Airway Interventions

pediatric intubation

Unit 4.2: Adult Intubation Indications

Contraindications and Complications
Reading References

 EganChapter 37
 Mosby Chapter 5
Objectives:
 To identify the potential indications for intubation
◦ To differentiate between the two types of respiratory failure
◦ To learn the meaning of VOPS

 To determine when nasal intubation would be

preferable over oral intubation

 To discuss the contraindications for intubation

 To discuss the complications of intubation and how

to minimize them
Indications For Intubation
Please see AARC guideline in Egan’s 11th
 Respiratory Failure
 Airway compromise
◦ Inability of conscious patient to ventilate
adequately
◦ Inability of rescuer to ventilate unconscious
patient with conventional methods
 Airway protection
◦ Protect lower airway from aspiration
◦ Protect lower airway from foreign objects
 Facilitate suctioning
 Medication delivery
Important things to remember..
 Not all conditions requiring airway management require
intubation

 Airway management techniques previously discussed may

prevent need for intubation (pt may improve enough not to
need it)

 Good airway management will at least improve conditions if

endotracheal intubation is required

 Some conditions will almost always require ET intubation

even if other airway management techniques are
temporarily successful
 VOPS

Ventilation
Oxygenation
Protection
Secretions
Respiratory Failure
 Inability to adequately oxygenate and/or
eliminate CO2

 Primarily diagnosis of acute respiratory failure

is aided by following criteria…...

◦ Hypoxemic (type 1) - failure to adequately oxygenate

blood  low O2

◦ Hypercapneic (type 2) - ventilation or ‘pump’ failure

 high CO2
 Combined Hypoxemic And
Hypercapneic Respiratory Failure
 PaO2 and PaCO2

 Any combination of hypoxemic causes resulting in

respiratory muscle fatigue  Ventilatory failure.
Example: Acute severe asthmatic exacerbation

 Likewise, pre-existing hypercapneic failure condition

such as neuromuscular weakness or chest wall
deformity complicated by pneumonia or atelectasis 
Hypoxemic failure
 ORAL OR NASAL?
 Patients may be intubated orally or nasally
 There are several factors which will determine

which route you will choose for intubation

◦ Urgency of the situation
◦ Age of the patient
◦ Reason for intubating patient
◦ Preference of intubator
◦ Resources available
◦ Situation
Advantages of Oral Intubation
 Insertion is faster, easier and usually less
traumatic
 Larger diameter tube is tolerated and shorter

(Less airflow resistance), ↓ WOB

 Easier to suction patient via ETT
 Easier passage of bronchoscope
 Reduced risk of tube kinking
 Avoidance of nasal complications
Disadvantages Of Oral Intubation
 Aesthetically displeasing, especially if long term
 Greater risk of self-extubation or inadvertent
extubation
 Greater risk of mainstem intubation
 Risk of tube occlusion by biting/trismus
 May require additional use of oral airway or “bite
block”
 Risk of injury to lips, teeth, tongue, palate, and oral
soft tissues
 Hard to perform oral hygiene on patient
 Greater risk of gagging, vomiting and aspiration
Advantages Of Nasal Intubation
 Less retching and gagging
 Greater comfort in long-term use
 Less salivation
 Improved ability to swallow oral secretions
 Improved mouth care/oral hygiene
 Avoidance of oral route complications
 Less posterior laryngeal ulceration
 Better tube anchoring
 Reduced risk of mainstem intubation
Disadvantages Of Nasal Intubation
 Pain and discomfort, especially with inadequate
preparation
 Nasal and paranasal complications including epistaxis,
sinusitis and otitis media
 More difficult intubation to perform
 Spontaneous breathing is required for blind nasal
intubation
 Smaller diameter but longer tube is necessary
◦ Increased airflow resistance
◦ Increased work of breathing
 Greater suctioning difficulty

 Difficulty passing bronchoscope

Oral Or Nasal-Conclusion
 In general, oral intubation is preferred for adult
patients whereas nasal intubation is preferred for
neonatal patients
 Nasal intubation is contraindicated in the
presence of:
◦ Nasal fractures
◦ Coagulopathy (oral-less traumatic, thus less bleeding)
◦ Nasal or nasopharyngeal obstruction from:
 deviated septum, polyps, cysts, abscesses, edema,
angioedema, coryza, inflamed adenoids, foreign-
bodies, hematoma
 Contraindications For
Any Intubation
 Intubation may be contraindicated when patient is a DNR
also known as “AND”, that has been clearly expressed and
documented in the patient’s medical record or other valid
legal document.

 Intubation may also be contraindicated if no one is

present with the ability to intubate

Relative Contraindication:
 There is controversy as to whether patients with

epiglottitis should be immediately intubated or not...it is

often suggested that the most experienced intubator
present perform this intubation
Complications Of Intubation
◦ Failure to establish an airway (i.e. Intubation of the
esophagus)
◦ Trauma to mouth, nose, lips, vocal cords, larynx,
pharynx, trachea, spine, eyes, teeth, esophagus
◦ Aspiration and/or infection
◦ Endotracheal tube problems (faulty cuff, blocked ETT)
◦ Autonomic or protective neural responses
(hypo/hypertension, brady/tachycardia, arrhythmias,
laryngospasm, bronchospasm)
◦ Bleeding, hematoma formation, stomal stenossi,
innominate artery erosion
◦ Hypoxia
 How To Minimize Complications
During Intubation:
 Preoxygenate the patient
 Gently introduce ETT, don’t force it!
 During endotracheal intubation, attempts should

be limited to 30 seconds
 BURP procedure when possible
 Ensure placement in tracheal orifice
 Oral suction prepared and readily available before
procedure begins
 Protect against regurgitation of gastric contents
 Confirm ETT placement by at least three methods
as quickly as possible