MTE

INTUBATION and EXTUBATION

AJI PRIMA PUTRA, S.Ked

2006112029

dr. Anna Millizia M.Ked(An), Sp.An

 Intubation
“the introduction of tube into a hollow organ”
Advantages of tracheal intubations:
• Airway patency
– Protects the airway
– Maintains patency during positioning
• Control of ventilation
– ventilation over a long period of time without intubation can
lead to gastric distention and regurgitation
• Route for inhalation anesthesia and emergency
medications
Complications of tracheal intubation:
• Trauma to the lips, teeth, and soft tissues of the
airway.
– Awareness
– meticulous technique
• Bronchial intubation
– frequent complication
– auscultation of the chest bilaterally
Complications of tracheal intubations:
• Laryngospasm
– common when extubation is done when the patient
is in a semiconscious state
– extubation should be done in a relatively deep
anesthesia or when the protective laryngeal reflex
has returned
• Postintubation hoarseness and sore throat
– due to mechanical presence of the tracheal tube
 Airway assessment
• Mouth opening : an incisor distance of 3 cm or greater is
desirable in an adult.
• Mallampati classification : examines the size of the tongue in
relation to the oral cavity.
• Thyromental distance : distance between the mentum (chin)
and the superior thyroid notch. A distance >3 fingerbreadths
is desirable.
• Neck circumference : > 17 inches is associated with difficulties
in visualization of the glottic opening.
 Preparation of Equipment
• Assemble pharyngeal airways in assorted sizes
– Nasopharyngeal
– Oropharyngeal
• Inspect laryngoscope for serviceability
– Batteries
– Light bulb
– Blades; curved/straight (Macintosh or Miller)
 Selection of laryngoscope blade (preference)

• Macintosh is a curved blade whose tip is

inserted into the vallecula (the space between
the base of the tongue and the pharyngeal
surface of the epiglottis). Most adults require
a Macintosh number 3 or 4 blade.
 Selection of laryngoscope blade (preference)

• Miller is a straight blade that is passed so that

the tip of the blade lies beneath the laryngeal
surface of the epiglottis. The epiglottis is then
lifted to expose the vocal cords. Most adults
require a Miller number 3 blade.
Preparation of Equipment -Inspect endotracheal tubes

• Tube size
• adult male 8 mm to 9 mm tube
• adult female 7 mm to 8 mm tube
• Tube length- extend from the lower incisor to a
point midway between the cricoid cartilage and
Louis's angle (the sternal angle) on the patient
• Endotracheal tube cuff
 Preparation of Equipment
• Malleable stylet
– should not extend past Murphy's eye
• Lubrication
• Laryngeal sprays
Inspect resuscitator (AMBU bag) for serviceability

• Bag
• Mask
• Intake valve
• Valve body with relief valve
 Inspect stethoscope
• Diaphragm
• Earpieces
• Tubing
 Laryngoscopy

• The key elements of successful direct

laryngoscopy :
– Correct positioning of the head and neck
– Correct insertion and manipulation of the
laryngoscope blade within the upper airway
 Positioning
“The optimal airway position is that which enables easy
airway management.”
 Insertion and manipulation
• The laryngoscope blade displaces the tongue to the left and
completes the flattening of the primary curve by elevating the
mandible and compressing the tissues in the submandibular space.
• The operator pushes the laryngoscope blade anterodistally to
– (i) lift the epiglottis anteriorly by pressure on the hyoepiglottic ligament,
– (ii) displace the submandibular tissues anteriorly
– (iii) push the tongue laterally.
• The result is to provide sufficient space for the operator to view the
vocal cords and insert the tracheal tube into the trachea.
 Intubation Technique
• ventilate with 100 percent oxygen for approximately 1 min
• Position bed height to bring the patient's head to a mid-
abdominal height
• Flex the cervical spine and extend the head at the atlanto-
occipital joint
• Long axis of the oral cavity, pharynx, and trachea lie almost in
a straight line
 Intubation Technique
• introduce the blade into the right side of the patient's
mouth
• move the blade posteriorly and toward the midline,
sweeping the tongue to the left and keeping it away
from the visual path with the flange of the blade
• ensure the lower lip is not being pinched by the lower
incisors and laryngoscope blade
• advance the laryngoscope until the epiglottis is in view
 Intubation Technique
• lift the laryngoscope upward and forward
• insert the endotracheal tube from the right with its
concave curve facing downward and to the right side
of the patient
• maneuver the endotracheal tube into the larynx,
midway between the cricoid cartilage and the sternal
angle
 Intubation Technique
• inflate the cuff and apply positive pressure
ventilation while the assistant auscultates
• secure the endotracheal tube in position
 Confirmation of tracheal intubation:
• Direct visualization of the ET tube passing
through the vocal cords
• CO2 in exhaled gases
• Bilateral breath sounds
• Absence of air movement during epigastric
auscultation
 Confirmation of tracheal intubation:
• Condensation (fogging) of water vapor in the tube on
exhalation
• Refilling of reservoir bag during exhalation
• Maintenance of arterial oxygenation
• Chest X-ray: the tip of the ET tube should be between
the carina and thoracic arc or approximately at the
level of the aortic arch
 Extubation
• Although removal of the tracheal tube is
usually uneventful, a smooth extubation is of
special importance for some patients and in
particular situations.
• Airway obstruction after extubation is the
commonest cause of major complications
 Deep Vs Awake
• Deep extubation is an inappropriate technique in
patients with anatomically difficult airways.
• Most adult patients are extubated after they are
awake, obeying instructions and demonstrating
adequate spontaneous ventilation and oxygenation.
• Extubation should be performed when the patient is
either deep or awake, not between these two states.
 Deep Vs Awake
• Deep extubation is an inappropriate technique in
patients with anatomically difficult airways.
• Most adult patients are extubated after they are
awake, obeying instructions and demonstrating
adequate spontaneous ventilation and oxygenation.
• Extubation should be performed when the patient is
either deep or awake, not between these two states.
 Extubation steps:
• Oxygenate patient with 100 percent high flow O 2 for
2 to 3 minutes
• if secretions are suspected in the tracheobronchial
tree, remove them with a suction catheter through
the lumen of the endotracheal tube
• ensure that the patient is not in a semiconscious
state
 Extubation steps:
• turn the patient onto his side if he is still unconscious
• unsecure the endotracheal tube from the patient's
face
• deflate the cuff and remove the endotracheal tube
quickly and smoothly during inspiration
• continue to give the patient O2 as required
Terima Kasih