Tracheal Intubation

Proper Positioning Flexion of the neck Elevation of head approximately 10 cm Goal: Alignment of the three axis

Proper Position of Laryngoscope Blade

Glottic opening during a direct laryngoscopy (elevated epiglottis)

Choose a Blade

Direct Laryngoscopy Mac vs Miller Confirmation of ETT placement Advantages with each Disadvantages with each Confirmation of ETT placement Simulation: Demonstrate intubation with MAC and Miller Blades

Choose a Tube

Optimal External Laryngeal Manipulation

Lehane McKormick Scale: document view for next person in a standard manner

Confirmation of Tube Placement End-tidal PCO2 Symmetric bilateral chest movements Bilateral breath sounds Feel of compliance while manually inflating the lungs Presence of expiratory refilling of bag Condensation of water in the tube lumen Arterial hemoglobin oxygen saturation

Securing the Tube

Nasal Intubations Indications: Contraindications: Complications: Oral surgery Emergent intubations (blind nasal) Prolonged intubation Contraindications: Basilar skull fracture Lefort II or Lefort III fractures Complications: Nasal necrosis Posterior pharyngeal wall tear Nasal/turbinate injury Epistaxis Adenoidectomy Perforation of piriform sinus Bactermia Retropharyngeal abscess

Nasal Endotracheal Tubes Nasal Rae Advantage is tube contour facilitates stability Endotrol Tubes Soft Ability to flex tip of tube

Equipment Necessary for Nasal Intubation Vasoconstrictor (afrin, phenylephrine drops) Local anesthetic (lidocaine jelly) Lubricant Magills forceps Possible Fiberoptic if ‘blind’ nasal fails Simulation: Demonstration of nasal intubation with Magill forceps

Common Complications of Intubation Bronchospasm Esophageal Intubation Dental trauma Aspiration Laryngospasm Endobronchial Intubation Laryngeal/Tracheal Trauma Hypertension Tachycardia Myocardial ischemia Cardiac dysrhythmias Pulmonary barotrauma

Bronchospasm Increased airway resistance probably related to reflex response to endotracheal intubation Accounts for approximately 5.3% of fatal or near-fatal peri-inducation complications Extensive list for differential diagnosis

Evaluation of Bronchospasm Auscultate while manually ventilating patient (evaluate compliance) Bilateral vs Unilateral Location of wheezing in lung fields (foreign body; cardiogenic) Determine patency of ETT (suction catheter; fiberoptic scope) Sequence of Events (induction; central line placement; surgical considerations, extubation)

Differential Diagnosis of Bronchospasm Reactive Airway Disease Chronic Obstructive Pulmonary Disease Endobronchial intubation Aspiration/foreign body Pneumothorax Light anesthesia Obstructed ETT (kinked; foreign body) Cardiogenic Pulmonary Edema Pulmonary embolus Vascular rings Drug induced histamine release Anaphylaxis

Signs of Bronchospasm Increased Peak Inspiratory Pressures (PIP) Decreased Tidal volumes (pressure ventilation) Decreased Compliance to manual ventilation Audible wheezing noted Obstructed wave forms on Capnogram Simulation: Demonstration of Bronchospasm (wheezing)

Treatment Supportive and determine cause Increased Inspired oxygen Bronchodilators Beta-2 Agonists Anticholinergics Steroids Epinephrine Treat underlying cause: pass suction catheter, deepen anesthetic, call attending for help----do not panic

Aspiration Risk Factors Risk Reduction Full stomach Hiatal Hernia GERD Trauma Narcotics Gastroparesis Uremia Hypothyroidism Risk Reduction Avoid Mask Ventilation Cricoid Pressure Rapid Sequence Induction Consider placing NG/OG tube and evacuate stomach contents

Management of Patient who Aspirates on Induction Maintain Cricoid pressure Turn head Suction Trendelenberg Broncscopy Intubation Supportive Measures (A-line; Oxygen, PEEP)

Training Exercise: Practice direct laryngoscopy and intubation with feedback from facilitator until advanced beginner Practice nasotracheal intubation using Magil forceps Demonstrate how to secure an endotracheal tube Practice laryngoscopy with a Miller blade