Endotracheal intubation
Dr. May Thandar Kyaw
Department of Anesthesiology
What is it?
• Endotracheal - inside the trachea
• Intubation - putting a tube in
• For what? - to keep a patent airway
By whom?
• Anesthesiologists
• Intensivists
• Emergency physicians
• Paramedics
Endotracheal intubation
• Use of an artificial airway
• A mean of maintaining the patency of air passage
• Required in situations where a person cannot keep their airway
open
Indications
• For general anesthesia - patients who are undergoing surgery
• Of body cavities
• Head and neck
• Positions of difficult airway access ( eg. Surgery in prone
position)
• Patients with impaired consciousness (GCS < 8)
• In ICU
Through which opening?
• Through nose - nasotracheal intubation
• Through mouth - orotracheal intubation
• If nothing is said, usually through mouth
The route
Anatomy of airway
• Upper airway = nose, mouth, pharynx,
larynx, trachea and mainstream bronchi
• 2 openings - nose —> nasopharynx
• Mouth —> oropharynx
• Separated anteriorly by palate but join
in pharynx
Larynx
Function of airway
• Conduct air (containing oxygen) from the environment into the
lungs
• Filter
• Humidify
• Must be patent for survival
How we do it
Airway assessment
Airway assessment
• General – obesity, facial deformities, injuries, etc.
• Mouth opening - incisor distance > 3cm
• Mallampati classification
• Thyromental distance - between chin and superior thyroid notch
> 3 finger breath
• Neck circumference
Equipments
Oxygen source
Bag and mask
Laryngoscopes
Endotracheal Oropharyngeal
tubes ariways
Nasopharyngeal
Supraglottic airway
airway
Suction
Suction catheter
machine
Monitors
NIBP
SPO2
ECG
ETCO2
IV access Tape/ bandages
Endotracheal tubes
• Endotracheal tubes - made from polyvinyl chloride
• Shape and rigidity alterable by stylet
• Beveled end to aid visualization and insertion thru vocal cords
• Murphy eye to reduce risk of occlusion
Endotracheal tubes
• Permits positive pressure ventilation and reduce aspiration
• Uncuff tubes used in young children
• Two types of cuffs - high pressure low volume and low pressure
high volume
The procedure
As for general anesthesia
Preparation
• Checking equipment
• Positioning the patient
• Examine the ETT, test the tube’s cuff
• Insert stylet and bent to shape like a hockey stick
Positioning
Positioning
• Direct line of vision from mouth to glottic opening
• Moderate head elevation (5-10cm above the table) and extension
of atlanto-occipital joint
• Lower part of cervical spine is flexed
Preoxygenation
• Oxygen delivered by mask for several minutes
• Replace nitrogen from patient’s FRC with oxygen
• If preoxygenated - up to 5-8 min oxygen reserve
• Longer time available for intubation
• Important in increase demand - eg. Sepsis, pregnancy
• Decrease FRC - morbid obesity, pregnancy, ascites
Induction and muscle
relaxation
• Induction of anesthesia - IV / Inhalational
• Injection of muscle relaxants
• Attempt direct laryngoscopy when patient is under adequate
anesthesia and muscle relaxation
Direct laryngoscopy
Intubation
• Laryngoscope in left hand
• Mouth open, blade insert into right side of oropharynx
• Tongue swept to the side
• Tip of the blade inserted into vallecula (base of tongue)
• Handle is raised away from the patient in a perpendicular plane
to mandible
• Expose the vocal cords
View of vocal cords
• ETT taken in right hand, tip passed through vocal cords
• ETT cuff should lie in upper trachea, beyond larynx
• Laryngoscope is withdrawn
• Cuff inflated
• ETT position confirm
Auscultation
Capnography
Secure the tube and connect to
circuit
Extubation
• When patient is either deeply anesthetized or awake
• Adequate recovery from neuromuscular blockers
• Pharynx thoroughly suctioned of blood and secretions
• Ventilate with 100% oxygen
• ETT is untapped and cuff deflated
• Tube withdrawn in one smooth motion
Complications of
intubation
During laryngoscopy and
intubation
• Airway trauma
• Malpostioning • Dental damage
• Esophageal intubation • Lip, tongue or mucosal
laceration
• Bronchial intubation
• Sore throat
• Laryngeal cuff position
• Dislocated mandible
• Retropharyngeal
dissection
During laryngoscopy and
intubation
• Physiological reflexes • Tube malfunction
• Hypoxia, hypercarbia • Cuff perforation
• Hypertension, tachycardia
• Intracranial hypertension
• Intraocular hypertension
• Laryngospasm
While tube is in place
• Airway trauma
• Malpositioning
• Mucosal inflammation and
• Unintentional extubation ulceration
• Bronchial intubation • Excoriation of nose
• Laryngeal cuff position • Tube malfunction
• Fire/explosion
• Obstruction
Following extubation
• Airway trauma
• Edema and stenosis (glottic, sub glottic, or tracheal)
• Hoarseness (vocal cord granuloma or paralysis)
• Laryngospasm
• Negative-pressure pulmonary edema
End.
