ENDOTRACHEAL INT

UBATION
 Indication for endotrac
heal
1) For supporting intubation
ventilation in patient with some p
athologic disease

: Upper airway obstruction

: Respiratory failure
: Loss of conciousness
 Indication for endotracheal intu
bation (con’t)
 2) For supporting ventilation during genera
l anesthesia

 Type of surgery
: Operative site near the airway
: Abdominal or thoracic surgery
Indication for endotracheal intu
bation (con’t)
: Prone or lateral position
: Long period of surgery
 Patient has risk of pulmonary aspiration

 Difficult mask ventilation

ANATOMY OF AIRWAY
 AIRWAY ASSESSMENTS
1) Condition that associated with difficult intubation

 : Congenital anomalies ---> Pierre

Robin syndrome , Down’s syndro
me
 : Infection in airway--> Retrophar
yngeal 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 la
teral or compress
ed tracheal lumen
 AIRWAY ASSESSMENT
1) Condition that associated with difficult intubation (con’t)
 : Maxillofacial ,cervical or laryngeal traum
a
 : Temperomandibular joint dysfunction
 : Burn scar at face and neck

 : Morbidly obese or pregnancy

 AIRWAY ASSESSMEN
T
 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 int

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

Grinding
Equipment prep
aration
 1) Laryngoscope : handle and blade
 LARYNGOSCOPIC BLADE
 Macintosh (curved) and Miller (straight) blade
 Adult : Macintosh blade, small children : Mille
r 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 m

ms
 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 : Midtrache
a 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
 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 endotrachea
l tube
 4. Monitoring success of endo
tracheal intubation
 4.1) Stethoscope
 4.2) Endtidal - CO2
 4.3) Pulse oximeter
Sniffing position

Flexion at lower cervical

spine
Extension at atlanto-occi
pital joint
Sniffing po
sition
Steps of oroendotra
cheal intubation
Steps of oroendotracheal intubatio
n
Steps of oroendotracheal int
ubation
Vareculla
Steps of oroendotracheal intubatio
n
Steps of oroendotracheal intubatio
n
Nasoendotracheal intub
ation
Nasoendotracheal intub
ation

Advantage
 1) Comfortable for prolong intubation
in postoperative period
 2) Suitable for oral surgery : tonsillect
omy , mandible surgery
 3) For blind nasal intubation
 4) Can take oral feeding
 5) Resist for kinking and difficult to ac
cidental extubation
 Disadvantage
 1) Trauma to nasal mucosa
 2) Risk for sinusitis in prolong
intubation
 3) Risk for bacteremia
 4) Smaller diameter than oral r
oute -> difficult for suction
 Contraindication
for nasoendotracheal intuba
tion
 1) Fracture base of skull
 2) Coagulopathy
 3) Nasal cavity obstruction
 4) Retropharyngeal abscess
 Complication of endotrachea
l intubation
 1) During intubation
 : Trauma to lip, tongue or teeth
 : Hypertension and tachycardia o
r arrhythmia
 : Pulmonary aspiration
 : Laryngospasm
 : Bronchospasm
Complication of endotracheal int
ubation (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 in
tubation(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 in
tubation(Con’t)
 2) During remained intubation
 : Pulmonary aspiration
 : Lib or nasal ulcer in case with p
rolong period of intubation
 : Sinusitis or otitis in case with pr
olong nasoendotracheal intubatio
n
Complication of endotracheal in
tubation(Con’t)
 3) During extubation
 Laryngospasm
 Pulmonary aspiration
 Edema of upper airway
 Complication of endotrache
al intubation(Con’t)
4) After
extubation
 Sore throat
 Hoarseness
 Tracheal stenosis
(Prolong
intubation)
 Laryngeal
granuloma