By: Jeffery L' Finkbeiner, EMTP, IC

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By Jeffery L. Finkbeiner, EMT-P, IC
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Overview

• Airway Anatomy
• Advantages of Intubation
• Indications
• Contraindications
• Complications
• Equipment
• Intubation Techniques
• Nasal Intubation
• Suctioning

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Airway Anatomy

• Laryngoscope view of the vocal cords

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Advantages of Intubation

• A cuffed endotracheal tube protects the airway
  from aspiration
• Access is gained to the tracheobronchial tree for
  the suctioning of secretions
• Ventilations via an entotracheal tube do not
  cause gastric distention
• Maintains a patents airway and assists in
  avoiding further obstruction
• Enables delivery of certain medications

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Indications

• Inadequate oxygenation (decreased arterial PO2)
  that is not corrected by supplemental oxygen
• Inadequate ventilation (increased arterial PCO2)
• Need to control and remove pulmonary secretions
• Any patient in cardiac arrest
• Ant patient in deep coma who cannot protect his
  airway (without a gag reflex)

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Indications, cont...

• A patient in immediate danger of upper airway
  obstruction (i.e. burns of the upper airways)
• A patient with a decreased level of
  consciousness
• A patient with severe head and facial injuries
  with a compromised airway
• A patient in respiratory failure or respiratory
  arrest

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Contraindications

• A patient with an intact gag reflex
• Patients likely to react with laryngospasm (i.e.
  children with epiglottitis)
• Basilar skull fracture (during nasal intubation)

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Complications

• Trauma to the teeth, vocal cords, soft tissues of
  the larynx and related structures
• Nasotracheal tubes can damage the turbinates,
  cause severe bleeding, and even perforate the
  nasopharyngeal membranes
• Hypertension and tachycardia can occur from the
  intense stimulation of intubation. This is
  potentially life-threatening in the cardiac
  patient

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Complications, cont...

• Cardiac arrhythmias related to vagal stimulation
  or sympathetic nerve stimulation may occur
• Damage to the endotracheal tube cuff, resulting
  in a cuff leak and/or poor seal
• Intubation of the esophagus, resulting in gastric
  distention and regurgitation upon attempting
  ventilation
• Trauma resulting from over ventilating with a BVM
  without a pressure release valve (pneumothorax)

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Complications, cont more...

• Over stimulation of the larynx resulting in
  laryngospasm, causing a complete airway
  obstruction
• Inserting the tube to deeply resulting in right
  main stem bronchus intubation
• Tube obstruction due to foreign material, dried
  respiratory secretion and/or blood

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Equipment

• Body Substance Isolation (BSI)

Face shield/mask, protective glasses and latex
examination gloves
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Equipment

• Laryngoscope with relevant size blades, 10cc
  syringe

Miller (straight) Blade
MacIntosh (curved) Blade
Laryngoscope with blades and 10cc syringe
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Equipment

• Magill Forceps,flexible ET tube stylet

Stylet with ET tube
Flexible ET tube stylet
Magill Forceps
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Equipment

• Relevant size ET tubes,
• tube holder and/or cloth tape

Cuffed and uncuffed ET tubes
Various sizes and styles of ET tubes
ET tube holder
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Equipment

• BVM with oxygen, suction unit with Yankauer and
  french ET catheter

French ET catheter
BVM connected to oxygen
Yankauer suction tip
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Intubation Techniques

• Position yourself at the patients head
• Inspect the oral cavity for secretions or foreign
  material. Suction if necessary
• Hyperventilate the patient with 100 oxygen for 2
  minutes prior to intubation attempt

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Intubation Techniques

• Place the patients head in the sniffing
  position
• Open the patients mouth with the fingers of the
  right hand (easily accomplished by the
  crossed-fingered technique)

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Intubation Techniques

• With the laryngoscopeheld in the left hand,
  insert the blade into the right side of the mouth
  displacing the tongue to the left
• When using a curved blade, advance the tip of the
  blade into the vallecula (the space between the
  base of the tongue and the pharyngeal surface of
  the epiglottis)

