1. INTUBATION REVIEW
SFC HILL

2. Advantages/Complications of Tracheal Intubation

3. Advantages of tracheal intubations:
Airway patency
Protects the airway
Maintains patency during positioning
Control of ventilation
ventilation over a long period of time without intubation can lead to gastric distention and regurgitation

4. Advantages of tracheal intubations:
Route for inhalation anesthesia and emergency medications
N - Narcan
A - Atropine
L - Lidocaine
E - Epinephrine

5. Complications of tracheal intubation:
Trauma to the lips, teeth, and soft tissues of the airway.
Awareness
meticulous technique
Bronchial intubation
frequent complication
auscultation of the chest bilaterally

6. Complications of tracheal intubations:
Laryngospasm
common when extubation is done when the patient is in a semiconscious state
extubation should be done in a relatively deep anesthesia or when the protective laryngeal reflex has returned
Postintubation hoarseness and sore throat
due to mechanical presence of the tracheal tube

7. Preparation of Equipment
Assemble pharyngeal airways in assorted sizes
Nasopharyngeal
Oropharyngeal
Inspect laryngoscope for serviceability
Batteries
Light bulb
Blades; curved/straight (Macintosh or Miller)

8. Selection of laryngoscope blade (preference)
Macintosh is a curved blade whose tip is inserted into the vallecula (the space between the base of the tongue and the pharyngeal surface of the epiglottis). Most adults require a Macintosh number 3 or 4 blade.

9. Selection of laryngoscope blade (preference)
Miller is a straight blade that is passed so that the tip of the blade lies beneath the laryngeal surface of the epiglottis. The epiglottis is then lifted to expose the vocal cords. Most adults require a Miller number 3 blade.

10. Preparation of Equipment -Inspect endotracheal tubes
Tube size
adult male 8 mm to 9 mm tube
adult female 7 mm to 8 mm tube
Tube length- extend from the lower incisor to a point midway between the cricoid cartilage and Louis's angle (the sternal angle) on the patient
Endotracheal tube cuff

11. Preparation of Equipment
Malleable stylet (should not extend past Murphy's eye)
Lubrication
Laryngeal sprays

12. Inspect resuscitator (AMBU bag) for serviceability
Mask
Intake valve
Valve body with relief valve

13. Inspect stethoscope
Diaphragm
Earpieces
Tubing

14. Gather and prepare all equipment necessary for an emergency Airway
Scalpel handle
Surgical blades
Curved hemostats
Endotracheal tube
Syringe

15. Intubation Technique
ventilate with 100 percent oxygen for approximately 1 min
Position bed height to bring the patient's head to a mid-abdominal height
Flex the cervical spine and extend the head at the atlanto-occipital joint
Long axis of the oral cavity, pharynx, and trachea lie almost in a straight line

16. Intubation Technique
introduce the blade into the right side of the patient's mouth
move the blade posteriorly and toward the midline, sweeping the tongue to the left and keeping it away from the visual path with the flange of the blade
ensure the lower lip is not being pinched by the lower incisors and laryngoscope blade
advance the laryngoscope until the epiglottis is in view

17. Intubation Technique lift the laryngoscope upward and forward
insert the endotracheal tube from the right with its concave curve facing downward and to the right side of the patient
maneuver the endotracheal tube into the larynx, midway between the cricoid cartilage and the sternal angle

18. Intubation Technique
inflate the cuff and apply positive pressure ventilation while the assistant auscultates
secure the endotracheal tube in position

19. Curved Blade Technique
The curved blade technique is essentially similar. The only difference being when the epiglottis is in view, advance the tip of the laryngoscope blade into the vallecula, formed by the base of the tongue and the epiglottis; lift upward and forward.

20. Nasotracheal intubation technique
topical lidocaine or phenylephrine should be applied to the nasal passages
% Neosynephrine and 4% Lidocaine, mixed 1:1 should also give satisfactory results
generously lubricate the nares and endotracheal tube
ET tube should be advanced through the nose directly backward toward the nasopharynx

21. Nasotracheal intubation technique
loss of resistance marks the entrance into the oropharynx
laryngoscope and Magill forceps can be used to guide the endotracheal tube into the trachea under direct vision
for awake spontaneous breathing patients, the blind technique can be used

22. Confirmation of tracheal intubation:
Direct visualization of the ET tube passing through the vocal cords
CO2 in exhaled gases
Bilateral breath sounds
Absence of air movement during epigastric auscultation

23. Confirmation of tracheal intubation:
Condensation (fogging) of water vapor in the tube on exhalation
Refilling of reservoir bag during exhalation
Maintenance of arterial oxygenation
Chest X-ray: the tip of the ET tube should be between the carina and thoracic arc or approximately at the level of the aortic arch

24. Extubation
ensure that the patient is recovering is breathing spontaneously with adequate volumes
evaluate the patient's ability to protect his airway by observing whether the patient responds appropriately to verbal commands

25. Extubation steps:
Oxygenate patient with 100 percent high flow O2 for 2 to 3 minutes
if secretions are suspected in the tracheobronchial tree, remove them with a suction catheter through the lumen of the endotracheal tube
ensure that the patient is not in a semiconscious state

26. Extubation steps:
turn the patient onto his side if he is still unconscious
unsecure the endotracheal tube from the patient's face
deflate the cuff and remove the endotracheal tube quickly and smoothly during inspiration
continue to give the patient O2 as required