ENDOTRACHEAL INTUBATION

1. ENDOTRACHEAL INTUBATION

4. Indication for endotracheal intubation 1) For supporting ventilation in patient with some pathologic disease : Upper airway obstruction : Respiratory failure : Loss of conciousness

5. Indication for endotracheal intubation (con’t) • 2) For supporting ventilation during general anesthesia • Type of surgery : Operative site near the airway : Abdominal or thoracic surgery

6. Indication for endotracheal intubation (con’t) : Prone or lateral position : Long period of surgery • Patient has risk of pulmonary aspiration • Difficult mask ventilation

7. ANATOMY OF AIRWAY

8. AIRWAY ASSESSMENTS • 1) Condition that associated with difficult intubation • : Congenital anomalies ---> Pierre Robin syndrome , Down’s syndrome • : Infection in airway--> Retropharyngeal abscess, Epiglottitis • : Tumor in oral cavity or larynx

9. AIRWAY ASSESSMENT • 1) Condition that associated with difficult intubation (con’t) • : Enlarge thyroid gland • trachea shift to lateral or compressed tracheal lumen

10. AIRWAY ASSESSMENT 1) Condition that associated with difficult intubation (con’t) • : Maxillofacial ,cervical or laryngeal trauma • : Temperomandibular joint dysfunction • : Burn scar at face and neck • : Morbidly obese or pregnancy

11. AIRWAY ASSESSMENT • 2) Interincisor gap : normal -> more than 3 cms

12. Soft palate Uvula AIRWAY ASSESSMENT • 3) Mallampati classification: Class 3,4 -> may be difficult intubation

13. AIRWAY ASSESSMENT Laryngoscopic view grade 3,4 -> risk for difficult intubation

14. AIRWAY ASSESSMENT • 4) Thyromental distance : more than 6 cms

15. AIRWAY ASSESSMENT • 5) Flexion and extension of neck

16. AIRWAY ASSESSMENT • 6) Movement of temperomandibular joint (TMJ) Grinding

17. Equipment preparation

18. 1) Laryngoscope : handle and blade

19. Miller blade Macintosh blade LARYNGOSCOPIC BLADE • Macintosh (curved) and Miller (straight) blade • Adult : Macintosh blade, small children : Miller blade

20. 2) Endotracheal tube

21. Endotracheal tube • 1) Size of endotracheal tube : internal diameter (ID) • 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

22. High volume Low pressure cuff Low volume High pressure cuff • 2) Material : Red rubber or PVC • 3) Endotracheal tube cuff

23. 4) Bevel • 5) Murphy’s eye

24. 6) Depth of endotracheal tube : Midtrachea or below vocal cord ~ 2 cms • Adult -> Male = 23 cms ,Female = 21 cms • Children • Oral endotracheal tube = (Age/2) + 12 (cm) • Nasal endotracheal tube = (Age/2) + 15 (cm)

25. 7) Tube markings • Z-79 • Disposible (Do not reuse) • Oral/ Nasal • Radiopaque marker

26. 3) Other equipments 3.1 Stylet

27. Oral airway Nasal airway • 3.2 Oropharyngeal or nasopharyngeal airway

28. 3.3) Suction catheter • 3.4) Slip joint

29. 3.5) Face mask and self inflating bag • 3.6) Magill forcep

30. Syringe Lubricating jelly Plaster for strap endotracheal tube Monitoring success of endotracheal intubation Stethoscope Endtidal - CO2 Pulse oximeter

31. Sniffing position Flexion at lower cervical spine Extension at atlanto-occipital joint

32. Sniffing position

33. Steps of oroendotracheal intubation

34. Steps of oroendotracheal intubation

35. Steps of oroendotracheal intubation

36. Steps of oroendotracheal intubation

37. Steps of oroendotracheal intubation

38. Nasoendotracheal intubation

39. Nasoendotracheal intubation • Advantage • 1) Comfortable for prolong intubation in postoperative period • 2) Suitable for oral surgery : tonsillectomy , mandible surgery • 3) For blind nasal intubation • 4) Can take oral feeding • 5) Resist for kinking and difficult to accidental extubation

40. Disadvantage • 1) Trauma to nasal mucosa • 2) Risk for sinusitis in prolong intubation • 3) Risk for bacteremia • 4) Smaller diameter than oral route -> difficult for suction

41. Contraindication for nasoendotracheal intubation • 1) Fracture base of skull • 2) Coagulopathy • 3) Nasal cavity obstruction • 4) Retropharyngeal abscess

42. Complication of endotracheal intubation • 1) During intubation • : Trauma to lip, tongue or teeth • : Hypertension and tachycardia or arrhythmia • : Pulmonary aspiration • : Laryngospasm • : Bronchospasm

43. Complication of endotracheal intubation (Con’t) • 1) During intubation • : Laryngeal edema • :Arytenoid dislocation -> hoarseness • : Increased intracranial pressure • : Spinal cord trauma in cervical spine injury • : Esophageal intubation

44. Complication of endotracheal intubation(Con’t) 2) During remained intubation : Obstruction from klinking , secretion or overinflation of cuff : Accidental extubation or endobronchial intubation : Disconnection from breathing circuit

45. Complication of endotracheal intubation(Con’t) • 2) During remained intubation • : Pulmonary aspiration • : Lib or nasal ulcer in case with prolong period of intubation • : Sinusitis or otitis in case with prolong nasoendotracheal intubation

46. Complication of endotracheal intubation(Con’t) • 3) During extubation • Laryngospasm • Pulmonary aspiration • Edema of upper airway

47. Complication of endotracheal intubation(Con’t) 4) After extubation • Sore throat • Hoarseness • Tracheal stenosis (Prolong intubation) • Laryngeal granuloma