ENDOTRACHEAL

INTUBATION
Indications of Endotracheal
Intubation
 Airway problems: external pressures on the airway, vocal cord paralysis,
tumor, infection, and laryngospasm.
 Respiratory deficiencies: patients with poor general condition,
hypoxemic/hypercapnic respiratory insufficiency (respiratory rate less than 8
or more than 30 per minute, PO 2 in blood gas less than 55 mmHg, PCO2above
55 mmHg).
 Inadequate circulation: cardiac arrest in hypothermic and hypotensive cases.
 Central nervous system problems: head injury, stroke, unconscious patients,
altered sensorium, raised intracranial pressure.
 Muscle weakness: (Guillain-Barre, amyotrophic lateral sclerosis, myasthenia
gravis, muscular dystrophy, acid-maltase insufficiency, phrenic nerve injury,
botulism, polymyositis, spinal cord injury, brainstem infarction, etc.).
 Patients at risk of aspiration of the stomach contents, blood, mucus, or
secretion.
 For general anaesthesia
What is this?
Suggested items to be ready for
Intubation
 Equipment :
 Personal protective equipment
 Direct Laryngoscope with blades
 Endotracheal tubes
 Magill forceps
 Stylets
 Intravenous catheters
 Syringes( 5ml, 10ml)
 Nasal/ Oral airways
 Suction
 Tape
 Tube exchanger
Method of Endotracheal Intubation
Step 1 Check the equipment

Step 2 Assemble all materials close at hand

Step 3 Position of the patient:

 Patient Positioning
Sniffing position
 Lower neck flexion
 Upper neck extension
 Important in obesity
 Unless contraindicated – ie. Trauma.
 Step 4 Curved blade technique:
 Open the patient’s mouth with the right hand, and remove any
dentures.
 Grasp the laryngoscope in the left hand.
 Spread the patient’s lips, and insert the blade between the teeth, being
careful not to break a tooth.
 Pass the blade to the right of the tongue, and advance the blade into
the hypo-pharynx, pushing the tongue to the left.
 Lift the laryngoscope upward and forward, without changing the angle
of the blade, to expose the vocal cords.
 Look for epiglottis
 If initially not found insert laryngoscope further
 If this maneuver does not work slowly pull laryngoscope back
 Once epiglottis visualized, push laryngoscope into vallecula and
apply traction at 45 degree angle to “push” epiglottis up and out of
the way

www.int-med.uiowa.edu/Research/TLIRP/Bronchos
 Look for vocal cords or arytenoid cartilages and try to
optimize view
 (i.e. lift head, apply more traction at 45 degree angle if
necessary)
 Do not move once view is optimized!
 Insert ETT into far right aspect of mouth
 Insert ETT above and between arytenoids and through vocal
cords
 Try to visualize the ETT passing between the vocal cords
 Verify Tube Placement
 Visualize tube passing through the cords.
 Misting of the tube with respirations (not always reliable).
 Movement of the chest with respirations.
 Auscultation of the chest (You should hear breath sounds on both sides
of the chest).
 Auscultation of the stomach (You shouldn’t hear gurgles here when
bagging).
 Wave form CO2 with numeric reading
 Esophageal detector device.
 Rising or stable O2 saturation.
 Clinical improvement of the patient.
COMPLICATIONS OF INTUBATION
(At the time of intubation)

 Failed intubation
 Trauma to lips, teeth, tongue and nose
 Laryngeal trauma, Cord avulsions, fractures and dislocation of
arytenoids
 Airway perforation
 Laryngospasm Bronchospasm
 Spinal cord and vertebral column injury
 Tension pneumothorax
 Pulmonary aspiration
 Hypertension, tachycardia, bradycardia and arrhythmia
COMPLICATIONS OF INTUBATION (After
intubation)

 Reasons for acute deterioration of the intubated patient: Think

DOPE
 Displacement of the tube.
 Obstruction of the tube (mucous plug, biting).
 Pneumothorax, PE, pulselessness (cardiac arrest or shock).
 Equipment failure (No oxygen, failure of the ventilator, disconnected
tubing).
DIFFICULT INTUBATION
An intubation is called difficult if a normally trained
anesthesiologist needs more than 3 attempts or more than 10
min for a successful endotracheal intubation
 Common problems
“I can’t see anything!”
 Make sure tongue is swept to the left
 You are probably too shallow or too deep. Even with
difficult intubations the epiglottis can be visualized
 Insert laryngoscope in further looking for epiglottis
 Pull laryngoscope back if this fails
“I can see the cords. But I can’t get the tube there!”
 You may not be giving yourself adequate room in the oral cavity
 Push up and to the left with the laryngoscope to make sure the
mouth is still fully opened and the tongue adequately swept away
 Slide the ETT in the mouth all the way to the right side, perhaps
even sideways
“I can’t see the cords!”
 Epiglottis is visualized, vocal cords are not
 Removing the epiglottis partly from view is necessary
to visualize the vocal cords below
 Push the end of the laryngoscope blade further into the
vallecula and “toe up”
 Lifting the patient’s head with your other hand may
improve the sniffing position and bring the vocal cords
into view
 Direct laryngoscopy – Cormack & Lehane
grading :
Gr I – Visualization of entire vocal cords
Gr II – Visualization of post. part of laryngeal aperture
IIa – post part of vocal cords visible
IIb – arytenoids only
Gr III – Visualization of epiglottis
IIIa – liftable
IIIb – adherent
Gr IV – No glottic structures seen

Gr I Gr II Gr III Gr IV
Rescue techniques (front of neck
access)
 Cannula cricothyroidotomy
 Surgical cricothyroidotomy
 Tracheostomy
Thank you