Assignment on

Endotracheal
intubation

SUBMITTED TO: SUBMITTED BY:

DR. G. RAJI, M.BAVITHRA,
HOD& PROFESSOR, M.SC(N) I YEAR
DEPT.MEDICAL SURGICAL NURSING VMCON,
VMCON, KARAIKAL
KARAIKAL.
 ENDOTRACHEAL INTUBATION

INTRODUCTION:

The patient in the ICU often requires mechanical assistance to maintain airway
patency. Inserting a tube into the trachea, bypassing upper airway and laryngeal structures,
crests an artificial airway. The tube is placed into the trachea via the mouth or nose past the
larynx (endotracheal intubation or through a stoma in the neck (tracheostomy).ET intubation
is more common in ICU patients. It can be performed quickly and safely at the bedside.

DEFINITION:
Endotracheal intubation is the placement of a flexible plastic tube into the trachea to
maintain an open airway or to serve as a conduit through which to administer certain drugs

PURPOSE:

Endotracheal intubation is performed to establish and maintain a patent airway,

facilitate oxygenation and ventilation, reduce the risk of aspiration, and assist with the
clearance of secretions.
NOTE:
This procedure should be performed only by physicians, advanced practice nurses, and other
health care professionals (including critical care nurses) with additional
knowledge, s k i l l s , a n d d e m o n s t r a t e d c o m p e t e n c e p e r p r o f e s s i o n a l l i c e n s e
o r institutional standard
FUNCTION:
 An endotracheal tube:
 Provides a passage for gases to flow between a patient’s lungs and an anaesthesia
breathing system
 Allow one to positive pressure ventilation.
 Protects the lung from contamination from gastric contents and nasopharyngeal matter
such as blood
INDICATIONS:

 Upper airway obstruction (e.g., secondary to swelling, trauma, tumor, bleeding)

 Apnea
 Ineffective clearance of secretions (e.g. Inability to adequately maintain airway)
 High risk of aspiration
 Respiratory distress
 Neuromuscular disease
 Fracture vertebrae and Spinal cord

WHAT TO DO:

 Pulse oximetry should be used during intubation so that oxygen desaturation can be
quickly detected.
 Pre-oxygenation with 100% oxygen using a bag-valve-mask device with a tight-fitting
face mask should be performed for 3 to 5 minutes before intubation.
 Intubation attempts should take no longer than 15 to 30 seconds.
 Applying cricoid pressure (Sellick maneuver) may decrease the in
c i d e n c e o f pulmonary aspiration and gastric distention. This procedure is
accomplished by
applying f i r m , d o w n w a r d p r e s s u r e o n t h e c r i c o i d r i n g , a n d
p u s h i n g t h e v o c a l c o r d s d o w n w a r d so they are more easily visualized. Once
begun, cricoid pressure must be maintained until intubation is completed.

CONTRAINDICATION

The following are only relative contraindications to tracheal intubation:

 Severe airway trauma or obstruction that does not permit safe passage of an
endotracheal tube. Emergency cricothyrotomy is indicated in such cases.
 Cervical spine injury, in which the need for complete immobilization of the cervical
spine makes endotracheal intubation difficult
 Mallampati classification of class III/IV or other determination of potentially difficult
airway.
EQUIPMENT:

 Personal protective equipment

 Endotracheal tube with intact cuff and 15 mm connector
 ( Adult female 7.5 to 8.0 mm tube, adult male 8.0 to 9.0 mm tube)
 Laryngoscope handle with fresh batteries
 Laryngoscope blades (straight or curved)
 Spare bulb for laryngoscope blades
 Flexible stylet
 Self-inflating resuscitation bag with mask connected to 100% oxygen
 Oxygen source and connecting tubes
 Non-sterile gloves
 Luer-tip 10 ml syringe for cuff inflation
 Water-soluble lubricant
 Rigid pharyngeal suction-tip catheter
 Suction apparatus
 Suction catheter
 ET Tube tape (adhesive ( 6 to 8 in long)
 Stethoscope
 Sedating or paralyzing medications
 Forceps to remove foreign bodies
 Local anaesthesia
LARYNGOSCOPE
MAGILL’S FORCEPS

