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Endotracheal Intubation

Sep 19, 20246 min read

Endotracheal tube is: A flexible hollow tube designed to enter the trachea via the oropharynx or the nasopharynx, facilitate gas exchange, and protect the airway from aspiration

Definitive Airway is: A tube placed in the trachea with cuff inflated below the vocal cord.

Advantages of Intubation

  • A cuffed endotracheal tube protects the airway from aspiration
  • Access is gained to the tracheobronchial tree for the suctioning of secretions
  • Ventilations via an endotracheal tube do not cause gastric distention
  • Maintains a patent’s airway and assists in avoiding further obstruction (like in burns)
  • Enables delivery of certain medications

Indications

  1. For supporting ventilation in patient with :-
  • Upper airway obstruction
  • Respiratory failure
  • Loss of conciousness

  1. For supporting ventilation during general anesthesia.

  2. Patients at risk of pulmonary aspiration

  • Massive hemoptysis
  • Uncontrollable vomiting

  1. Difficult mask ventilation

  2. Anticipated airway obstruction (inhalation Burns).

  3. Cardiac arrest

Contraindications

  • Laryngeal disruption / Fracture
  • DNAR (Do Not Attempt Resuscitation)

Conditions that associated with difficult Intubation

  • Congenital anomalies ⇒ Down’s syndrome
  • Infection in airway ⇒ Retropharyngeal abscess, Epiglottitis
  • Tumor in oral cavity or larynx
  • Enlarge thyroid gland ⇒ trachea shift to lateral or compressed tracheal lumen
  • Maxillofacial ,cervical or laryngeal trauma
  • Temperomandibular joint dysfunction
  • Burn scar at face and neck
  • Morbid obesity

Air way assessmentZ

  1. Mallampati classification This test is performed with the patient in the sitting position, head in a neutral position, the mouth wide open and the tongue protruding to its maximum
  • Class I: Visualization of the soft palate, uvula, anterior and the posterior pillars.
  • Class II: Visualization of the soft palate and uvula.
  • Class III: Visualization of soft palate and base of uvula.
  • Class IV: Only hard palate is visible. Soft palate is not visible at all

Class III, IV difficult to intubate

  1. Interincisor gab: Normal >4.5 cm (3 fingers)

 3) Thyromental distance (TMD) :

 4) Flexion and extension of neck

  1. Laryngoscopic view

 6) Movement of temperomandibular joint (TMJ)

Preparing the procedure…

Essentials that must be present to ensure a safe intubation!.. They can be remembered by the mnemonic SALT

  • Suction. This is extremely important. Often patients will have secretions in the pharynx, making visualization of the vocal cords difficult.

  • Airway. the oral airway is a device that lifts the tongue off the posterior pharynx, often making it easier to mask ventilate a patient. Also a source of O2 with a delivery mechanism (ambu-bag and mask) must be available.

  • Laryngoscope. This is vital to placing an endotracheal tube.

  • Tube. Endotracheal tubes come in many sizes. In the average women adult, a size 7.0 or 8.0 endotracheal tube and 7.5 to 8.5 mm in men

Instruments used…

  • Self-refilling bag-valve combination (eg, Ambu bag), tubing, and oxygen source.
  • Plaster or tube holder .
  • Introducer (stylets or Magill forceps).
  • Laryngoscope
  • Suction apparatus
  • Syringe, 10-mL, to inflate the cuff.
  • Mucosal anesthetics (eg, 2% lidocaine)
  • Water-soluble sterile lubricant.
  • Gloves.
  • Pulse oximeter
  • Stethoscope

Oropharyngeal or nasopharyngeal airway

Laryngoscope : handle and blade

LARYNGOSCOPIC  BLADE

  • Macintosh (curved) and Miller (straight) blade
  • Adult : Macintosh blade (No 3 and No 4),
  • Children : Miller blade (No 2 and No 3)

Video Laryngoscopy (Glidescope)

