ENDOTRACHEAL INTUBATION

SKILLS LAB WEEK 2

EDRM 2023-2024
 Indication for endotracheal
intubation
1) For supporting ventilation in patient
with some pathologic disease

: Upper airway obstruction

: Respiratory failure

: Loss of conciousness
Indication for endotracheal intubation (con’t)
2) For supporting ventilation during general
anesthesia

▪ Type of surgery

: Operative site near the airway

: Abdominal or thoracic surgery

Indication for endotracheal intubation (con’t)
: Prone or lateral position

: Long period of surgery

▪ Patient has risk of pulmonary aspiration

▪ Difficult mask ventilation

Function of ETT

Provides a passage for gases to flow between a patients lungs and

an anaesthesia breathing system
Allows one to provide positive pressure ventilation.
Protects the lung from contamination from
Gastric contents and nasopharyngeal matter such as blood.
Indication of ETT

Indications for ET intubation include :

Upper airway obstruction (e.g. secondary to burn, tumor, bleeding)
Apnea
High risk of aspiration
Ineffective clearance of secretions
Respiratory distress
Respiratory arrest.
Cardiac arrest
Contraindication of ETT
The following are only relative contraindications to
tracheal intubation:
Severe airway trauma or obstruction that does not permit safe passage of an
endotracheal tube.
Emergency cricothyrotomy is indicated in such cases.
Cervical spine injury, in which the need for complete immobilization of the
cervical spine makes endotracheal intubation difficult.
Mallampati Classification of class III / IV or other determination of potential
difficult airway.
ANATOMY OF AIRWAY
 AIRWAY ASSESSMENTS
1) Condition that associated with difficult
intubation
: Congenital anomalies ---> Pierre Robin
syndrome , Down’s syndrome
: Infection in airway--> Retropharyngeal
abscess, Epiglottitis
: Tumor in oral cavity or larynx
 AIRWAY ASSESSMENT
1) Condition that associated with difficult intubation (con’t)

: Enlarge thyroid gland

trachea shift to lateral or

compressed tracheal lumen
 AIRWAY ASSESSMENT
1) Condition that associated with difficult intubation (con’t)
: Maxillofacial ,cervical or laryngeal trauma
: Temperomandibular joint dysfunction
: Burn scar at face and neck
: Morbidly obese or pregnancy
 AIRWAY ASSESSMENT
2) Interincisor gap : normal -> more than 3 cms
 AIRWAY ASSESSMENT
3) Mallampati classification: Class 3,4 -> may be difficult
intubation

Soft palate

Uvula
 AIRWAY ASSESSMENT

Laryngoscopic view

grade 3,4 -> risk for difficult intubation

 AIRWAY ASSESSMENT
4) Thyromental distance : more
than 6 cms
 AIRWAY ASSESSMENT
5) Flexion and extension of neck
 AIRWAY ASSESSMENT
6) Movement of temperomandibular joint (TMJ)

Grinding
Equipment preparation
Equipment

Endotracheal tube for proper size

Average female size, 7.5-8.0 mm
Average male sixe, 8.5-9.0 mm
Stylet (metal wire)
Larynscope and blade
Straight blade (Miller)
Curved blade (Macintosh)
Suction
Suction kit
Equipment
Syringe to inflate balloon
Topical anesthetic
Lidocaine jelly or other agent
Water soluble lubricant
Tape or device to secure tube
Stethoscope
Bag-valve device/ manual bag With reservoir
Connected to oxygen at 15 L/min
Optional equipment
– Magill forceps
– Oropharyngeal airway
Advantages and Disadvantages of ETT insertion
ADVANTAGES
easily and quickly performed
larger tube facilitates suction and procedures such as bronchoscopy
less kinking of tube
DISADVANTAGES
not recommended in patients with suspended cervical injury
uncomfortable
mouth care more difficult to perform
impairs ability to gag and swallow
may increase salivation
may cause irritation and ulceration of the mouth
1) Laryngoscope : handle and blade
 LARYNGOSCOPIC BLADE
Macintosh (curved) and Miller (straight) blade
Adult : Macintosh blade, small children : Miller blade

