1. Endotracheal Tube By Dr. Hanan Said Ali

2. Objectives 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

3. Oral Endotracheal Intubation
It refers to the procedure of inserting a tube directly into the trachea via the mouth
Indications
To 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.

4. Oral Endotracheal Intubation
Contraindications and Cautions
Potential or actual cervical spin injury.
Equipment
Endotracheal tubes
Laryngoscope handle
Laryngoscope blades
Curved (size2 to 4)
Straight (size 1 to 4)

6. Oral Endotracheal Intubation
Equipment Cont.
Stylets to fit each size of endotracheal tube
10-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 device
Stethoscope

7. Oral Endotracheal Intubation
Patient Preparation
Place 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.

8. Oral 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.

9. Procedural Steps
Ensure that all laryngoscopic equipment is in appropriate working order
Inflate the ETT cuff to test for air leaks and deflate after testing.
Insert the stylet into the ETT and apply a water- soluble lubricant.

10. Procedural Steps
Confirm 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.

11. Procedural 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.

13. Procedural 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.

14. Procedural 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.

15. Procedural 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 complications
When tap is used, it should encircle the head completely for maximum security.

16. Procedural 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.

17. Oral Endotracheal Intubation
Complications
Esophageal intubation: The lung are not ventilated and gastric distention may occur.
Dislodgment of the tube.
Damage to teeth, nasal mucosa, posterior pharynx.
Patient Teaching
You will not be able to speak while the tube is in place.
Do not move or manipulate the tube in any way.

18. Nasotracheal Intubation
Indication
To place an endotracheal tube via the nose in a patient with spontaneous respiration.
Contraindication and Cautions
Suspected facial , nasal, or basilar skull fractures.
Concurrent coagulopathy, anticoagulant therapy, or thrombolytic therapy which increase the risk of epistaxis.

19. Nasotracheal Intubation
Contraindication and Cautions Cont.
Obstructions of the nose or posterior nasopharynx, including trauma. Tumor, and foreign body
Equipment
As oral intubation
(Note that no laryngoscope or stylet is used with this technique.)

20. Nasotracheal Intubation
Patient Preparation
As oral intubation.
Procedural steps
Ensure 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.

21. Nasotracheal 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.

23. Nasotracheal 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

24. Nasotracheal 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.

25. Nasotracheal Intubation
Complications
Nasal bleeding during the intubation procedure or after extubation.
Turbinate disruption or retropharyngeal perforation.
Laryngeal injury or spasm.
Sinusitis

26. Care of the Patient with an Endotracheal Tube
Immediately After Intubation
Check 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

27. Care 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.

28. Care 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.

29. Care 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.

30. Care 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.

31. Care of the Patient with an Endotracheal Tube
Care of Patient Following Extubation
Give 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.

32. Care of the Patient with an Endotracheal Tube
Care of Patient Following Extubation
Keep NPO or give only ice chips for next few hours
Provide mouth care
Teach patient how to perform coughing and deep-breathing exercises.

33. Thank You