 2) Endotracheal tube

Endotracheal tube -  Size of endotracheal tube : internal diameter (ID)Y

Male: ID 8.0 mms . Female : ID 7.5 mms New born - 3 months : ID 3.0 mms 3-9 months : ID 3.5 mms 9-18 months : ID 4.0 mms 2- 6 yrs : ID = (Age/3) + 3.5 6 yrs : ID = (Age/4) + 4.5

Depth of endotracheal tube :

Midtrachea or below vocal cord ~ 3-4 cms ,

  • Adult: Male = 23 cms ,
  • Female = 21 cms
  • Children:  endotracheal tube   =   (Age/2) + 12     (cm)

The goal is to place the tip of the ETT 2 to 4 cm from the carina (to avoid endobronchial intubation) and the proximal edge of the cuff at least 3 cm below the vocal cords (to avoid vocal cord damage and inadvertent extubaion).

Technique:

Sniffing position

  • Flexion at lower cervical spine
  • Extension at atlanto-occipital joint
  1. Make sure that all materials are assembled and close at hand
  2. Make sure that the balloon inflates
  3. Check the laryngoscope and blade for proper fit, and make sure that the light works
  4. Anesthetize the mucosa of the oropharynx, and upper airway with lidocaine 2%, if time permits and the patient is awake.
  5. Hyperventilate the patient with 100% oxygen for 1 minute prior to intubation attempt
  6. Place the patient in the sniffing position.
  7. Open the patient’s mouth with the right hand,.
  8. Grasp the laryngoscope in the left hand
  9. Spread the patient’s lips, and insert the blade between the teeth, being careful not to break a tooth.
  10. Pass the blade to the right of the tongue, and advance the blade into the hypopharynx, pushing the tongue to the left.
  11. Lift the laryngoscope upward and forward, without changing the angle of the blade, to expose the vocal cords.
  12. Take the endotracheal tube in the right hand and starts inserting it through the mouth opening.
  13. The tube is inserted through the cords to the point that the cuff rests just below the cords (between 21-23 mark on the tube)
  14. Holding the tube firmly in place, quickly remove the laryngoscope
  15. Remove the stylet from the endotracheal tube (if used)
  16. Finally, the cuff is inflated with 5-10 ml of air
  17. Ventilate the patient
  18. Observing the chest rise and fall with each ventilation
  19. Listens for breathing sounds to ensure correct placement of the tube (in stomach and chest)
  20. If no breath sounds and there is bubble sound in stomach (it is in stomach) remove the tube and ventilate the patient and start all over again
  21. If the tube is advanced too far, it will get into the right bronchus and only the right lung is ventilated. If this occurs deflate the cuff with draw 2-3 cm and re-inflate the cuff and listen again
  22. Attach the tube to the patient and to the ventilating apparatus

Confirmation of Tube Placement

  1. Direct visualization of endotracheal tube

  2. Auscultation: breath sounds audible over both lung fields

  3. Condensation: consistently visible in the tube during exhalation

  4. CO2 detection: gold standard of successful endotracheal intubation

  5. Imaging CXR: The distal tip of the endotracheal or tracheal tube should be 2–6 cm above the carina Trained practitioners only: Ultrasound may be used to confirm tube position.

Complication of endotracheal intubation

  1. During intubation
  • Trauma to lip, tongue or teeth
  • Hypertension and tachycardia or arrhythmia
  • Pulmonary aspiration
  • Laryngospasm
  • Bronchospasm
  • Laryngeal edema
  • Increased intracranial pressure
  • Spinal cord trauma in cervical spine injury
  • Esophageal intubation
  1. During remained intubation
  • Obstruction from secretion or overinflation of cuff
  • Accidental extubation or endobronchial intubation
  • Disconnection from breathing circuit
  • Lip or nasal ulcer in case with prolong period of intubation
  1. During extubation
  • Laryngospasm
  • Pulmonary aspiration
  • Edema of upper airway
  • Failed extubation
  1. After extubation
  • Sore throat
  • Hoarseness
  • Tracheal stenosis (Prolong intubation)
  • Laryngeal granuloma

Source:

•AMBOSS •UpToDate •Essential Clinical Procedures 2nd edition

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