INTUBATION REVIEW SFC HILL

Advantages/Complications of Tracheal Intubation

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

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

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

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

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

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.

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.

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

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

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

Inspect stethoscope Diaphragm Earpieces Tubing

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

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

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

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

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

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.

Nasotracheal intubation technique topical lidocaine or phenylephrine should be applied to the nasal passages 0.5-1.0% 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

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

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

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

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

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

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