Endotracheal Intubation By JUNAEDI STUDENT POST GRADUATE OF NURSING BRAWIJAYA UNIVERSITY- INDONESIAN

Definition: Advantages: Introducing a tube through the mouth (or nose) into the trachea to secure open airways. Advantages: Cuffed E.T tubes protect the airway from aspiration. E.T tube provides access to the tracheobronchial tree for suctioning of secretions. E.T tube does not cause gastric distention and associated danger of regurgitation. E.T tube maintains a patent airway and assists in avoiding further obstruction. E.T tube enables delivery of aerosolized medication. the mouth (or nose) into the trachea to secure open airways.

Indication Endotracheal Intubation: Respiratory Failure: Hypoxia, Hypercapnia, tachypnea, or apnea ; ie. ARDS, asthma, pulmonary edema, infection, COPD exacerbation Inability to ventilate unconscious patient Maintenance or protection of an intact airway Cardiac Arrest Medication administration

Contraindication : Inability of patient to extend head Moderate to severe trauma to the cervical spine or anterior neck Infection in the epiglottal area Mandibular fracture or trismus Mild hypoxia Uncontrolled oropharyngeal hemorrhage Intact tracheostomy Basilar skull fracture (during nasal intubation)

Complications: Hypoxia (Long duration of procedure, Intubation of a bronchus ( right more common,Failure to recognize misplacement of tube, Aspiration) Pneumothorax (resulting from over ventilating with a BVM without a pressure release valve) Trauma (to the teeth, vocal cords, soft tissues of the larynx and related structures) Hypertension and tachycardia (can occur from the intense stimulation of intubation. This is potentially life-threatening in the cardiac patien) Gastric distention and regurgitasi (Failure to secure the placement into esophagus). Cardiac arrhythmias (related to vagal stimulation or sympathetic nerve stimulation may occur)

Difficult to intubation: Difficult to bag (MOANS) : Mask Seal : Small Hands, Wrong Mask Size, Oddly Shaped Face, Bushy Beard, Blood/Vomit, and Facial Trauma Obesity or Obstruction: Heavy chest, Abdominal contents inhibit movement of the diaphragm, Increased supra glottic airway resistance, Billowing cheeks, Difficult mask seal, Quicker desaturation Age > 55: Associated with BVM difficulty, possibly due to loss of tone in the upper airway No Teeth: Face tends to “cave in”, Consider leaving dentures in for BVM and remove for intubation. Stiff : Refers to Poor Compliance, Reactive Airway Disease, COPD, Pulmonary Edema/Advance Pneumonia, History of Snoring/Sleep Apnea, Also predicts a higher Mallampati score

Difficult to Laringoscopy and intubation: LEMONS: Look Externally : Beards or facial hair, Short, fat neck, Morbidly obese patients, Facial or neck trauma, Broken teeth (can lacerate balloons), Dentures (should be removed), Large teeth, Protruding tongue, A narrow or abnormally shaped face. Evaluate 3-3-2 : Bottom of Jaw/Chin to Neck > 3 fingers, Jaw/Palate > 3 fingers wide, Mouth opens > 2 fingers wide.

Mallampati Score : Obstruction : Anatomy, Trauma, Foreign body obstruction, Edema (burns). Best view grade 1 Grade 1

Scene and Situation : Scene safety and Environment Neck Mobility : Ideally the neck should be able to extend back approximately 35° Problems: Cervical Spine Immobilization, Ankylosing Spondylitis, Rheumatoid Arthritis, Halo fixation Scene and Situation : Scene safety and Environment Do you have a reasonable chance to get the tube? Space, positioning, access Egress Will you be able to ventilate during egress? A respiratory rate of 4 is better than a rate of 0! Enough meds for a long extrication?

Oral Intubation With local anesthesia: It is also practical to apply surface anesthesia: vagal excitation is less, the patient may tolerate the tube better, arrhytmias and laryngospasm after extubation are rare. Apply 10% Lidocain spray (2 or 3 spurts - 1 spurt=4.8 mg) If the distal end of tube is also sprayed with Lidocain before intubation, the patient will also tolerate the tube after recovering consciousness. Except : Reserved for the completely unconscious, unresponsive, and apneic, and Arrest situations only (without drug).

Equipment

Equipment Endotracheal Intubation: Laryngoscope Blades: curved (MacIntosh) and straight (Miller) Endotracheal tubes of various sizes: Neonates and full term infants: no. 0 and 1, Adult women: 7.0 mm i.d., Adult men: 7.0 to 8.5 mm i.d. Pediatric size: (age in years/4) + 4 or width of fingernail of the fifth digit

Lubricant, Malleable stylet 10-ml syringe (to inflate ET cuff) Oxygen and manual bag valve mask Suction apparatus Stethoscope Sterile gloves and goggles Oropharyngeal airway CO2 Detector

Handle and Blade (Laryngoscope) Blade tipe Macintosh (curve blade) Blade tipe Miller (straight blade)

Engaging laryngoscope blade and handle

ETT, Stylet, and Syringe

High volume Low pressure cuff Low volume High pressure cuff

Magil Forceps, sterile gloves and goggle

Procedure

Position patien’s head 4 rules of suctioning: Never suction further than you can see. Always suction on the way out. Never suction for longer than15 seconds. Always oxygenate the patient before and after suctioning Position yourself at the patient’s head Inspect the oral cavity for secretions or foreign material. Suction if necessary

Hiper ventilate with 100 % oxygen for approximately 1 min (prior 2 minutes)

Intubation Technique 22 cm Bring your body down to the airway level With the laryngoscope held in the left hand, insert the blade into the right side of the mouth displacing the tongue to the left When using a curved blade, advance the tip of the blade into the vallecula (the space between the base of the tongue and the pharyngeal surface of the epiglottis) When using a straight blade, insert the tip under the epiglottis. The glottic opening is exposed by exerting upward traction on the handle To allow full visulization of the vocal cords, it may be helpful for an assistant to employ the Selleck’s Maneuver (applying moderate pressure to the cricoid cartilage) Resist the urge to use a prying motion with the handle. Lift only upward to avoid damaging the patient’s bottom teeth Advance the ET tube through the right corner of the mouth Under direct vision, continue advancing the tube through the vocal cords

Helps prevent regurgitation and reduces gastric distention. Locate the cricoid cartilage by palpating the thyroid cartilage and the feel the depression just below it (cricothyroid membrane). Using your thumb and index finger of one hand, apply pressure to the anterior and lateral aspects of the cricoid cartilage just next to the midline. Sellick Manuver

Laringoscopic View

CO2 exhaled from the lungs: color change to MELLO YELLOW During ventilation, confirm proper tube placement First auscultate the abdomen while visualizing chest expansion Then auscultate the chest bilaterally ensuring equal breath sounds

NEVER let go of the tube until secured (Tape, Commercial tube holder), ETT easily displaced so requires ongoing assessment Oro Pharyngeal Airways (OPA) Secure the tube in place using a tube holder and cloth tape If no tube holder is available, the tube may be secured using cloth tape and an oropharyngeal airway Continue with ventilating the patient

Documentation ET Tube Placement On patient care report: ET (size)___depth___cm Post ET lung sounds ET Attempt (x___) Capnography Checked Suction Boxes used to indicate crew member activity

Thank you