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Intubation Assist


Prior to intubation all required equipment should be prepared for use: Check cuff on ETT ... Patient should be positioned as close to the head of the bed as possible. ... – PowerPoint PPT presentation

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Title: Intubation Assist

Intubation Assist
  • Respiratory Services
  • Oct. 2009

Intubation Assist
  • Indications for intubation
  • Endotracheal tube sizes
  • Equipment required for ETT intubation
  • Equipment preparation
  • Patient Preparation
  • Communication
  • Post Intubation
  • Rapid Sequence Intubation

Indications for Intubation
  • To prevent or relieve upper airway obstruction.
  • To protect the airway from gross aspiration.
  • To facilitate tracheal suctioning.
  • To provide a closed system to deliver positive
    pressure ventilation.

Equipment Required for ETT Intubation
  • Typical Oral ETT Sizing
  • Adult Female 7.0-8.0 O.D with approximate
    insertion depth of 20-22 cm.
  • Adult Male 7.5-8.5 O.D with approximate insertion
    depth of 22-24 cm.
  • EVAC ETTs outer diameter is, on average, 0.8
    mm larger than a standard ETT, so one should
    consider using an EVAC ETT one half size smaller
    than usual.
  • Evac Tubes are available in sizes 6-9 O.D.

ETT Sizing - Pediatrics
  • Standard ETT for pediatric patients is 4.0-6.5
  • Predicted size for Pediatric ETT age/4 4
  • Age Tube Size
    Tube length (incisors to tip)
  • 18 mo 3.5-4.5
  • 3 yrs 4.5-5.0
  • 5 yrs 4.5-5.0
  • 6 yrs 5.5-6.0
  • 8 yrs 6.0-6.5
  • 12 yrs 6.0-7.0
  • 16 yrs 6.5-7.0

ETT Sizing - Neonates
  • Birth weight (g) Gestational Age (Wks)
    ETT Size (mm) Tube Length(cm)
  • lt 1000 Below 28
    2.5 9-11
  • 1000- 2000 28-34
    3.0 9-11
  • 2000 - 3000 34-38
    3.5 10-12
  • gt 3000 gt 38
    3.5 - 4.0 11-12

Equipment Required for Intubation
  • Laryngoscope handle
  • Laryngoscope blade Mac 3, Mac 4 (curved blades)

  • Miller 4 (straight)
  • Magill forceps
  • Stylet
  • ETT securing device
  • ETT tubes in various sizes
  • Water soluble lubricant
  • Xylocaine spray
  • 10 cc syringe
  • Assorted size of oral or nasopharyngeal airways
  • Suction equipment including yaunker and suction
  • Bag-valve-mask
  • ETCo2 monitoring device or esophageal intubation
    detecting device (EDD)

Equipment Contd
  • Only required equipment should be taken into the
    patients room. This will prevent contamination
    and need for disinfection or disposal of unused
  • It is helpful to have another staff member remain
    outside the patient room to obtain extra
    equipment without contaminating a whole
    intubation kit.

Bag-Valve-Mask (BVM)
  • The patient will require pre-oxygenation with
    100 O2 and hyperventilation (except with Rapid
    Sequence Intubation) via a BVM.
  • It is vital to ensure that a filter is placed
    between the mask and bagging unit to minimize
    risk of exposure to infection.

Equipment Preparation
  • Prior to intubation all required equipment should
    be prepared for use
  • Check cuff on ETT
  • Insert stylet
  • Lubricate ETT
  • Check light on laryngoscope blade
  • Set up End tidal CO2 or open EDD
  • Check suction set up
  • Prepare ETT securing device

Patient Preparation
  • Patient position is vital in preparing for
  • Ensure bed is at appropriate height for person
  • Patient should be positioned as close to the head
    of the bed as possible.
  • Patients head should be positioned such that the
    mouth, pharynx and larynx are aligned. This is
    achieved by combining moderate cervical flexion
    and extension of the atlanto-occipital joint.
  • Placement of a small pillow or towel under the
    head can help achieve this position.

Team Communication
  • Communication amongst team members is very
    important during intubation
  • The person assisting intubation should ask the
    person performing it what their back up plan is
    if the first attempt is unsuccessful.
  • The person assisting can then have alternative
    airway adjuncts ready to be used or have extra
    personnel on stand by to assist.

  • During the intubation, the person assisting
    should ask the intubator if he/she can visualize
    the vocal cords and if they require laryngeal
  • Laryngeal pressure is often referred to as BURP
    which stands for Backward, Upward, Rightward,
  • This pressure is applied to the thyroid cartilage
    which in turn presses against the larynx and
    helps bring it into full view.

After Placement of ETT
  • Once the ETT is in place assessment of correct
    position must begin
  • Attach EDD or ETCO2 monitor.
  • Auscultate over the stomach first, then the
    lungs, checking for bilateral breath sounds.
  • Watch for misting of the ETT.
  • Once placement has been achieved, check the tube
    position and secure tube into place.
  • ETT placement should then be confirmed with chest

Rapid Sequence Intubation (RSI)
  • In a RSI, the patient is pre-oxygenated and
    rapidly rendered unconscious and paralyzed within
    45-60 seconds to facilitate emergent ETT
    intubation without the use of bag valve mask
    ventilation to minimize the risk of aspiration.

RSI Procedure
  • Pre-oxygenate the patient with 100O2 for 3-5
    min. by placing the BVM over the patients face,
    creating a tight seal and allowing the patient to
    breathe on their own.
  • This will wash out nitrogen and establish an
    oxygen reservoir. This reservoir will allow for
    several minutes of apnea without arterial
  • A healthy adult can maintain an SpO2 gt90
    for 8 min. of apnea with pre-oxygenation.
  • Young children, adults with
    cardiorespiratory disease, obese patients and
    pregnant women may desaturate to lt90 in less
    than 3 min.
  • BVM ventilation should only be provided if the
    patients SpO2 falls below 90.

RSI Procedure
  • The patients airway can be protected from
    aspiration by avoiding BVM ventilation and
    applying cricoid pressure.
  • Cricoid pressure (Sellicks maneuver) is achieved
    by using the thumb and index or middle finger to
    apply firm downward pressure on the cricoid
    cartilage. This will cause compression of the
    esophagus against the vertebrate and prevent
    regurgitation of gastric contents into the larynx
    and pharynx.
  • Cricoid pressure should only be applied after the
    patient is rendered unconscious and should not be
    released until ETT placement has been confirmed.

Airway Adjuncts
  • A variety of airway adjuncts are available if
    conventional intubation cannot be achieved
  • Staff must make themselves aware of the various
    devices available in their hospital, how to use
    them and where these pieces of equipment are
  • Examples of the adjuncts are
  • 1. Bougie
    5. LMA
  • 2. Glidescope
    6.. Fastrach LMA
  • 3. Lighted Stylet
    7. Bronchoscope
  • 4. McCoy Blade 8.
    Surgical airway equipment