ENDOTRACHEAL INTUBATION DR DEEPAK SINGLA

Indications of Endotracheal Intubation Airway problems: external pressures on the airway, vocal cord paralysis, tumor, infection, and laryngospasm. Respiratory deficiencies: patients with poor general condition, hypoxemic/hypercapnic respiratory insufficiency (respiratory rate less than 8 or more than 30 per minute, PO2 in blood gas less than 55 mmHg, PCO2above 55 mmHg). Inadequate circulation: cardiac arrest in hypothermic and hypotensive cases. Central nervous system problems: head injury, stroke, unconscious patients, altered sensorium, raised intracranial pressure. Muscle weakness: (Guillain-Barre, amyotrophic lateral sclerosis, myasthenia gravis, muscular dystrophy, acid-maltase insufficiency, phrenic nerve injury, botulism, polymyositis, spinal cord injury, brainstem infarction, etc.). Patients at risk of aspiration of the stomach contents, blood, mucus, or secretion. For general anaesthesia

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Suggested items to be ready for Intubation Equipment : Personal protective equipment Direct Laryngoscope with blades Endotracheal tubes Magill forceps Stylets Intravenous catheters Syringes( 5ml, 10ml) Nasal/ Oral airways Suction Tape Tube exchanger

Method of Endotracheal Intubation Step 1 Check the equipment Step 2 Assemble all materials close at hand Step 3 Position of the patient:

Patient Positioning Sniffing position Lower neck flexion Upper neck extension Important in obesity Unless contraindicated – ie. Trauma.

Step 4 Curved blade technique: Open the patient’s mouth with the right hand, and remove any dentures. Grasp the laryngoscope in the left hand. Spread the patient’s lips, and insert the blade between the teeth, being careful not to break a tooth. Pass the blade to the right of the tongue, and advance the blade into the hypo-pharynx, pushing the tongue to the left. Lift the laryngoscope upward and forward, without changing the angle of the blade, to expose the vocal cords.

If initially not found insert laryngoscope further Look for epiglottis If initially not found insert laryngoscope further If this maneuver does not work slowly pull laryngoscope back Once epiglottis visualized, push laryngoscope into vallecula and apply traction at 45 degree angle to “push” epiglottis up and out of the way www.int-med.uiowa.edu/Research/TLIRP/Bronchos

Look for vocal cords or arytenoid cartilages and try to optimize view (i.e. lift head, apply more traction at 45 degree angle if necessary) Do not move once view is optimized! Insert ETT into far right aspect of mouth Insert ETT above and between arytenoids and through vocal cords Try to visualize the ETT passing between the vocal cords

Verify Tube Placement Visualize tube passing through the cords. Misting of the tube with respirations (not always reliable). Movement of the chest with respirations. Auscultation of the chest (You should hear breath sounds on both sides of the chest). Auscultation of the stomach (You shouldn’t hear gurgles here when bagging). Wave form CO2 with numeric reading Esophageal detector device. Rising or stable O2 saturation. Clinical improvement of the patient.

COMPLICATIONS OF INTUBATION (At the time of intubation) Failed intubation Trauma to lips, teeth, tongue and nose Laryngeal trauma, Cord avulsions, fractures and dislocation of arytenoids Airway perforation Laryngospasm Bronchospasm Spinal cord and vertebral column injury Tension pneumothorax Pulmonary aspiration Hypertension, tachycardia, bradycardia and arrhythmia

COMPLICATIONS OF INTUBATION (After intubation) Reasons for acute deterioration of the intubated patient: Think DOPE Displacement of the tube. Obstruction of the tube (mucous plug, biting). Pneumothorax, PE, pulselessness (cardiac arrest or shock). Equipment failure (No oxygen, failure of the ventilator, disconnected tubing).

DIFFICULT INTUBATION An intubation is called difficult if a normally trained anesthesiologist needs more than 3 attempts or more than 10 min for a successful endotracheal intubation

Common problems “I can’t see anything!” Make sure tongue is swept to the left You are probably too shallow or too deep. Even with difficult intubations the epiglottis can be visualized Insert laryngoscope in further looking for epiglottis Pull laryngoscope back if this fails

“I can see the cords. But I can’t get the tube there!” You may not be giving yourself adequate room in the oral cavity Push up and to the left with the laryngoscope to make sure the mouth is still fully opened and the tongue adequately swept away Slide the ETT in the mouth all the way to the right side, perhaps even sideways

“I can’t see the cords!” Epiglottis is visualized, vocal cords are not Removing the epiglottis partly from view is necessary to visualize the vocal cords below Push the end of the laryngoscope blade further into the vallecula and “toe up” Lifting the patient’s head with your other hand may improve the sniffing position and bring the vocal cords into view

Direct laryngoscopy – Cormack & Lehane grading : Gr I – Visualization of entire vocal cords Gr II – Visualization of post. part of laryngeal aperture IIa – post part of vocal cords visible IIb – arytenoids only Gr III – Visualization of epiglottis IIIa – liftable IIIb – adherent Gr IV – No glottic structures seen Gr I Gr II Gr III Gr IV

Rescue techniques (front of neck access) Cannula cricothyroidotomy Surgical cricothyroidotomy Tracheostomy

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