1. Endotracheal intubation
Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics-
PhD ( physiology), IDRA, FICA

2. Indications Provides a patent airway
Protects the airway against aspiration of secretions, blood, and gastric contents
Allows positive-pressure ventilation
Allows removal of tracheobronchial secretions
Decreases the anatomic dead space
Oxygenation—provides a controlled FiO2 to 100%
7. Route for emergency drug administration during cardiac arrest

3. Same indications , but a different eye

4. Oral , pharyngeal and laryngeal axis

6. Three axes theory
Sniffing the morning air ( bannister )
10 cm thickness cushion
Adnet challenged – neutral postion beneficial in many cases with imaging and clinical comparisons
But keep the pillow , any problem , easy to remove

8. Correct patient positioning
Ventilation with 100% oxygen
Preparation of necessary equipment (including suction devices)
Sometimes drugs

12. best aid to inexperienced operators learning laryngoscopy would be a 10-pin bowler's wrist brace, which would immobilize the wrist.
Don’t lever

13. In or out ? straight or curved !
Pharyngeal surface of epiglottis – glossopharyngeal nerve
Laryngeal surface – superior laryngeal nerve
Laryngospasm
Identification of epiglottis ! Essential

14. Curved blades are also thought to be less traumatic to the teeth and to provide more room for passage of the tracheal tube through the oropharynx. On the other hand, straight blades provide a better view of the glottis in a patient with a long, floppy epiglottis or an anterior larynx.
Therefore, straight blades are preferred in infants, pediatric patients, and patients with an anterior larynx.

15. Problem number 1 – too deep

16. Problem number 2
important to keep the tongue completely to the left side of the mouth with the flange of the laryngoscope blade.
Many unsuccessful or difficult intubations result from the tongue protruding over the flange of the blade toward the right side of the mouth

17. Problem number 3
in an effort to keep the tongue to the left, displacement of the blade tip to the right of the midline. This position obscures the view of the epiglottis and may precipitate trauma and bleeding from friable tissue in the tonsillar bed

18. Problem number – 4
In barrel-chested, obese, or large-breasted patients, it may be difficult initially to insert the blade of a laryngoscope correctly into the mouth and avoid obstruction to movement of the handle of the laryngoscope by the chest wall. In these patients, further initial neck extension or a 45-degree rotation of the laryngoscope handle to the right permits easier introduction of the blade of the laryngoscope into the mouth.
Alternatively, a short laryngoscope handle

20. Obese patients may often require more extensive padding (planking) starting at the midpoint of the back to the head in order to assume an optimal position for laryngoscopy. (Rapid airway management position – RAMP )

22. Jackson position

23. Intubation Correct size From the lateral side
Assistant can retract lips !
Tip to enter on vision
Don’t do along the blade
Cuff disappears - insertion
Inflation and check

24. Moderate tension in the pilot balloon

26. The use of optimal external laryngeal pressure can improve the laryngoscopic view. may reduce the incidence of a grade III view from 9% to a range from 5.4% to 1.3%.
Optimal external laryngeal pressure is usually backward, upward, and to the right (BURP) on the thyroid cartilage,
What is the best ?
He himself ! Bimanual laryngoscopy

27. Is it not endobronchial ?
21 cm in women and 23 cm in men – may be OK
3 times the endotracheal tube size in children (for a 4.0-mm endotracheal tube, 12 cm; for a 5.5-mm endotracheal tube, 16.5 cm).
Auscultate both sides.
Palpate for pulsed pressures in suprasternal notch with and the cuff simultaneous
Fiberoptic bronchoscopy.
Outside the operating room – Xray - Ideally, the tip of the tube should be 2 to 4 cm above the carina at the clavicular (midtracheal) level.

28. Fixation Ideal is maxilla Tincture benzoin ( alcohol + benzoin)
Fan the alcohol out
Wire with upper incisor if movement is possible
Change every two days prolonged intubation
Beards – umbilical tape around the neck – careful about venous compression

31. Previoulsy used for cases of mechanical ventilation
Nasal intubation
Previoulsy used for cases of mechanical ventilation
But now possible bacteremia and sepsis goes against nasal intubation for long time ET tubes
dental procedures,
mandibular fixation
Rarely in pediatrics
Oral procedures

32. Vasoconstrictors
Well gelled
Deflate the cuff maximum
Floor below the inferior turbinate
Resistance - withdrawal, rotation, and reinsertion of the tube.
Extension of the neck may help
Usually the right nares !

33. Concavity anterior
Concavity posterior

34. The laryngoscopy
Similar

35. Nasopharynx
Guide through the tip in front of glottis
An assistant can push the tube
Macgill forceps
Hold the tube – not in cuff – swinging movement – backhand of a ping pong ball
Hinging ? Flexion of the neck may help
Put some air in the cuff – direct it and deflate

36. Length 24 to 25 cm for women and 26 to 27 cm for men 3 cm more
Fixation in maxilla
Suture to nose !
Checking – similar

37. Success tips Readiness with equipments Position Lubricate
Hold the handle close to the blade
Use force , at least delicate
Don’t bend the wrist ( prying)
every action has an equal and opposite reaction!

38. To put the tube what do we need ?
Can we put the tube in you ? – NO
Afferents pass on a big motor reaction( efferents) comes
Nerve blocks
Local spray
Muscle relaxants

39. Summary Indications Axes Position Laryngoscopy Four problems Length
Nasotracheal