a patient and it possess many advantages over other methods of airway management . This
statement is supported by an epidemeological study which was conducted by Kapadia, Farhad N,
Bajan to assess the rate of occurrence and nature of airway accidents in intubated patients Hinduja
National Hospital and Medical Research Center, Mumbai .Prospective recording of all airway
accidents in a 16-bed multidisciplinary intensive care unit was done. A total of 5,046 ventilated
patients intubated for 9,289 days during 4 yrs .Results of the study showed the total accident rate
was 36 of 5,046 patients during 9,289 intubated patient days; Researchers draw Conclusion that
Airway accidents occurred at low levels with even lower rates of resultant morbidity and mortality.
Tracheostomy accidents are more common than those with an endotracheal tube.

SUMMARY

Today we have discussed about:

 Definition of endotracheal intubation
 Indications of endotracheal intubation
 Routes of endotracheal intubation
 Techniques of endotracheal intubation
 Equipments required for endotracheal intubation
 Procedure of endotracheal intubation
 Complications of endotracheal intubation
 Nursing care of patient with endotracheal intubation
 Conclusion
 BIBLIOGRAPHY

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