Miller blade Macintosh blade

2) Endotracheal tube
 Endotracheal tube
1) Size of endotracheal tube : internal diameter (ID)

Male: ID 8.0 mms . Female : ID 7.5 mms

New born - 3 months : ID 3.0 mms
3-9 months : ID 3.5 mms
9-18 months : ID 4.0 mms
2- 6 yrs : ID = (Age/3) + 3.5
> 6 yrs : ID = (Age/4) + 4.5
2) Material : Red rubber or PVC

3) Endotracheal tube cuff

High volume Low volume

Low pressure cuff High pressure cuff
4) Bevel
5) Murphy’s eye
6) Depth of endotracheal tube : Midtrachea or below vocal
cord ~ 2 cms
Adult -> Male = 23 cms ,Female = 21 cms
Children
Oral endotracheal tube = (Age/2) + 12 (cm)
Nasal endotracheal tube = (Age/2) + 15 (cm)
7) Tube markings

Z-79 – passed on animal testing

Disposible (Do not reuse)
Oral/ Nasal
Radiopaque marker
3) Other equipments

3.1 Stylet
3.2 Oropharyngeal or nasopharyngeal airway

Oral airway Nasal airway

3.3) Suction catheter
3.4) Slip joint
3.5) Face mask and self inflating bag

3.6) Magill forcep

 3.7) Syringe
3.8) Lubricating jelly
3.9) Plaster for strap endotracheal tube

4. Monitoring success of endotracheal intubation

4.1) Stethoscope
4.2) End tidal - CO2 meter
4.3) Pulse oximeter
 Sniffing position

Flexion at lower cervical spine

Extension at atlanto-occipital joint
Sniffing
position
Steps of oroendotracheal
intubation
Steps of oroendotracheal intubation
Steps of oroendotracheal intubation

Vareculla
Nasoendotracheal intubation
 Nasoendotracheal intubation
Advantage
1. Comfortable for prolong intubation in postoperative
period
2. Suitable for oral surgery : tonsillectomy , mandible
surgery
3. For blind nasal intubation
4. Can take oral feeding
5. Resist for kinking and difficult to accidental extubation
 Disadvantage
1. Trauma to nasal mucosa
2. Risk for sinusitis in prolong intubation
3. Risk for bacteremia
4. Smaller diameter than oral route -> difficult for
suction
 Contraindication
for nasoendotracheal intubation

1) Fracture base of skull

2) Coagulopathy
3) Nasal cavity obstruction
4) Retropharyngeal abscess
 Complication of endotracheal intubation

1) During intubation
Trauma to lip, tongue or teeth
Hypertension and tachycardia or arrhythmia
Pulmonary aspiration
Laryngospasm
Bronchospasm
Complication of endotracheal intubation (Con’t)
1) During intubation
: Laryngeal edema
: Arytenoid dislocation -> hoarseness
: Increased intracranial pressure
: Spinal cord trauma in cervical spine injury
: Esophageal intubation
Complication of endotracheal intubation(Con’t)
2) During remained intubation

• Obstruction from klinking , secretion or

overinflation of cuff
• Accidental extubation or endobronchial intubation
• Disconnection from breathing circuit
 Complication of endotracheal
intubation(Con’t)
2) During remained intubation
Pulmonary aspiration
Lib or nasal ulcer in case with prolong period
of intubation
Sinusitis or otitis in case with prolong
nasoendotracheal intubation
Complication of endotracheal
intubation(Con’t)
3) During extubation
Laryngospasm
Pulmonary aspiration
Edema of upper airway
 Complication of endotracheal
intubation(Con’t)
4) After extubation
Sore throat
Hoarseness
Tracheal stenosis (Prolong intubation)
Laryngeal granuloma