PROCEDURE:
 The patient is placed in a sniffing position to align the airway structures. Placing a
folded towel or bath blanket under the head may help achieve this position.
 If the procedure is performed electively, a topical anaesthetic and/or premedication
with sedative or paralytic agent may be used so that the patient better tolerates the
procedure.
 Before the procedure is performed the patient is hyper oxygenated and
hyperventilated with 100% oxygen by use of a bag-valve device with a face mask.
 The proper sized tube is chosen.
 All ETTs increase the work of breathing, however a tube that is too small
substantially increase the work of breathing and may make ventilation and weaning
difficult.
 The average sized ETT used for females ranges from to 8.0mm, whereas the average
size ETT used for male’s ranges from 8.5 to 9.0mm.
 After the tube is selected, the cuff on the balloon is inflated to check for proper
functioning and/ or any leaks.
 A stylet is used to stiffen the ETT and facilitate insertion.
 The ETT is lubricated with a water-soluble lubricant. The laryngoscope is attached to
the appropriate size and type of blad (straight or curved). The choice of blades varies.
 The straight blade elevates the epiglottis anteriorly to expose the vocal cords. The tip
of the curved blade fits into the vallecula. When upward traction is placed on the
laryngoscope, the epiglottis is displaced anteriorly.
 The person doing the intubation inserts the laryngoscope into the mouth to visualize
the vocal cords.
 Excess secretion and/or vomitus is sanctioned to facilitate visualization of the vocal
cords, the tonsil suction tip is very efficient in removing the secretion
 The ETT is inserted 5 to 6 cm beyond the vocal cords, and the cuff is inflated.
 The procedure should be performed within 30 seconds.
 If the intubation is difficult, the patient should be manually ventilated between
intubation attempts.
 Frequently, the patient requires endotracheal sanctioning for removal of excess
secretions immediately after intubation.
 If the patient needs assistance with breathing ventilations achieved with either the bag
valve device or ventilator.
 Placement of the ETT is verified by the movement of air in and out of the tube,
observation of bilateral chest expansion with inspiration and auscultation of bilateral
breath sounds while the patient is ventilated with bag valve device
 After intubation a portable chest x -ray study is always performed for verification of
the tube placement. The tip of the ETT should be approximately 2 to 5 cm above the
carina.
  Once proper tube placement is verified, the ETT is secured with tape or another
device in order to prevent dislodging.
ADVANTAGE:
 Easily and quickly performed
 Large tube facilitates suction and procedures such as bronchoscopy
 Less kinking of tube
DISADVANTAGE:
 Not recommended in patients with suspended cervical injury
 Uncomfortable
 Mouth care more difficult to perform
 Impairs ability to gag and swallow
 May increase salivation
 May cause irritation and ulceration of the mouth

NASOGASTRIC INTUBATION

A nasogastric (na-so-gas-tric) tube is a thin, soft tube passed through the nostril, down
the back of the throat, and into the stomach.
INDICATION:
o An NG is normally put in so that specially prepared liquid food can be put down the tube to
feed the client. The reason may include:
o If the client (pediatric clients) has problems with their sucking and swallowing
o If your client is not getting enough nutrition through their normal diet
o If clients cannot swallow medications they need
o Sometimes, an NGT may be put in to empty the stomach contents through the tube.
o For gastric lavage
Contraindication:
Recent nasal surgery and severe midface trauma
Other contraindications include: coagulation abnormality, esophageal varices, recent
banding of esophageal varices, and alkaline ingestion.
RISKS AND COMPLICATIONS

As with most procedures, NG tube insertion is not all beneficial to the patient as certain risks
and complications are involved:

 Aspiration.
 Discomfort.
 Trauma.
 Wrong placement.
 Other complications include: abdominal cramping or swelling from feedings that are
too large, diarrhoea, regurgitation of the food or medicine, a tube obstruction or
blockage, a tube perforation or tear, and tubes coming out of place and causing
additional complications
 An NG tube is meant to be used only for a short period. Prolonged use can lead to
conditions such as sinusitis, infections, and ulcerations on the tissue of your sinuses,
throat, oesophagus, or stomach

