ENDOTRACHEAL
INTUBATION
ANATOMY AND PHYSIOLOGY
ANATOMY OF AIRWAY
What is ENDOTRACHEAL
INTUBATION?
• Endotracheal intubation - is a
medical procedure in which a
flexible tube is placed into the
trachea in order to maintain an
open airway in patients who
are unconscious or unable to
breathe on their own.
What is ENDOTRACHEAL
INTUBATION?
• Involves passing an endotracheal tube
through the mouth or nose into the trachea.
• Intubation provides a patent airway when the
patient is having respiratory distress that
cannot be treated with simpler methods.
• It is the method of choice in emergency care.
• There are different types of intubation
classified according to the location of the
tube and what it’s trying to accomplish.
Purposes of intubation
• To open up the airway to give oxygen, anesthesia, or
medicine.
• To remove blockages.
• To help a person breathe if they have collapsed lungs, heart
failure, or trauma.
• To allow doctors to examine the airways.
• To prevent aspiration.
Indications
• Airway obstruction
• Cardiac arrest
• Respiratory arrest
• Hypoxemia
• Inability to ventilate patient
– (rising PaCO2, respiratory acidosis, mental status change or
other symptoms)
• Inability to oxygenate patient
– (SpO2 < 90%, PaO2 < 55)
• Decreased LOC
CONTRAINDICATIONS
• Severe airway trauma or obstruction
• Cervical spine injury. DO NOT LIFT THE CHIN.
• Fractured larynx
Complications
• Infection
• Aspiration
• Dental injury
• Pneumothorax
• Laryngeal edema
• Bleeding
• Tracheal or esophageal perforation
Equipment:
• Laryngoscope
VIDEO ASSISTED
LARYNGOSCOPE
WITH BLADE
Equipment:
• Laryngoscopic Blade
• Adult: Macintosh blade
• Children: Miller blade
Miller blade
Selection of laryngoscope blade
(preference)
• Macintosh is a curved blade whose tip is
inserted into the vallecula (the space between
the base of the tongue and the pharyngeal
surface of the epiglottis). Most adults require
a Macintosh number 3 or 4 blade.
Selection of laryngoscope blade
(preference)
• Miller is a straight blade that is passed so that
the tip of the blade lies beneath the laryngeal
surface of the epiglottis. The epiglottis is then
lifted to expose the vocal cords. Most adults
require a Miller number 3 blade.
Equipment:
• Endotracheal tube
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
• The size of the tube may also be determined by the size of the
patient’s little finger.
Equipment:
• Endotracheal tube cuff
High volume Low volume
Low pressure cuff
High pressure cuff
Equipment:
• Stylet
Equipment:
• Stylet or guidewire
Other equipment
• Oxygen source
• Bag Valve mask
• Pre-medications
• Lubricating jelly
• Esophageal syringe or
bulb syringe
Other equipment
• Plaster or tape for securing
endotracheal tube
• Stethoscope
• Pulse oximeter and cardiac
monitor
POSITION:
Sniffing Position
(10 cm elevation)
Patient positioning equipment
• Bed or procedure table (can be raised and
lowered)
• Pillows or blankets (can be rolled and placed
under patient for optimal positioning)
Positioning
“The optimal airway position is that which enables easy
airway management.”
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)
• Always recheck tube placement manually guided by oxygen
saturation readings.(Spo2).
Intubation Procedures
1. Position patient
1. Bed at comfortable height for
laryngoscopist/aesthesiologist/intensivist.
2. Patient aligned without lateral deviation of
head or neck
3. Shoulders and/or neck supported with rolls
or pillows to allow positioning of head
4. Neck flexed approximately 15 degrees on
chest
5. Head hyperextended on neck to maximum
comfortable degree
Intubation Procedures
2. Preoxygenate patient
5 minutes on 100% oxygen
via mask
Intubation Procedures
3. Laryngoscopy technique
1. Hold laryngoscope in dominant
hand and endotracheal tube in
non-dominant hand
2. Open the patient's mouth with a
right-handed scissor technique
3. Insert the laryngoscope blade on
the right side of the mouth and
use it to sweep the tongue to the
left
Intubation Procedures
3. Laryngoscopy technique
4. Advance the blade until landmarks are
recognized-usually the tip of the epiglottis or
the arytenoid cartilages
5. Lift (not lever) the laryngoscope in the
direction of the handle to lift the tongue
bringing the glottis into view
6. When the vocal cords are clearly seen,
advance the tube down the right side of the
mouth, keeping the vocal cords in view until
the last possible moment, then advance the
tube through the vocal cords
Intubation Procedures
3. Laryngoscopy technique
7. Insert the tube to 23 cm (at incisors) in men and 21 cm in
women, remove the stylet, then inflate the cuff
Intubation Procedures
3. Laryngoscopy technique
8. Attach bag ventilator to
tube and verify tube position
immediately
– Listen for breath sounds
– Attach CO2 detector to
tube or use end-tidal CO2
monitor to verify return of
carbon dioxide with each
breath
Confirmation of tracheal intubation:
• Direct visualization of the ET tube passing
through the vocal cords
• CO2 in exhaled gases
• Bilateral breath sounds
• Absence of air movement during epigastric
auscultation
Confirmation of tracheal intubation:
• Condensation (fogging) of water vapor in the tube on
exhalation
• Refilling of reservoir bag during exhalation
• Maintenance of arterial oxygenation
• Chest X-ray: the tip of the ET tube should be
between the carina and thoracic arc or
approximately at the level of the aortic arch
Nursing Care of the patient
with an endotracheal tube
Immediately After Intubation
1. Check symmetry of chest expansion.
2. Auscultate breath sounds of anterior and lateral chest bilaterally.
3. Obtain order for chest x-ray to verify proper tube placement.
4. Check cuff pressure every 6-8 hours.
5. Monitor for signs and symptoms of aspiration.
6. Ensure high humidity; a visible mist should appear in the T-piece or
ventilator tubing.
Nursing Care of the patient
with an endotracheal tube
Immediately After Intubation
7. Secure the tube to the patient’s face with tape, and mark the
proximal end for position maintenance, noting the centimeter marking
on the patient’s lipline.
8. Use sterile suction technique and airway care to prevent iatrogenic
contamination and infection.
9. Continue to reposition patient every 2 hours and as needed to
prevent atelectasis and to optimize lung expansion.
10. Provide oral hygiene and suction the oropharynx when ever
necessary.
11. Attach a continuous ETCO2 monitoring if available.
Laryngeal mask airway
What is laryngeal mask
airway?
• Curved, wide-bore tube with a spoon-shaped inflatable cuff.
• It is an alternative airway device used for anesthesia and
airway support.
• It consists of an inflatable silicone mask and rubber
connecting tube.
• It is introduced into the
hypopharynx to form a seal
around the larynx thus
permitting positive pressure
ventilation without
penetration of the larynx or
esophagus.
• The LMA has proven to be
very effective in the
management of airway crisis
Indications
• May be used as a back-up device where endotracheal intubation is
not successful.
• May be used as a “second-last-ditch” airway where a surgical airway
is the only remaining option.
• Can be used for bronchoscopy in awake patients.
Contraindications
• Morbidly obese patients
• Obstructed or abnormal lesion of the oropharynx
• Greater than 14 to 16 weeks pregnant
• Massive thoracic injury
• Patients at risk of aspiration
SIDE EFFECTS
• Throat soreness
• Dryness of the throat and/or mucosa
• Side effects due to improper placement vary based on the
nature of the placement
Laryngeal mask airway