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Intubation Techniques

• When using a straight blade, insert the tip under
  the epiglottis. The glottic opening is exposed
  by exerting upward traction on the handle
• To allow full visulization of the vocal cords, it
  may be helpful for an assistant to employ the
  Sellecks Maneuver (applying moderate pressure to
  the cricoid cartilage)

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Intubation Techniques

• Resist the urge to use a prying motion with the
  handle. Lift only upward to avoid damaging the
  patients bottom teeth
• Advance the ET tube through the right corner of
  the mouth
• Under direct vision, continue advancing the tube
  through the vocal cords

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Intubation Techniques

• Holding the tube firmly in place, quickly remove
  the laryngoscope blade
• Observe the depth markings on the the ET tube in
  relation to the patients teeth (19 to 23cm in an
  adult)
• Inflate the cuff with 5 to 10 cc of air via the
  pre-drawn syringe

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Intubation Techniques

• Attach the tube to a mechanical ventilation
  device such as a BVM and begin ventilating and
  oxygenating the patient
• Ensure distal cuff is inflated correctly and
  observe for any air leaks
• Observe end-tidal CO2 monitor and fogging of the
  tube

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Intubation Techniques

• During ventilation, confirm proper tube
  placement
• First auscultate the abdomen while visualizing
  chest expansion
• Then auscultate the chest bilaterally ensuring
  equal breath sounds

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Intubation Techniques

• Secure the tube in place using a tube holder and
  cloth tape
• If no tube holder is available, the tube may be
  secured using cloth tape and an oropharyngeal
  airway
• Continue with ventilating the patient

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Nasal Intubation

• Nasal intubation may be indicated for any of the
  following
• Endotrachael intubation has proven difficult
• C-spine motion must be limited (c-spine injury)
• If the patients jaw is clenched

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Nasal Intubation

• Hyperventilate the patient with 100 oxygen for 2
  minutes prior to intubation attempt
• Select a cuffed ET tube 1mm smaller than that
  used for normal endotracheal intubation
• Lubricate the end of the tube with a sterile,
  water-soluble jelly

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Nasal Intubation

• Select the nostril that is largest and most
  direct
• With the bevel of the tube toward the septum,
  advance the tube along the nasal floor

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Nasal Intubation

• If the nostril is impassible, attempt the other
  nostril. If unsuccessful, reduce the size of the
  tube by 0.5mm
• The curve of the tube should follow the natural
  curve of the airway

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Nasal Intubation

• Gently advance the tube while rotating it
  medially 15 to 30 degrees
• Continue advancing until airflow is heard through
  the tube
• Quickly and gently advance the tube early during
  the next inspiration (in a non-apnic patient)

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Nasal Intubation

• Observe for fogging of the tube while advancing.
  This indicates exhaled breath
• If no fogging or breath sounds are are noted,
  then placement may be in the esophagus. Withdraw
  and another attempt will be required

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Nasal Intubation

• Attach the tube to a mechanical ventilation
  device such as a BVM and begin ventilating and
  oxygenating the patient
• Ensure distal cuff is inflated correctly and
  observe for any air leaks
• Secure the tube with cloth tape

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Nasal Intubation

• During ventilation observe end-tidal CO2 monitor
  and confirm proper tube placement
• First auscultate the abdomen while visualizing
  chest expansion
• Then auscultate the chest bilaterally ensuring
  equal breath sounds

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Suctioning

• It may be necessary to suction secretions from
  the ET tube
• Measure the length of the catheter from the
  corner of the mouth to the tip of the earlobe
• Place your thumb and forefinger on the catheter
  at the point of maximum depth

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Suctioning

• Gently insert the catheter into the ET tube
  (without suction) until you reach the maximum
  depth determined by your thumb and forefinger
• Place your other thumb over the suction hole to
  begin the vacuum

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Suctioning

• While holding vacuum, maintain suction while
  slowly withdrawing the catheter from the tube
• Do not suction longer than 15 seconds
• Hyperventilate the patient before and after
  suctioning

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THE END