ENDOTRACHEAL INTUBATION DR DEEPAK SINGLA - PowerPoint Presentation

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ENDOTRACHEAL INTUBATION

DR DEEPAK SINGLA

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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, PO2 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

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What is this?

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Suggested items to be ready for Intubation

Equipment

:Personal protective equipmentDirect Laryngoscope with bladesEndotracheal tubesMagill forcepsStyletsIntravenous cathetersSyringes( 5ml, 10ml)Nasal/ Oral airwaysSuction TapeTube exchanger

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Method

of Endotracheal Intubation

Step 1 Check the equipment Step 2 Assemble all materials close at hand Step 3 Position of the patient:

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Patient Positioning

Sniffing position

Lower neck flexionUpper neck extensionImportant in obesityUnless contraindicated – ie. Trauma.

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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.

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Look for epiglottis

If initially not found insert laryngoscope further

If this maneuver does not work slowly pull laryngoscope backOnce epiglottis visualized, push laryngoscope into vallecula and apply traction at 45 degree angle to “push” epiglottis up and out of the waywww.int-med.uiowa.edu/Research/TLIRP/Bronchos

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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 mouthInsert ETT above and between arytenoids and through vocal cordsTry to visualize the ETT passing between the vocal cords

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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.

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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 perforationLaryngospasm Bronchospasm Spinal cord and vertebral column injury Tension pneumothorax Pulmonary aspiration Hypertension, tachycardia, bradycardia and arrhythmia

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COMPLICATIONS OF INTUBATION (

After intubation)

Reasons for acute deterioration of the intubated patient: Think DOPEDisplacement 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).

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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

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Common problems

“

I can’t see anything!”Make sure tongue is swept to the leftYou are probably too shallow or too deep. Even with difficult intubations the epiglottis can be visualizedInsert laryngoscope in further looking for epiglottisPull laryngoscope back if this fails

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“

I can see the cords. But I can’t get the tube there!”

You may not be giving yourself adequate room in the oral cavityPush up and to the left with the laryngoscope to make sure the mouth is still fully opened and the tongue adequately swept awaySlide the ETT in the mouth all the way to the right side, perhaps even sideways

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“

I can’t see the cords!”

Epiglottis is visualized, vocal cords are notRemoving the epiglottis partly from view is necessary to visualize the vocal cords belowPush 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

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Direct

laryngoscopy – Cormack & Lehane grading :Gr I – Visualization of entire vocal cordsGr 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

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Rescue techniques (front of neck access)

Cannula

cricothyroidotomySurgical cricothyroidotomyTracheostomy

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Thank you