SESSION 4

ASSISTING IN ENDOTRACHEAL
INTUBATION

Presented by Krys Lopez, RN, MD

 ASSISTING IN ENDOTRACHEAL INTUBATION

• involves passing an endotracheal tube through the

mouth or nose into the trachea.
• provides a patent way when the patient is having
respiratory distress that cannot be treated with
simpler methods and is the method of choice in
emergency care.
 ASSISTING IN ENDOTRACHEAL INTUBATION

• An Endotracheal tube usually is passed with the aid

of a laryngoscope by specifically trained medical,
nursing, or respiratory therapy personnel.
• Once the tube is inserted, a cuff is inflated to
prevent air from leaking around the outer part of the
tube in order to minimize the possibility of
aspiration and secure the tube
 PURPOSE:

• Endotracheal intubation is performed to establish and

maintain a patent airway.
• Facilitate oxygenation and ventilation.
• Reduce the risk of aspiration.
• Assist with the clearance of secretions.
 INDICATIONS:

• Inadequate oxygenation and • Apnea

ventilation • Ineffective clearance of secretions (i.e.,
• Altered mental status (e.g., inability to
head injury, drug overdose) maintain or protect airway adequately)
for airway protection • High risk of aspiration
• Anticipated airway obstruction • Respiratory distress, respiratory fail
(e.g., facial burns, epiglottitis,
major facial or oral trauma)
• Upper airway obstruction (e.g.,
from swelling, trauma,
Tumor, bleeding)
 Prerequisite Nursing Knowledge:

1. Pulse oximetry should be used during

intubation so that oxygen desaturation can be
quickly detected and treated
2. Proper positioning of the patient is critical for
successful intubation.
 3. Two types of laryngoscope blades exist:
a. Straight:
The straight (Miller) blade is
designed so that the tip extends
below the epiglottis to lift and
expose the glottic opening.
The straight blade is recommended
for use in obese patients, pediatric
patients, and patients with short
necks because their tracheas may
be located more anteriorly.
 3. Two types of laryngoscope blades exist:

b. Curved:
When a curved (Macintosh) blade
is used, the tip is advanced into the
vallecula (the space between the
epiglottis and the base of the
tongue) to expose the glottis
opening.
4. Laryngoscope blades
are available with bulbs
or with a fiberoptic light
delivery system.
Fiberoptic light delivery
systems provide a brighter
light. Bulbs are prone to
becoming scratched or
covered with secretions.
5. Video laryngoscopy is
gaining increased popularity
as a method for oral
intubation. This involves
using fiberoptics or a micro
video camera encased in the
laryngoscope that provides a
wide-angle view of the glottic
opening while attempting oral
intubation.
6. Endotracheal tube
size reflects the size
of the internal
diameter of the tube.
Tubes range in size
from 2 mm for
neonates to 9 mm
for large adults.
7. Visualization of the vocal
cords can be aided by using
laryngeal manipulation.
This is accomplished by
applying
Backward, Upward, and
Rightward Pressure
(BURP) on the thyroid
cartilage to move the larynx
to the right while the tongue
is displaced to the left by the
laryngoscope blade.
8. Application of cricoid
pressure (Sellick maneuver)
may increase the success of the
intubation as long as it does not
interfere with ventilation or
placement of the endotracheal
tube. This procedure is
accomplished by applying firm
downward pressure on the
cricoid ring, pushing the vocal
cords downward so that they
are visualized more easily.
9. Endotracheal intubation can be
done via nasal or oral routes.
The route selected will depend
on the skill of the practitioner
performing the intubation and
the patient’s clinical condition.
Nasal intubation requires a
patient who is breathing
spontaneously and is relatively
contraindicated in trauma
10. Improper intubation technique may result in trauma to the
teeth, soft tissues of the mouth or nose, vocal cords,
and posterior pharynx.
11. In trauma patients with suspected spinal cord injuries and
those not completely evaluated, manual in-line cervical
immobilization of the head must be maintained during
endotracheal intubation to keep the head in a neutral position.
12. Endotracheal tube cuff pressure should be checked
after verifying correct endotracheal tube position. The cuff
pressure recommended for assistance in preventing both
micro aspiration and tracheal damage is 20 to 30 cm H 2 O.
13. Intubation attempts should take no longer than 15 to 20
seconds. If more than one intubation attempt is necessary,
ventilation with 100% oxygen using a self-inflating manual
resuscitation bag device with a tight-fitting face mask should
be performed for 3 to 5 minutes before each attempt.
14. It is important to have a clearly
defined difficult/failed airway plan
and alternative airway equipment
available at the bedside in case of
unsuccessful intubation.
15. Those assisting with intubation
should have additional knowledge,
skills, and demonstrated competence
per professional licensure and
institutional standard.
 EQUIPMENT
• Personal protective equipment, including eye protection
• Endotracheal tube with intact cuff and 15-mm connector (women,
7-mm to 7.5-mm tube; men, 8-mm to 9-mm
tube)
• Laryngoscope handles with fresh batteries
• Laryngoscope blades (straight and curved)
• Spare bulb for laryngoscope blades
• Flexible stylet
 EQUIPMENT

