HOW TO INTUBATE | ||
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Watch airway anatomy video Prior to intubation, always check equipment and make sure everything you might need is not only within your reach, but also properly working. If in the operating room, a complete check of the anesthesia equipment at the start of each day as well as a modified check before each new case is imperative. If in the emergency room or the hospital wards, make sure you know where all of your equipment is and, also, that you have the necessary resources to support the patient once intubated. Prior to positioning the patient:
Proper patient positioning can be the difference between a successful and failed intubation.
Mask Ventilation is often used in the operating room after induction, prior to intubation. If you are able to achieve signs of ventilation using this technique, you are afforded the knowledge that, if intubation fails, you are able to achieve ventilation using the bag-mask-valve device. Further, it allows for pre-oxygenation. Preparation for induction and intubation in the operating room also involves pre-oxygenation with several (eight) deep breaths of 100% oxygen. Preoxygenation provides an extra margin of safety in case the patient is not easily ventilated after induction. After preoxygenating the patient and positioning the patient in the Sniff position, with the patient’s mouth widely open, carefully introduce the blade, held in your LEFT HAND, into the right side of the mouth. Regardless of which blade is used, IT MUST NEVER PRESS AGAINST THE TEETH or dental trauma will result. The tongue is then swept to the left and up into the floor of the pharynx by the blade’s flange.
With either blade, the handle is raised up and away from the patient in a plane perpendicular to the patient’s mandible. Avoid trapping a lip between the teeth and the blade and AVOID using the teeth as leverage and avoid posterior rotation of the blade. Once a view of the larynx is obtained via laryngoscopy, the ETT is introduced with the RIGHT HAND through the right side often mouth. Directly observe the tip of the tube passing into the larynx, between the abducted cords. Pass the tube 1 cm through the cords. The ETT should lie in the upper trachea but beyond the larynx (3 to 4 cm proximal to the carina). If the patient is going to be repositioned, the cuff should be closer to 2 cm beyond the cords. Remove the laryngoscope, careful not to displace the ET tube and not to cause trauma to the teeth, lips or mucosa. Inflate the cuff with the least amount of air necessary to create a seal during positive pressure ventilation (usually 4-8 mL of air). Remove the mask from the bag-valve device and attach the 15 mm connector on the proximal end of the ET tube to the bag-valve device (into which oxygen is flowing and to which the carbon dioxide detector is attached). Provide positive pressure and immediately (and quickly):
If there is any question as to whether the tube is in the esophagus or trachea, remove the tube, ventilate with a mask and try again, this time attempting to adjust anything that may have interfered with your first attempt. You might reposition the patient, use a different blade, decrease tube size, or add a stylet. If you are sure that your intubation is successful, turn on the mechanical ventilator. Continuously provide positive-pressure ventilation at a volume of 350-700 ML per 70 kg (5-10 mL/Kg) and at a sufficient rate to maintain normal end tidal CO2 (8-12 respirations per minute). Proceed to tape or tie the tube to secure its position. Do not tape or tie the cuff. To prevent the patient from biting and occluding the ETT during emergence from anesthesia, a roll of gauze can be placed between the teeth or an OPA can be inserted. Document the view of the larynx obtained during laryngoscopy using the following criteria:
OTHER WAYS TO INTUBATE Nasotracheal Intubation: Nasal intubation is similar to oral intubation except that the ETT is advanced through the nose into the oropharynx before laryngoscopy. If the patient is awake, local anesthetic drops and nerve blocks can be used. A lubricated ETT is introduced along the floor of the nose, below the inferior nasal turbinate, perpendicular to the face. Often, a nasopharyngeal airway can be used. The tube is advanced until it can be visualized in the oropharynx. Via laryngoscopy, the tube is then advanced in between the abducted vocal cords. Nasal instrumentation (with ETTs, NPOs, or nasal catheters) is contraindicated in all patients with severe midfacial trauma.
Light Wand: Lightwands, when inserted into an endotracheal tube, may be useful for blind intubations of the trachea (when the laryngeal opening cannot be visualized). The end of the ET tube is at the entrance of the trachea when light is well transilluminated through the neck (the jack o’lantern effect). The tube can then be threaded off the light wand and into the trachea in a blind fashion.
Flexible Fiberoptic Bronchoscopy: Laryngoscopy may be contraindicated in a patient who requires intubation and mechanical ventilation. This is often the case in trauma patients who may have an unstable cervical spine or in patients with poor range of motion of the temporo-mandibular joint. In such patients, flexible fiberoptic bronchoscopy allows for indirect visualization of the larynx. The endoscope is introduced through the mouth or nose. Once anatomic structures are recognized, and the larynx or trachea are entered under direct visualization. COMPLICATIONS OF INTUBATION Complications of laryngoscopy and intubation are most frequently secondary to airway trauma, tube malpositioning, tube malfunction or physiologic responses to airway instrumentation. Trauma such as tooth damage, lip/tongue/mucosal laceration, sore throat, dislocated mandible, retropharyngeal dissection can occur during laryngoscopy and intubation. Mucosal inflammation and ulceration and excoriation of nose can occur while the tube is in place. Laryngeal malfunction and aspiration, glottic, subglottic or tracheal edema and stenosis, vocal cord granuloma or paralysis during extubation. Malpositioning of the endotracheal tube can result in esophageal intubation and unintentional extubation. Physiologic responses to intubation include hypertension, tachycardia, intracranial hypertension, and laryngospasm. Laryngospasm, which occurs during induction and recovery from anesthesia or, rarely, in an awake patient, is a forceful involuntary spasm of the laryngeal musculature caused by sensory stimulation of the superior laryngeal nerve. Treatment includes positive pressure ventilation via a bag-mask device using 100% oxygen or administration of IV lidocaine.
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Make sure that your laryngoscope is locked into position and that the incandescent light on the blade tip functions.
hockey stick to facilitate intubation of an anteriorly positioned larynx.
The curved Macintosh blade is inserted past the tongue into the vallecula (at the base of the tongue).
The straight Miller blade is inserted deep into the oropharynx, PAST the epiglottis.
Bougie: The Bougie is a straight, semi-rigid stylette-like device with a bent tip that can be used when intubation is (or is predicted to be) difficult – often helpful when the tracheal opening is anterior to the visual field.