ENDOTRACHEAL TUBE INTUBATION

INTRODUCTION
Endotracheal tube intubation is the definite way of providing airway maintenance. It
protects the airway from aspiration and allows spontaneous assisted or controlled
ventilation. It provides an excellent means for suctioning secretions from the pulmonary
tree.
DEFINITION
Endotracheal tube involves passing an endotracheal tube through the mouth or nose
into the trachea.
OR
Assisting in passing of a slender hollow tube into the trachea through nose or mouth
using aseptic technique to facilitate artificial ventilation and resuscitation.
ARTIFICIAL AIRWAY MANAGEMENT
Airway management may be indicated in patients with loss of consciousness, facial
or oral trauma, copious respiratory secretions, respiratory distress and need for
mechanical ventilation.
TYPES OF AIRWAYS
1) Oropharyngeal airway – curved plastic device inserted through the mouth and
positioned in the posterior pharynx to move tongue away from palate and open the
airway.
a) Usually for short term use in the unconscious patient, or may be used along with
an oral endotracheal tube.
b) Not used if recent oral trauma, surgery, or loose teeth are present.
c) Does protect against aspiration.
2) Nasopharyngeal airway- soft rubber or plastic tube inserted through nose into
posterior pharynx.
a) Facilitates frequent nasopharyngeal suctioning.
b) Use extreme caution with patients on anticoagulants or bleeding disorders.
c) Select size that is slightly smaller than diameter of nostril and slightly longer than
distance from tip of nose to earlobe.
d) Check nasal mucosa for irritation or ulceration, and clean airway with H2O2 and
water.

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3) Endotracheal tube- flexible tube inserted through the mouth or nose and into the
trachea beyond the vocal cords that acts as an artificial airway.
a) Allows for deep tracheal suction and removal of secretions.
b) Permits mechanical ventilation.
c) Inflated balloon seals off trachea so aspiration from the gastro intestinal tract
cannot occur.
d) Generally easy to insert in an emergency, but maintaining placement is more
difficult so this is not for long-term use.
4) Tracheostomy tube- firm curved artificial airway inserted directly into the trachea
at the level of the second or third tracheal ring through a surgically made incision.
a) Permits mechanical ventilation and facilitates secretion removal.
b) Can be for long term use.
c) Bypasses upper airway defences, increasing susceptibility to infection.
PURPOSES
 To treat acute respiratory failure, persistent hypoxaemia, persistent rise in PCO2.
 To maintain patent airway.
 To ensure adequate oxygenation.
 To provide ventillatory assistance when indicated.
INDICATIONS
To establish and maintain a patent airway:
 In a patient who is unconscious as a result of head injury, drug over dose,
cardiac arrest etc.
 In respiratory arrest.
 In grave asphyxia neonatorum.
 In airway obstruction due to inflammation (acute laryngeal oedema, laryngeal
diphtheria with obstruction etc.) or tumour.
 To facilitate bronchial and tracheal suction in the presence of sputum retention.
 For giving general anaesthesia.
 CNS depression.
 Neuromuscular disease.
 Chest wall injury.
 Fracture of cervical, vertebral and spinal cord injury.

ADVANTAGES OF ENDOTRACHEAL INTUBATION

a. Provides an unobstructed airway when properly placed

b. Prevents aspiration of secretions (blood, mucous, stomach / bowel
contents) into the lungs

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 c. Can be easily maintained for a lengthy period of time
d. Decreases anatomic dead space by approximately 50%
e. Facilitates positive pressure breathing without gastric inflation
f. Facilitates body positioning and movement of the patient
g. May be utilized to pass medications
1. Narcan
2. Atropine
3. Epinephrine
4. Lidocaine

DISADVANTAGES OF ENDOTRACHEAL INTUBATION:

a. Need advanced training to properly perform procedure

b. Bypasses the nares function of warming and filtering the air
c. Increased incidence of trauma due to neck manipulation when spinal cord
injury is suspected
d. May increase respiratory resistance
e. Improper placement

CONTRAINDICATION
 Hypoxia should be corrected before intubation.
 Cervical spine injury.
PRECAUTIONS
There are relative
i. Aneurysm of aortic arch.
ii. Acute laryngitis.
iii. Suspected fracture of the cervical spine.
iv. Cervical spondylosis.
v. Laryngeal obstruction caused by tumour or vocal cord paralysis.

