Download - Endotracheal Intrubation
Tubes, Lines, and Vents in the ICU:Endotracheal IntubationMechanical Ventilation
Central Venous CatheterizationArterial Catheterization
Swan Ganz Catheterization
Curt Sessler, MDProfessor of Medicine
Medical Director of Critical CareVirginia Commonwealth University Health System
May 4, 2004
Endotracheal Intubation: Outline
AnatomyPreparation» Patient evaluation» Equipment / Medications
Pre-intubation patient managementProcedure of intubationDifficult airway
Goals of EndotrachealIntubation
Secure and protect airwayVentilationOxygenation
Anatomy for Tracheal Intubation
Pathway to vocal cords: mouth, pharynx, larynxGlottis: vocal cords, epiglottis, valeculae, esophagus
Pre-Intubation Patient Evaluation: Critical Issues
Difficult mask fit / bag-mask ventilationDifficult intubationMedical conditions which influence choice of medicationsAlternative airway options
Pre-Intubation Evaluation:‘NDOTRAC’
Parameter Abnormality ActionN Neck Short Difficult*D Dentition Loose teeth Caution w bladeO Oral cavity Small, limited view Difficult*T Tongue Large Difficult, curved bladeR ROM Limited FiberopticA Adam’s apple Prominent (anterior) straight bC Chin Receding Difficult** consider awake intubation, alternatives, backup
Equipment for Intubation
Laryngoscope: handle, straight & curved bladesEndotracheal tubesAirwaysWater soluble lubricantStyletSyringe
Suction equipmentOxygenBag and maskPulse oximetryET CO2 detectorTape / benzoinCardiac monitorDefibrillatorMedications
Patient Preparation
Open airway by placing patient in sniffing positionLift at chin or angles of jaw
Patient Preparation
Towel / blanket beneath head / upper shouldersProvide effective mask ventilation with 100% O2» May need oral airway» May need PEEP valve
Apply pressure to cricoid cartilage
Visualize Vocal CordsAlign axes of pharynx, larynx, mouthPlace towels beneath head to align larynx & pharynxUsing laryngoscope, hyperextend at C1-C2 vertebra
Orotracheal Intubation
Position patient in sniffing position, hyper-extend at C1-C2Laryngoscope blade is inserted into the right corner of the mouth and advanced halfway as
moved to the midline» Tongue swept out of the way» Epiglottis visualized
Orotracheal Intubation
Curved blade: tip of blade advanced above epiglottisStraight blade: tip of blade advanced under epiglottisLaryngoscope lifted to visualize cords
Orotracheal Intubation
ET tube tip is passed between cords until cuff is beyond cords
How to Hold the Endotracheal Tube?
Steps in OrotrachealIntubation
Insert bladeVisualize epiglottisReposition blade and visualize vocal cordsInsert ET tube
Rapid Sequence Intubation(RSI)
Short acting sedatives and neuromuscular blocking agent to facilitate immediate intubation in unstable patientFeatures» Adequate sedation and amnesia» Rapid muscle relaxation» Reduced risk of aspiration» Reduced rise in ICP
Induction Agents
Smooth rapid amnesticShort duration of actionStable hemodynamicsFew side effects
Etomidate (Amidate)Midazolam (Versed)Thiopental (Pentothal)Methohexital (Brevitol)Ketamine (Ketalar)
Nasotracheal Intubation
Patient selection» Must be spontaneously breathing
Useful alternative to orotracheal intubation» Cervical spine injury» Avoid IV sedatives and NMBA
Contra-indications: apnea, upper airway foreign body, bleeding diathesis, epiglottitis, CSF rhinorrhea / head trauma, nasal polyp or abscess
Nasotracheal Intubation: Technique
Determine nasal patency, consider applying vasoconstricting agentInsert nasal airway coated
with topical anesthetic / lubricant
Nasotracheal Intubation: Technique
With patient sitting upright, ET tube is inserted and advanced towards the back of the head above the hard palletET tube advanced toward cords while listening for breath sounds
Nasotracheal Intubation: Technique
Endotracheal position confirmed by breath sounds through ET tube, cough.Methods to improve successful placement» head in sniffing position» protrude tongue» cricoid pressure» maintain slight downward pressure if meeting
resistance and patient cannot speak: tip likely is against cords and will pass when pt breathes
Endotracheal Intubation: Complications
Trauma: teeth, mouth, pharynx, nasopharynx, tracheaEsophageal intubation» Avoid by measuring
exhaled CO2 (bag for 5-10 breaths to confirm)
Endotracheal Intubation: Complications
Bronchial intubation» Confirm bilateral = BS » Confirm ET tube position
Reflex response to airway stimulation:» Tachycardia, hypertension,
increased ICP resulting in MI, Aspiration of gastric contentsHypotension: dehydration, poor LV function
22 cm
27 cm
Difficult Airway:Esophageal Tracheal Tube
Manually (blindly) inserted. Double lumen tube with 2 cuffs. One tube (arrow) opens to multiple holes between cuffs and is used to ventilate if tip is in esophagus. Other lumen opens beyond distal cuff and is used to ventilate if tip is placed in trachea.
Blanda. J Crit Illness 2000
Difficult Airway:Laryngeal Mask
Manually (blindly) inserted. Slightly inflate cuff and insert to fit over the larynx. Inflate tube and bag.
Cricothyroidotomy / Transtracheal Ventilation
Endotracheal Intubation: Summary
Preparation for intubation» Patient assessment» Equipment» Intubation
Endotracheal intubation procedure» Pre-intubation» Procedure
Difficult airway management