2Objectives Define of endotracheal tube. List indications, contraindications and cautions of endotracheal tube.Explain how to prepare the patient.Explain how to insert the tube.Demonstrate the care of patient with a endotracheal tube.Perform endotracheal tube extubation .Demonstrate the care of patient following extubation
3Oral Endotracheal Intubation It refers to the procedure of inserting a tube directly into the trachea via the mouthIndicationsTo maintain an adequate, patent airway.To facilitate mechanical ventilation.To provide a route for pulmonary secretion evacuation.To provide a route for medication administration for a patient in cardiac arrest.
4Oral Endotracheal Intubation Contraindications and CautionsPotential or actual cervical spin injury.EquipmentEndotracheal tubesLaryngoscope handleLaryngoscope bladesCurved (size2 to 4)Straight (size 1 to 4)
6Oral Endotracheal Intubation Equipment Cont.Stylets to fit each size of endotracheal tube10-ml syringe for inflating the cuff of the tube.Lubricating or lidocaine jelly for nasal intubation.Cocaine drops or spray for nasal intubation.Medication or prescribed for sedation.Tube- securing deviceStethoscope
7Oral Endotracheal Intubation Patient PreparationPlace the patient in the supine position with the head in the sniffing position.Initiate oxygenation with 100%oxygen using a bag-mask for apneic or hypoventilated patient.
8Oral Endotracheal Intubation Patient Preparation Cont.Apply cardiac and oxygen saturation monitors.Administer sedative or topical anesthesia.Restrain the patient as indicated to prevent inadvertent extubation.
9Procedural StepsEnsure that all laryngoscopic equipment is in appropriate working orderInflate the ETT cuff to test for air leaks and deflate after testing.Insert the stylet into the ETT and apply a water- soluble lubricant.
10Procedural StepsConfirm appropriate placement of the stylet within the ETT.Ensure that the stylet has not been advanced beyond the end of the ETT.Turn on suction and place the tonsil- tip suction next to the patient head.Insert the laryngoscope with the left hand.
11Procedural Steps Cont. Visualize the epiglottis and the vocal cords. Using the right hand, pass the ETT through the cords.Remove the laryngoscope while maintaining a grip on the ETT to keep it in place.
13Procedural Steps Cont. Remove the stylet. Ferify correct ETT placement, and secure the tube.Inflate the cuff and instill air until an adequate seal is attained; 10 to 15 ml or air is usually required.Ventilate the patient with 100% oxygen.
14Procedural Steps Cont. Secure the endotracheal tube Principles to be applied:Insert oral air way after oral intubation to prevent the patient from biting the tube and occluding the airway.To allow suctioning and mouth care, the mouth must be not completely occluded by tape or other devices.The method used should prevent the inadvertent advancement or withdrawal of the tube.
15Procedural Steps Cont. Secure the endotracheal tube Principles to be applied:When possible, the method used should minimize pressure points on the skin to prevent long- term complicationsWhen tap is used, it should encircle the head completely for maximum security.
16Procedural Steps Cont. Secure the endotracheal tube Tear off approximately 24 inches of 1- inch adhesive tape.Split the tape in half for the last 4 inches at each end.Slide the tape under the middle of the neck, adhesive side up.Bring each end of the tap alongside the patient's head and wrap the split ends securely around the tube.Split the tape farther if necessary.
17Oral Endotracheal Intubation ComplicationsEsophageal intubation: The lung are not ventilated and gastric distention may occur.Dislodgment of the tube.Damage to teeth, nasal mucosa, posterior pharynx.Patient TeachingYou will not be able to speak while the tube is in place.Do not move or manipulate the tube in any way.
18Nasotracheal Intubation IndicationTo place an endotracheal tube via the nose in a patient with spontaneous respiration.Contraindication and CautionsSuspected facial , nasal, or basilar skull fractures.Concurrent coagulopathy, anticoagulant therapy, or thrombolytic therapy which increase the risk of epistaxis.
19Nasotracheal Intubation Contraindication and Cautions Cont.Obstructions of the nose or posterior nasopharynx, including trauma. Tumor, and foreign bodyEquipmentAs oral intubation(Note that no laryngoscope or stylet is used with this technique.)
20Nasotracheal Intubation Patient PreparationAs oral intubation.Procedural stepsEnsure that all equipment is in appropriate working order.Inflate the ETT cuff to test for air leaks and deflate after testing.Apply a water- soluble lubricant to the ETT.
21Nasotracheal Intubation Procedural steps Cont.Turn on suction and place the tonsil- tip suction next to the patient head.Insert the ETT through the naris, advance the tube until it reaches the glottis, usually heralded by a cough.Listen to the breath sounds to develop a sense of timing and rhythm.
23Nasotracheal Intubation Procedural steps Cont.Advance the tube through the glottis on inspiration.Continue to listen for breath sounds through the tube. ( if not heard assume the tube has entered the esophagus.Verify correct ETT placement, and secure the tube
24Nasotracheal Intubation Procedural steps Cont.Inflate the cuff and instil air until an adequate seal is attained; 10 to 15 ml or air is usually required.Ventilate the patient with 100% oxygen.
25Nasotracheal Intubation ComplicationsNasal bleeding during the intubation procedure or after extubation.Turbinate disruption or retropharyngeal perforation.Laryngeal injury or spasm.Sinusitis
26Care of the Patient with an Endotracheal Tube Immediately After IntubationCheck symmetry of chest expansion.Auscultate breath sounds of anterior and lateral chest bilaterally.Obtain order for chest x-ray to verify proper tube placement.Check cuff every 8–12 hours.Monitor for signs and symptoms of aspiration
27Care of the Patient with an Endotracheal Tube Immediately After Intubation Cont.Administer oxygen concentration as prescribed by physician.Secure the tube to the patient’s face with tape, and mark it.Insert an oral airway or mouth device to prevent the patient from biting and obstructing the tube.
28Care of the Patient with an Endotracheal Tube Immediately After Intubation Cont.Use sterile suction technique and airway care to prevent contamination and infection.Continue to reposition patient every 2 hours and as needed to optimize lung expansion.Provide oral hygiene and suction the oropharynx whenever necessary.
29Care of the Patient with an Endotracheal Tube Extubation (Removal of Endotracheal Tube)Explain procedure.Have self-inflating bag and mask ready in case ventilatory assistance is required immediately after extubation.Suction the tracheobronchial tree and oropharynx, remove tape, and then deflate the cuff.
30Care of the Patient with an Endotracheal Tube Extubation (Removal of Endotracheal Tube)Give oxygen for a few breaths, then insert a new, sterile suction catheter inside tube.Have the patient inhale. At peak inspiration remove the tube.suctioning the airway through the tube as it is pulled out.
31Care of the Patient with an Endotracheal Tube Care of Patient Following ExtubationGive heated humidity and oxygen by face mask.Monitor respiratory rate and quality of chest expansions. Note color change, and change in mental alertness or behaviour.Monitor the patient’s oxygen level using a pulse oximetry.
32Care of the Patient with an Endotracheal Tube Care of Patient Following ExtubationKeep NPO or give only ice chips for next few hoursProvide mouth careTeach patient how to perform coughing and deep-breathing exercises.