INTUBATION
Perioperative intubation provides a means for:
1. Airway patency and protection
2. Mechanical ventilation
3. Ability to remove secretions
Primary Need
Surgery
Prevention of loss of control of the airway
Cases where gas exchange is likely to be impaired
Prolonged general anesthetic
Complicated cases
Unusual positions for surgery
Need for muscle relaxants during surgery
Patient
Airway protection
Need for tight control over CO2
Need for post op ventilation
Secondary Need:
Complications Arise: Surgical procedure changes
Primary route of airway management becomes
inadequate: Inadequate ventilation due to total or partial
pharyngeal obstruction/laryngospasm
A surgical/anesthestic complication occurs
High/total spinal
Massive blood loss
Malignant hyperthermia
Regional anesthetic is inadequate or wears off
Types of Laryngoscopes/Blades
Pediatric considerations
Estimation of ET tube size: 4 age/4
Uncuffed ET tubes should be used in patients 8 years old
Straight Miller blade is preferred in patients 3 years old
Preferred surgical airway is PTV for patients 12 years old
Types of Endotracheal Tubes
Estimation of ET tube size: 4 age/4
Uncuffed ET tubes should be used in patients 8 years old
Straight Miller blade is preferred in patients 3 years old
Preferred surgical airway is PTV for patients 12 years old
Preparation for General Anesthesia
Check airway equipment to ensure proper functioning
Free flowing IV, suction, O2
IV or inhalational anesthetics and muscle relaxants
Proper positioning of the patient
Preoxygenation
“Sniffing” Position
Why Preoxygenate?
How to Preoxygenate
3 minutes of tidal volume breathing
1 min of 8 deep breaths
0.5 min of 4 deep breaths
Intubation Technique
Cormack-Lehane Laryngeal View
Confirmation of Endotracheal Intubation
1. Observe chest wall movement/Palpation of chest
excursion
2. Auscultation of chest and epigastrium: Auscultate over
stomach, axillae, and anterior lung fields
3. Characteristic “feel” of the reservoir bag
4. Palpation of the cuff in the suprasternal notch
5. Tube condensation with exhalation
6. Carbon Dioxide detection (standard of care), End-tidal CO2
colorimetric device
Capnometry
Capnography
7. Fail safe methods: most reliable
Direct visualization of the ETT between the cords
Bronchoscopy
Complications of Intubation
Airway trauma
Tooth/soft tissue damage, sore throat to tracheal
stenosis, post-intubation croup, hoarseness (VC
damage/paralysis)
Nasal—epistaxsis, sinusitis
Physiologic responses to airway manipulation
Hypertension/tachycardia
IOH, ICH
Laryngospasm
Tube malpositioning
Esophageal/endobronchial intubation, unintended
extubation, laryngeal cuff position
Tube malfunction
Ignition, cuff perforation, obstruction
The Difficult Airway and the Failed Airway
“The difficult airway is something you predict whereas the
failed airway is something you experience”
--Ron Walls, MD
The Failed Airway ~1%
Definition
Inability to maintain saturations >90%
Inability to intubate after 3 attempts
Two Situations
Can’t intubate, can ventilate: Have time
Can’t intubate, can’t ventilate (CICV), NO TIME!!!,
1/2,500-1/10,000
Number 1 reason—failure to perform an a/w exam
The Difficult Airway
Very difficult to define
Based on predictors known to be associated with
challenging airway
The geometry of the airway: MP, MO, TMD, TMJ mobility,
head extension, buck teeth, short/thick neck…..