SL NO ARTICLES USES

1. Laryngoscope with curved or straight To visualise the passage.

blade and working light source.
2. Endotracheal tube with low pressure To connect tube to ventilator or
cuff and adapter. resuscitation bag.
3. Stylet To guide the endotracheal tube.

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 4. Oral airway or bite block. To keep patient from biting into
and occluding the endotracheal
tube
5. Adhesive tape To fix the tube in place.
6. Sterile anaesthetic lubricant jelly To lubricate the tube.

7. 10ml syringe To take air for inflating the

balloon.
8. Suction source To suction the secretion.

9. Suction catheter and tonsil suction To suction the secretions if present.

10. Resuscitation bag and mask To maintain patent airway.

connected to oxygen source
11. Sterile towel To maintain aseptic technique.

12. Gloves To protect form infection.

13. Face shield To protect face and eyes from

infection.

POSITION
Patient is in supine with neck extended on the small pillow or a sand bag.

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 PROCEDURE RATIONALE
PREPARATORY PHASE
1. Assess the patient’s heart rate, level of 1. Provide a baseline to estimate patient’s
consciousness and respiratory status. tolerance of procedure.
PERFOMANCE PHASE
1. Remove the patient’s dental bridge 1. May interfere with insertion. Will not be
work and plates. able to remove easily from patient once
intubated.
2. Prepare equipment.
2.
a) Ensure function of resuscitation bag
with mask and suction. a) Patient may require ventillatory assistance
during procedure. Suction should be
functional, because gagging and emesis may
b) Assemble the laryngoscope. Make occur during procedure.
sure the light bulb is tightly attached and
functional.
c) Select an endotracheal tube of
appropriate size (6-9mm for average
adult).
d) Place the endotracheal tube on a sterile
towel. d) Although the tube will pass through the
contaminated mouth or nose, the airway
below the vocal cords is sterile and efforts
must be made to prevent iatrogenic
contamination of the distal end of the tube and
cuff. The proximal end of the tube may be
handled, because it will reside in the upper
airway.
e) Inflate the cuff to make sure it assumes
a symmetric shape and holds volume
without leakage. Then deflate maximally. e) Malfunction of the cuff must be ascertained
before tube placement occurs.
f) Lubricate the distal end of the tube
liberally with the sterile anaesthetic water f) Aids in insertion.
soluble jelly
g) Insert the stylet into the tube (if oral g) Stiffens the soft tube, allowing it to be more
intubation is planned). Nasal intubation easily directed into the trachea.
does

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not employ use of the stylet.
4. Aspirate stomach contents if nasogastric
tube is in place.
5. If time allows, inform the patient of
impending ability to talk and discuss
alternative means of communication. 6. Restraint of the confused patient may be
6. If the patient is confused, it may be necessary to promote patient safety and
necessary to apply soft wrist restraints maintain sterile technique.
7. Prevents contact with patient’s oral
secretions.
7. Put on gloves and face shield.
8. During oral intubation if cervical spine
is not injured, place patient’s head in a 8. Upper airway is open maximally in this
“sniffing” position (i.e., extended at the position.
junction of the neck and thorax and flexed
at the junction of the spine and skull).
9. Will decrease gagging.
9. Spray the back of the patient’s throat
with anaesthetic spray if time is available.
10. Ventilate and oxygenate the patient 10. Preoxygenation decreases the likelihood
with the resuscitation bag and mask before of cardiac dysrhythmias or respiratory distress
intubation. secondary to hypoxemia.
11. Hold the handle of the laryngoscope in 11. Leverage is imposed by crossing the
the left hand and hold the patient’s mouth thumb and index fingers when opening the
open with the right hand by placing patient’s mouth (scissor- twist technique).
crossed fingers on the teeth.
12. Rolling the lip away from teeth prevents
12. Insert the curved blade of the injury by being caught between teeth and
laryngoscope along the right side of the blade.
tongue, push the tongue to the left and use
right thumb and index finger to pull
patient’s lip lower lip away from lower
teeth.
13. Do not use teeth as a fulcrum; this could
13. Lift laryngoscope forward (toward lead to dental damage.
ceiling) to expose the epiglottis. to expose
glottis and visualise vocal cords.
14. Lift laryngoscope upward and forward 14.This stretches the hypoepiglottis ligament,
at a 45 degree angle.

