1. Orotracheal intubation เพชรรัตน์ วิสุทธิเมธีกร, พบ., ว. ว. ( วิสัญญี ) ภาควิชาวิสัญญีวิทยา วิทยาลัยแพทยศาสตร์ กรุงเทพมหานครและวชิรพยาบาล

3. CONTENTS INDICATION AIRWAY ASSESSMENT PREPARING THE PROCEDURE THE PROCESS OF OROTRACHEAL INTUBATION

4. WHY DO WE INTUBATE PATIENTS 1.maintenance of a clear airway 2.protection of the trachea and lungs 3.tracheobronchial toilet 4.controlled mechanical ventilation

5. AIRWAY ASSESSMENT Airway anatomy

8. AIRWAY ASSESSMENT History taking

9. AIRWAY ASSESSMENT Physical examination

10. Difficult to Bag (MOANS) Mask Seal Obesity or Obstruction Age > 55 No Teeth Stiff Physical examination AIRWAY ASSESSMENT

11. Difficult Airway Assessment 4 D’s Distortion, Disproportion, Dysmobility, Dentition BONES Beard, Obese, No teeth, Elderly, Snores (sleep apnea) SHORT Surgery (head/neck/jaw), Hematoma, Obese, Radiation, Tumor LEMON MALLAMPATI Always have a “Rescue Airway” technique ready“Rescue Airway”

12. 60-SECOND EXAM “LEMON” Look for external difficulty Evaluate using 3=3=2 rule Mallampati (Class I & II) Obstruction Neck Mobility 3 fingers fit in mouth 3 fingers fit from mentum to hyoid cartilage 2 fingers fit from mandible to top of thyroid cartilage

14. AIRWAY ASSESSMENT Laboratory data chest x ray : tracheal deviation

16. Preparing the procedure 1.performer Lion heart, lady hand, fully brain Protect yourself-risk infection Team provider

17. Preparing the procedure 2. the patient Monitors : NIBP, EKG, pulse oximeter Position : the height of the table –adjust the patient’s face is at the level of the xiphoid of the standing person

18. Preparing the procedure 2. the patient sniffing position Sniffing the morning air: Neck slightly flexed and the head Extended, a pillow under the head And neck(10 cm.) but NOT under the shoulders-serve to align the oral pharyngeal,and laryngeal axis

19. Preparing the procedure 3. equipment SALT : suction, airway, laryngoscope, tube *1.self-refilling bag-valve combination (Ambu bag), connector, tubing and oxygen source *2.laryngoscope with curved (Macintosh) and straight (Miller) *3.ET-T( several different sizes)

20. Preparing the procedure 3. equipment * 4.oral airways *5.tincture of benzoin and precut tape *6.introducer (stylets or Magill forceps) *7.suction apparatus *8.syringe 10 ml. to inflate the cuff *9.mucosal anesthetics (lidocaine spray) *10.water-soluble sterile lubricant (K-Y jelly)

21. Preparing the procedure 3. equipment ET-T : For most women ---PVC c cuff no. 7.5 mm. For most man ---PVC c cuff no. 8 mm. For most laryngoscopes the blade is curved (Macintosh no.3)

23. The process of intubation * place the patient in the sniffing position * check the laryngoscope and blade for proper fit, and make sure that the light works * make sure that all materials are assembled and close at hand

24. The process of intubation * select the proper-sized tube * with the 10 ml syringe, inflate the balloon with 5-8 ml. of air. Make sure that the balloon is functional and intact. Lubricate the end * insert the stylet, and bend the tube and stylet gently into a crescent shape, tip of stylet is at least 1 cm proximal to the end of the tube

25. The process of intubation *Topical anesthesia: anesthetize the mucosa of the oropharynx, and upper airway with lidocaine spray, if time permit and the patient is awake

26. The process of intubation A. Mask ventilation 1.select the proper-sized mask, place the mask over the pt.mouth and nose with the Rt. Hand 2.with the Lt.hand, place the small and ring fingers under the pt.mandible, and lift up to open the airway. Grasp the mask with the thumb and index finger, and press it to the pt.face while lifting the mandible with the ring and small fingers 3.compress the bag with the Rt.hand and begin ventilation 1-2 mins with 100%oxygen at rate of 10-15 L/min

27. THE PROCESS OF INTUBATION B. Direct laryngoscopy 1. open the pt.mouth with the Rt.hand, and remove any dentures. 2. grasp the laryngoscope in the Lt.hand, the laryngoscope is introduced into the Rt.hand side of the mouth 3. spread the pt.lips, and insert the blade between the teeth.

28. THE PROCESS OF INTUBATION B. Direct laryngoscopy 4. pass the blade to the Rt. of the tongue, and advance the blade into the hypopharynx, pushing the tongue to the Lt. 5. lift the laryngoscope upward and forward, without changing the angle of the blade, to expose the vocal cords.

31. Laryngoscopic View Grades Grade 1:Full aperture visible Grade 2:Lower part of cords visible Grade 3:Only epiglottis visible Grade 4:Epiglottis not visible

33. THE PROCESS OF INTUBATION C. orotracheal intubation 1.when visualizing the glottis and vocal cords, gently pass the tube next the laryngoscope blade through the vocal cords into trachea, far enough so that the balloon is just beyond the cord *for most women the tube is sited at 19-20cm *for most man this is 21-23 cm at lip level 2.withdraw the stylet

34. THE PROCESS OF INTUBATION C. orotracheal intubation 3.connect the bag-valve combination, begin ventilation with 100%oxygen confirm the tube is properly and inflate the cuff with the 10 ml syringe until there is no air leak around the tube when positive pressure is applied 4.apply tincture of benzoin, wrap adhesive tape around the tube where it comes out of the mouth

35. THE PROCESS OF INTUBATION D. check tube placement **subjective 1. visualize 2. listening 3. chest movement

36. THE PROCESS OF INTUBATION D. check tube placement ** objective 1. vital signs 2. pulse oxymetry 3. ET-co2 4. fiberoptic bronchoscopy 5. chest x ray

37. Endotracheal Intubation IF Endotracheal Intubation fails, you must have a back-up plan...