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Endotracheal Intubation/Extubation

Endotracheal Intubation/Extubation. Upper Airway Anatomy (p. 158). Visualization of Vocal Cords. Indications for Intubation.

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Endotracheal Intubation/Extubation

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  1. Endotracheal Intubation/Extubation

  2. Upper Airway Anatomy (p. 158)

  3. Visualization of Vocal Cords

  4. Indications for Intubation • In conditions of, or leading to resp. failure, such as; - trauma to the chest or airway - neurologic involvement from drugs myasthenia gravis, poisons, etc. -CV involvement leading to CNS impairment from strokes, tumors, infection, pulmonary emboli -CP arrest

  5. Indications (cont’d) • Relief of airway obstruction • Protection of airway (I.e. seizures) • Evacuation of secretions by tracheal aspiration • Prevention of aspiration • Facilitation of positive press. ventilation

  6. Relieving Airway Obstruction • Obstruction classified as upper ( above the glottis and includes the areas of the nasopharynx, oropharynx, and larynx) or lower (below the vocal cords) • Can also be classified as partial or complete obstruction • Causes include trauma, edema, tumors, changes in muscle tone or tissue support

  7. Hazards of tracheal tubes & cuffs • Infection • Trauma • Dehydration • Obstruction • Trauma

  8. Hazards (cont’d) • Accidental intubation of the esophagus or right mainstem bronchus • Bronchospasm, laryngospasm • Cardiac arrhythmias resulting from stimulation of the vagus nerve • Aspiration pneumonia • Broken or loosened teeth

  9. Later Complications of Intubation • Paralysis of the tongue • Ulcerations of the mouth • Paralysis of the vocal cords • Tissue stenosis and necrosis of the trachea

  10. Routes for Intubation • Orotracheal • Nasotracheal • Tracheotomy

  11. Oral Intubation

  12. Advantages of Oral Intubation • Larger tube can be inserted • Tube can be inserted usually with more speed and ease with less trauma • Easier suctioning • Less airflow resistance • Reduced risk of tube kinking

  13. Disadvantages of Oral Intubation • Gagging, coughing, salivation, and irritation can be induced with intact airway reflexes • Tube fixation is difficult, self-extubation • Gastric distention from frequent swallowing of air • Mucosal irritation and ulcerations of mouth (change tube position)

  14. Nasal Intubation

  15. Advantages of Nasal Intubation • More comfort long term • Decreased gagging • Less salivation, easier to swallow • Improved mouth care • Better tube fixation • Improved communication

  16. Disadvantages of Nasal Intub. • Pain and discomfort • Nasal and paranasal complications, I.e., epistaxis, sinusitis, otits • More difficult procedure • Smaller tube needed • Increased airflow resistance • Difficult suctioning • Bacteremia

  17. Intubation Equipment • Endotracheal Tube and stylet • Laryngoscope • Sterile water-soluble jelly • Syringe to inflate cuff • Adhesive tape or tube fixation device • Bite block to prevent biting oral ET tube • Suction Equipment, bag- mask, O2 • Local anesthetic • Stethoscope

  18. Endotracheal Tube

  19. Endotracheal Tube • ET tube size and depth of insertion (see p. 594) • For children older than 2 years - tube size = age/4 + 4 - depth = age/2 + 12 • Adult - tube size female = 8.0, male = 9.0 - depth female = 19-21 and 24-26 male = 21-23 and 26-28

  20. Stylet

  21. Light stylet (light wand)

  22. Laryngoscope

  23. Laryngoscope • Blade and handle • Blade - has a flange, spatula, light, and tip - curved blade (Macintosh) - straight blade (Miller, Wisconsin) • Fiber optic vs. traditional laryngoscope • Blade size: 0 - 1 infant, 2 from 2-8 years 3 from age 10 - adult, 4 large adult

  24. Straight blade (Miller)

  25. Curved blade (Macintosh)

  26. Oral Intubation Procedure • Assemble and check equipment - suction equipment - laryngoscope - select proper size tube, check tube • Position patient - align mouth, pharynx, larynx - “sniffing” position

  27. Patient Positioning

  28. Oral Intubation Proced. (cont’d.) • Preoxygenate the patient - bag-valve mask - *intubation attempt should take no longer than 30 sec, if unsuccessful, then ventilate again with bag and mask for 3-5 minutes • Insert laryngoscope - hold laryngoscope in left hand & insert in right side of mouth, displace tongue toward center

  29. Oral procedure (cont’d.) • Visualize glottis and displace epiglottis

  30. Oral proced. (cont’d.) • Insert ET tube - do not use laryngoscope blade to guide tube - once you see the tube pass the glottis, advance the cuff passed the cords by 2 -3 cm • Hold tube with right hand and remove laryngoscope & stylet - inflate cuff with 5 - 10 cc of air - ventilate with bag

  31. Oral proced. (cont’d) • Inflate cuff with 5 - 10 cc of air • Ventilate with “bag” • Assess tube position - auscultation of chest & epigastric - cm mark at teeth - capnometry/colorimetry - light “wand” • Stabilize tube/Confirm placement - chest x-ray

  32. Extubation • Guidelines for extubation (see table, p. 613) • Cuff-leak test

  33. Extubation Procedure • Assemble Equipment - intubation equipment - in addition to intubation equipment, O2 device and humidity, SVN with racemic epi • Suction ET tube • Oxygenate patient • Unsecure tube, deflate cuff

  34. Extubation proced. (cont’d.) • Place suction catheter down tube and remove ET tube as you suction • Apply appropriate O2 and humidity • Assess/Reassess the patient

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