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 folding the epiglottis upward and exposing the
glottis.

15. Do not use wrist. Use shoulder and arm to

15. As the epiglottis is lifted forward lift the epiglottis.
(toward ceiling), the vertical opening of
the larynx between the vocal cords will
come into view.
16. Make sure you do not insert tube into
16. Once vocal cords are visualised, insert oesophagus; the oesophageal mucosa is pink
tube into the right corner of the mouth and and the opening is horizontal rather than
pass the tube while keeping vocal cords in vertical.
constant view.
17. If the vocal cords are in spasm (closed),
17. Gently push the tube through the wait a few seconds before passing tube.
triangular space formed by the vocal cords
and back wall of trachea. 18. Advancing tube further may lead to its
entry into a main stem bronchus (usually the
18. Stop insertion just after tube cuff has right bronchus) causing collapse of the
disappeared from view beyond the cords. unventilated lung.

19. Withdraw laryngoscope while holding

ET tube in place. Disassemble mask from
resuscitation bag, attach bag to ET tube 20. Listen over the cuff area with a
and ventilate the patient. stethoscope. Occlusion occurs when no air
leak is heard during ventilator inspiration or
20. Inflate cuff with the minimal amount compression of the resuscitation bag.
of air required to occlude the trachea.
21. This keeps patient from biting down on the
tube and obstructing the airway.
21. Insert bite block if necessary. 22. Observation and auscultation help in
determining that tube remains in position and
has not slipped into the right main stem
22. Ascertain expansion of both sides of bronchus.
the chest by observation and auscultation 23. This will allow for detection of any later
of breath sounds. change in tube position.
23. Record distance from proximal end of
tube to the point where the tube reaches the
teeth. 24. The tube must be fixed securely to ensure
that it will not be dislodged. Dislodgement of
24. Secure tube to the patient’s face with tube with an inflated cuff may result in
adhesive tape or apply a commercially damage

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available ET tube stabilization device.
to the vocal cords.
25. Obtain chest X-ray to verify tube
position.
FOLLOW UP PHASE
1. Record tube type and size, cuff pressure
and patient tolerance to the procedure.
Auscultate breath sounds every 2hrs or if 1. ABGs may be prescribed to ensure
signs and symptoms of respiratory distressadequacy of ventilation and oxygenation.
occur. Assess ABGs after intubation if Tube displacement may result in extubation,
requested by the health care provider. tube touching carina (causing paroxysmal
coughing) or intubation of a main stem
bronchus (results in collapse of unventilated
2. Measure cuff pressure with manometer; lung).
adjust pressure. Make adjustment in tube
placement on the basis of the chest x-ray
results. 2. The tube may be advanced or removed
several centimetres for proper placement on
the basis of the chest x-ray results.

COMPLICATIONS
 Injury to lips, gums, teeth, tongue, uvula, palate, cords, trachea.
 Laryngeal oedema.
 Laryngitis, laryngotracheatis.
 Pressure necrosis.
 Collapse of lung due to one lung ventilation.
SUCTIONING
 Ineffective coughing may cause secretion collection in the artificial airway
or tracheobronchial tree, resulting in narrowing of the airway, respiratory
insufficiency, and stasis of secretions.
 Assess the need for suctioning at least every 2hrs through auscultation of
the chest.
 Ventilation with a manual resuscitation bag will facilitate
auscultation and may stimulate coughing, decreasing the need for
suctioning.
 Maintain sterile technique while suctioning.