• Bite-block or oropharyngeal airway

• Endotracheal tube–securing apparatus or appropriate
tape
❖ Commercially available endotracheal tube holder
❖ Adhesive tape (6 to 8 inches long)
• Stethoscope
 EQUIPMENT
• Self-inflating manual resuscitation bag-valve-mask device with tight
fitting face mask connected to supplemental oxygen (15 L/min)
• Oxygen source
• Luer-tip 10-mL syringe for cuff inflation
• Water-soluble lubricant
• Rigid pharyngeal suction-tip (Yankauer) catheter
• Suction apparatus (portable or wall)
• Suction catheters
 EQUIPMENT
• Monitoring equipment: cardiac monitor, pulse oximeter, and
sphygmomanometer
• Drugs for intubation as indicated (induction agent, sedation,
paralyzing agents, lidocaine, atropine)
• Magill forceps (to remove foreign bodies obstructing the airway if
present)
EQUIPMENT
EQUIPMENT
 CARE OF THE PATIENT WITH ENDOTRACHEAL
TUBE
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 signs and symptoms of aspiration.
6. Ensure high humidity; a visible mist should appear in the T – piece
of ventilator tubing
 Care of Patient Following Extubation
1. Give heated humidity and oxygen by facemask and maintain the patient in a
sitting or High Fowler’s position.
2. Monitor respiratory rate and quality chest excursions. Note stridor, color
change, and change in mental alertness or behavior.
3. Monitor the patient’s oxygen level using pulse oximeter.
4. Keep patient NPO (nothing by mouth ), or give only ice chips for next few
hours.
5. Provide mouth care.
6. Educate the patient about how perform coughing and deep – breathing
exercises.
 CARE OF THE PATIENT WITH ENDOTRACHEAL
TUBE
7. Administer oxygen concentration as prescribed by the primary care giver.
8. Secure the tube to the patient’s face with tape, and mark the proximal end for position
maintenance.
a. Cut proximal end of tube if it is longer than 7.5 cm (3 inches ) to prevent kinking.
b. Insert an oral airway mouth to prevent the patient from biting or obstructing the tube.
9. Use sterile suction technique and airway care to prevent iatrogenic contamination and
infection.
10. Continue reposition patient every 2 hours and as needed to prevent atelectasis and to
optimize lung expansion.
11. Provide oral hygiene and suction the oropharynx whenever necessary.
 END

ANY QUESTIONS?
 QUIZ # 3 :

ASSISTING IN ENDOTRACHEAL
INTUBATION
1.

A. Miller
B. Macintosh
 An Endotracheal tube usually is passed with the
• 2.

aid of a _________ by specifically trained medical,

nursing, or respiratory therapy personnel.
3. Endotracheal tube can only
be inserted through oral route

TRUE OR FALSE
4. In trauma patients with suspected spinal
cord injuries and those not completely
evaluated, the head should be maintained in
a neutral position.

TRUE OR FALSE
5. Post care of client after extubation
includes placing the client in a supine
position

TRUE OR FALSE