EQUIPMENT

 All necessary equipment should be prepared, assembled, and available at the bedside before starting
the NG tube. Basic equipment includes:
 Personal protective equipment
 NG/OG tube
 Catheter tip irrigation 60ml syringe
 Water-soluble lubricant, preferably 2% Xylocaine jelly
 Adhesive tape
 Low-powered suction device OR Drainage bag
 Stethoscope
 Cup of water (if necessary)/ ice chips
 Emesis basin
 pH indicator strips
PREPARATION

Unlike the person who will perform the procedure, patients do not have to prepare for an NG
intubation or feeding. However, a patient may need to blow their nose and take a few sips of
water (if allowed) before the procedure. Once the tube is inserted into the nostril, the
patient may need to swallow or drink water to help ease the NG tube through the esophagus.

ANESTHESIA

In some institutions, topical anesthesia for nasogastric (NG) intubation has been
considered. It is used for pain relief and to improve the possibility of successful NG
intubation.

Another method used before the procedure is the viscous lidocaine (the sniff and
swallow method). It was found to significantly reduce the pain and gagging sensation
associated with NG tube insertion.

Alternative techniques include the following:

 Nebulization of lidocaine 1% or 4% through a face mask

 An anesthetic spray of benzocaine or a tetracaine/benzocaine/butyl
aminobenzoate combination

STEPS IN INSERTING A NASOGASTRIC TUBE

Listed below are the step-by-step procedure in inserting a nasogastric tube.

1. Review the physician’s order and know the type, size, and purpose of the NG tube. It
is widely acceptable to use a size 16 or 18 French for adults while sizes suitable for children
vary from a very small size 5 French for children to size 12 French for older children.

2. Check the client’s identification band. Just like in administering medications, it is very
important to be sure that the procedure is being carried out on the right client.
3. Gather equipment, set up tube-feeding equipment or suction equipment mentioned
above. This is to make sure that the equipment is functioning properly before using it on the
client.

4. Briefly explain the procedure to the client and assess his capability to participate. It is
not advisable to explain the procedure too far in advance because the client’s anxiety about
the procedure may interfere with its success. It is important that the client relax, swallow, and
cooperate during the procedure.

5. Observe proper hand washing and don non-sterile gloves. Clean, not sterile, technique
is necessary because the gastrointestinal (GI) tract is not sterile.

6. Position client upright or in full Fowler’s position if possible. Place a clean towel over
the client’s chest. Full Fowler’s position assists the client to swallow, for optimal neck-
stomach alignment and promotes peristalsis. A towel is used as a covering to protect bed
linens and the client’s gown.

7. Measure tubing from bridge of nose to earlobe, then to the point halfway between the
end of the sternum and the navel. Mark this spot with a small piece of temporary tape or
note the distance. Each client will have a slightly different terminal insertion point.
Measurements must be made for each individual’s anatomy.

8. Wipe the client’s face and nose with a wet towel. Wipe down the exterior of the nose
with an alcohol swab. The NG tube will stay more secure if taped on a clean, nonoily nose. If
the nose has been cleaned with an alcohol swab, the tape will stay more secure and the tube
will not move in the throat—causing gagging or discomfort later.

9. Cover the client’s eyes with a cloth. This protects the client’s eyes from any alcohol
fumes from the alcohol swab.

10. Examine nostrils for deformity or obstruction by closing one nostril and then the
other and asking the client to breathe through the nose for each attempt. If the client has
difficulty breathing out of one nostril, try to insert the NG tube in that one. The client may
breathe more comfortably if the “good” nostril remains patent. The blocked nasal passage
may not be totally occluded and thus you may still be able to pass an NG tube. It may be
necessary to use the more patent nostril for insertion.

11. Lubricate 4 to 8 inches of the tub with a water-soluble lubricant. The NG

intubation is very uncomfortable for many patients, so a squirt of Xylocaine jelly in the
nostril, and a spray of Xylocaine to the back of the throat will help alleviate the discomfort.

