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7/31/2019 ETintubate-ppt

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ENDOTRACHEAL INTUBATION


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Indication for endotracheal intubation1) For supporting ventilation in patient

with some pathologic disease: Upper airway obstruction

: Respiratory failure

: Loss of conciousness


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Indication for endotracheal intubation (cont)2) For supporting ventilation during general

anesthesia Type of surgery

: Operative site near the airway

: Abdominal or thoracic surgery


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Indication for endotracheal intubation (cont): Prone or lateral position

: Long period of surgery

Patient has risk of pulmonary aspiration

Difficult mask ventilation


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ANATOMY OF AIRWAY


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AIRWAY ASSESSMENTS

: Congenital anomalies ---> Pierre Robin syndrome ,

Downs syndrome

: Infection in airway--> Retropharyngeal abscess,

Epiglottitis: Tumor in oral cavity or larynx

1) Condition that associated with difficult intubation


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AIRWAY ASSESSMENT: Enlarge thyroid gland

trachea shift to lateral or

compressed tracheal

lumen

1) Condition that associated with difficult intubation (cont)


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AIRWAY ASSESSMENT: Maxillofacial ,cervical or laryngeal trauma: Temperomandibular joint dysfunction: Burn scar at face and neck

: Morbidly obese or pregnancy

1) Condition that associated with difficult intubation (cont)


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AIRWAY ASSESSMENT2) Interincisor gap : normal -> more than 3 cms


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AIRWAY ASSESSMENT3) Mallampati classification: Class 3,4 -> may bedifficult intubation

Soft palateUvula


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AIRWAY ASSESSMENT

grade 3,4 -> risk for difficult intubation

Laryngoscopic view


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AIRWAY ASSESSMENT4) Thyromental distance : more than 6 cms


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AIRWAY ASSESSMENT5) Flexion and extension of neck


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AIRWAY ASSESSMENT6) Movement of temperomandibular joint (TMJ)

Grinding


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Equipment preparation


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1) Laryngoscope : handle and blade


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LARYNGOSCOPIC BLADEMacintosh (curved) and Miller (straight) blade Adult : Macintosh blade, small children : Miller blade

Miller bladeMacintosh blade


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2) Endotracheal tube


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Endotracheal tubeMale: 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

1) Size of endotracheal tube : internal diameter (ID)


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3) Endotracheal tube cuff

High volume

Low pressure cuff Low volumeHigh pressure cuff

2) Material : Red rubber or PVC


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4) Bevel5) Murphys eye


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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)


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7) Tube markings

Z-79Disposible (Do not reuse)Oral/ NasalRadiopaque marker


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3) Other equipments

3.1 Stylet


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3.2 Oropharyngeal or nasopharyngeal airway

Oral airway Nasal airway


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3.3) Suction catheter3.4) Slip joint


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3.5) Face mask and self inflating bag

3.6) Magill forcep


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3.7) Syringe3.8) Lubricating jelly3.9) Plaster for strap endotracheal tube4. Monitoring success of endotracheal

intubation4.1) Stethoscope4.2) Endtidal - CO24.3) Pulse oximeter


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Sniffing positionFlexion at lower cervical spine

Extension at atlanto-occipital joint


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Sniffing position


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Steps of oroendotracheal intubation


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Steps of oroendotracheal intubationVareculla


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Nasoendotracheal intubation


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Nasoendotracheal intubation Advantage1) Comfortable for prolong intubation in postoperative

period2) Suitable for oral surgery : tonsillectomy , mandible

surgery3) For blind nasal intubation4) Can take oral feeding5) Resist for kinking and difficult to accidental

extubation


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Disadvantage1) Trauma to nasal mucosa2) Risk for sinusitis in prolong intubation3) Risk for bacteremia4) Smaller diameter than oral route ->

difficult for suction


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Contraindication

for nasoendotracheal intubation1) Fracture base of skull2) Coagulopathy3) Nasal cavity obstruction4) Retropharyngeal abscess


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Complication of endotracheal intubation1) During intubation: Trauma to lip, tongue or teeth: Hypertension and tachycardia or arrhythmia: Pulmonary aspiration: Laryngospasm: Bronchospasm


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Complication of endotracheal intubation (Cont)1) During intubation

: Laryngeal edema

:Arytenoid dislocation -> hoarseness: Increased intracranial pressure: Spinal cord trauma in cervical spine injury: Esophageal intubation


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Complication of endotracheal intubation(Cont): Obstruction from klinking , secretion or

overinflation of cuff

: Accidental extubation or endobronchial

intubation

: Disconnection from breathing circuit

2) During remained intubation


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Complication of endotracheal intubation(Cont)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


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3) During extubation

Laryngospasm

Pulmonary aspiration

Edema of upper airway

Complication of endotracheal intubation(Cont)


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Complication of endotracheal intubation(Cont)4) After extubation

Sore throat

Hoarseness

Tracheal stenosis

(Prolong intubation)

Laryngeal granuloma

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