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  Administer supplemental 100% oxygen through the mechanical
ventilator or manual resuscitation bag before, after and between
suctioning passess to prevent hypoxemia.
 Closed system suctioning may be done with the suction catheter
contained in the mechanical ventilator tubing. Ventilator disconnection
is not necessary so time is saved, sterility is maintained, and risk of
exposure to body fluids is eliminated.
PROCEDURAL STEPS FOR THE REMOVAL OF THE ENDOTRACHEAL
TUBE (EXTUBATION)

a. Determine that endotracheal intubation is no longer required

b. Patient begins spontaneous respiration’s
c. Medical Officer orders removal of endotracheal tube
d. Remove tape from endotracheal tube
e. Remove oropharyngeal airway from patient’s mouth
f. Suction the endotracheal tube, the patient’s mouth, and the patient’s
posterior pharyngeal area
g. Deflate the endotracheal tube’s cuff
h. Withdraw the endotracheal tube with one smooth motion
i. Monitor the patient for signs / symptoms of respiratory distress or
difficulty

NASOTRACHEAL INTUBATION

INDICATION

 Patients with oral trauma.

 Patients requiring long term care.

CONTRAINDICATIONS

 Nasal and upper facial trauma.

EQUIPMENTS

 Same as orotracheal intubation.

 1% phenyl ephrine, 2% lignocaine or 5% cocaine.

POSITION
 Semi sitting position with head in neutral position.

PROCEDURE

 Clear the pharyngeal airway.

 Remove the dentures.

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  Ensure adequate oxygenation.
 Administer topical anaesthesia using ant one of the agents.
 Prepare the tube selecting 1 size smaller than the corresponding oral
tube.
 Insert the tube into the trachea during inspiration with a single rapid but
gentle movement.
 Secure the tube after ensuring the tube in the trachea and inflating the
cuff.

COMPLICATIONS

 Vomiting during suctioning which can result in aspiration.

 Inadequate visualization of the cord resulting oesophageal intubation.
 Bronchial intubation can occur if the tube is advanced too far.
 Injury to the nasal mucosa and epistaxis can result.
NURSING CARE
Immediately after intubation
1. Check symmetry of chest expansion.

 Auscultate breath sounds of anterior and lateral chest bilaterally.

 Obtain order for chest X-ray to verify proper tube placement.
 Obtain cuff pressure every 8-12hrs.
 Monitor for signs and symptoms of aspiration.
2. Ensure high humidity; a visible mist should appear in the T-piece or ventilator tubing.
3. Administer oxygen concentration as prescribed by physician.
4. Secure the tube to the patient’s face with tape, and mark the proximal end for position
maintenance.
 Cut proximal end of tube if it is too longer than 7.5cm to prevent kinking.
 Insert an oral airway or mouth device to prevent the patient from biting and
obstructing the tube.
5. Use sterile suction technique and airway care to prevent iatrogenic contamination and
infection.
6. Continue to reposition patient every 2hrs and as needed to prevent atelectasis and to
optimize lung expansion.
7. Provide oral hygiene and suction the oropharynx whenever necessary.
External tube site care
1. Secure an ET tube so it cannot be disrupted by the weight of the ventilator or oxygen
tubing or by patient movement.
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 a) Use strips of adhesive tape wrapped around the tube and secured to tape on the
patient’s cheeks or around the back of patient’s head.
b) Replace when soiled or insecure or when repositioning of tube is necessary.
c) Position tubing so traction is not applied to endotracheal tube.
2. Have available at all times at the patient’s bedside a resuscitation bag, oxygen source
and mask to ventilate the patient in the event of accidental tube removal. Know location
and assembly of reintubation equipment including replacement ET tube. Know how to
contact someone immediately for reintubation.
Care of patient following intubation
1. Give heated humidity and oxygen by face mask.
2. Monitor respiratory rate and quality of chest excursions. Note stridor, colour change
and change in mental alertness or behaviour.
3. Monitor the patient’s oxygen level using a pulse oximeter.
4. Keep NPO or give only ice chips for next few hours.
5. Provide mouth care.
6. Teach patient how to perform coughing and deep breathing exercises.
CONCLUSION
By performing endotracheal tube intubation we can save the life of patients in
emergency settings by maintaining patent airway. It is also used for giving anaesthesia.

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