12. Flex the client’s head forward, tilt the tip of the nose upward, and pass the tube
gently into the nose to as far as the back of the throat. Guide the tube straight
back. Flexing the head aids in the anatomic insertion of the tube. The tube is less likely to
pass into the trachea.

13. Once the tube reaches the nasopharynx, allow the client to lower his head
slightly. Ask the assistant to hold the glass of water. Ready the emesis basin and tissues. The
positioning helps the passage of the NG to follow anatomic landmarks. Swallowing water, if
allowed, helps the passage of the NG tube.

14. Instruct the client to swallow as the tube advances. Advance the tube until the correct
marked position on the tube is reached. Encourage the client to breathe through his
mouth. Swallowing of small sips of water may enhance the passage of the tube into the
stomach rather than the trachea.

15. If changes occur in patient’s respiratory status, if tube coils in mouth, if the patient
begins to cough or turns cyanotic, withdraw the tube immediately. The tube may be in
the trachea.

16. If obstruction is felt, pull out the tube and try the other nostril. The client’s nostril
may deflect the NG into an inappropriate position. Let the client rest a moment and retry on
the other side.

17. Advance the tube as far as the marked insertion point. Place a temporary piece of tape
across the nose and tube. In this way, you can check for placement before securing the tube.
The tube may move out of position if not secured before checking for placement.
18. Check the back of the client’s throat to make sure that the tube is not curled in the
back of the throat. On instance, the NG will curl up in the back of the throat instead of
passing down to the stomach. Visual inspection is needed in this situation. Withdraw the
entire tube and start again if such thing occurred

19. Check tube placement with these methods. Check the tube for correct placement by at
least two and preferably three of the following methods:

 A. Aspirate stomach contents. Stomach aspirate will appear cloudy, green,

tan, off-white, bloody, or brown. It is not always visually possible to
distinguish between stomach and respiratory aspirates. Special note: The small
diameters of some NG tubes make aspiration problematic. The tubes
themselves collapse when suction is applied via the syringe. Thus, contents
cannot be aspirated.
 B. Check pH of aspirate. Measuring the pH of stomach aspirate is considered
more accurate than visual inspection. Stomach aspirate generally has a pH
range of 0 to 4, commonly less than 4. The aspirate of respiratory contents is
generally more alkaline, with a pH of 7 or more.
 C. Inject 30 mL of air into the stomach and listen with the stethoscope for
the “whoosh” of air into the stomach. The small diameter of some NG tubes
may make it difficult to hear air entering the stomach.
 D. Confirm by x-ray placement. X-ray visualization is the only method that
is considered positive.
20. Secure the tube with tape or commercially prepared tube holder once stomach
placement has been confirmed. It is very important to ensure that the NG tube is in its
correct place within the stomach because, if by accident the NG is within the trachea, serious
complications in relation to the lungs would appear. Securing the tube in place will prevent
peristaltic movement from advancing the tube or from the tube unintentionally being pulled
out.

CONCLUSION:
Adequate ventilation is dependent on the free movement of air through the upper and lower
airway. In many conditions, the airway becomes narrowed or blocked as a result of disease
process, broncho-constriction, foreign body or secretion.

Maintaining a patent (open) airway is achieved through meticulous airway management,

whether in an emergency such as airway obstruction or in long-term management, as in
caring for a patient with an endotracheal or a tracheostomy tube.

BIBLIOGRAPHY:

1. Black.M.Joyce (2005), “Medical Surgical Nursing”, 7th edition, Elsevier publication, New
Delhi, Page No : 2042 – 2044.

2. Clark and Kumar (2005), “Clinical Medicine” 6th edition, Elsevier Saunders publication,
New Delhi, Page: 1204.

3. Suddarth’s & Brunner (1996), “Text Book of Medical Surgical Nursing”, 8th edition
Lippincott publication, page No: 1698 – 1699.

4. Vivian Rose Ramsden (1999), “Manual on Nursing Principle & Practice”, 1st edition
Omayalachi College of Nursing, Avadi, Page No: 179-181 5. Wilson Rose (2006), “Anatomy
& Physiology”, 10th edition, Churechil Livingston Elsevier publication, Page No: 149 – 150