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Subject: Endotracheal Intubation
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Laryngoscope handle (adult and pediatric) with charged batteries
Laryngoscope blades of various size (shown in Step 1):
Miller nos. 3 and 4 for most adults
Macintosh nos. 3 and 4 for most adults
Miller no. 0 for premature infants and neonates
Miller no. 1 for term infants
Miller no. 2 for small children
Endotracheal tubes of various sizes (shown in Step 2):
7.0 to 7.5 mm for most adult females
7.5 to 8.0 mm for most adult males
BVM attached to high-flow oxygen source
Suction with tip
Nasopharyngeal and oropharyngeal airways (shown in Step 1)
Capnography device (shown in Step 11)
Spare batteries and light bulbs
Tracheal tube securing device:
Tape and mastic
Tracheal cloth ties
Magill forceps to remove foreign material in posterior oropharynx
Respiratory or cardiopulmonary arrest
Severe exacerbation of a chronic medical condition, resulting in an unstable patient who cannot oxygenate and/or ventilate, which leads to
Hypoxia despite appropriate therapy
Hypercarbia, especially with altered mental status
Failure to ventilate because of
Central nervous system trauma associated with Glasgow coma scale (CS) ≤8
Injury to neck with airway compromise—Listen for stridor or voice changes:
Penetrating trauma associated with expanding hematoma
Blunt trauma associated with hematoma
Severe flail chest
Pulmonary injury resulting in poor oxygenation or ventilation
Multisystem trauma resulting in an unstable patient
Loss of airway protection because of altered mental status:
Advanced disease process
Anticipated clinical course:
Predicted decompensation of medical condition leading to respiratory failure
Severely injured patient requiring emergent surgery
Inhalation thermal injuries
Chemical injuries to the airway
Patient with increased work of breathing and fatigue despite therapy
Transfer of a patient to another facility with any of the previously mentioned conditions
Unstable cervical spine fracture is a relative contraindication but should not prevent intubation when it is required to sustain life. If time permits, a clinician skilled in fiber optic laryngoscopy can intubate with minimal manipulation of the cervical spine.
Severe facial trauma is a relative contraindication but should not prevent intubation when it is required to sustain life. Debris and blood may prevent visualization of the vocal cords. Cricothyrotomy should be considered in this situation.
PITFALL: Factors contributing to difficult intubation include these:
An obese patient with a short “bull” neck: This patient will be harder to position and will deoxygenate more quickly. The larynx in a patient with a short neck is often more anterior and higher than normal, leading to difficulty aligning the axes.
Large teeth and tongue or the inability to open the mouth more than 3 cm: This leads to less room to place and maneuver equipment in the mouth.
Trauma, blood, debris, or vomitus obscure landmarks.
Severe ankylosing arthritis or a cervical collar limits movement of cervical spine.
PITFALL: A patient with a cervical spine injury should not have any movement of the neck and will be more difficult to position.
PITFALL: If the blade is started in the center of the mouth, the tongue will not be adequately displaced to the left and will obscure the view.
PITFALL: Rotation of the handle represented by the red arrow in the figure instead of lifting up and out along its axis will lead to the handle or blade pressing against the lips and teeth, causing lacerations or avulsions.
PITFALL: Pushing the Macintosh blade too deeply into the vallecula will displace the epiglottis inferiorly, thus obscuring the view of the vocal cords.
PITFALL: If the Miller blade is passed beyond the epiglottis, the up and out force can lift the larynx and vocal cords out of view.
Pearl: If unable to visualize the vocal cords, the “B.U.R.P.” technique may be used. The clinician may apply backward, upward, and rightward pressure to the cricoid cartilage. This will maneuver the larynx into a more favorable position.
PITFALL: Failure to observe the tube and cuff pass the vocal cords will increase risk of placing the tube into the esophagus.
PITFALL: Forcing the tube between the vocal cords can lead to vocal cord damage. See the section on complications.
PITFALL: Failure to auscultate for breath sounds in the axillae may lead to a failure to identify a right mainstem bronchus intubation or esophageal intubation. In a right mainstem bronchus intubation, the clinician may hear breath sounds that have been transmitted from the right lung to the left when listening to the left parasternal area.
Pearl: The desired depth of the tube is 3 to 7 cm above the tracheal carina. This position will prevent damage to the carina by the tube if the patient’s head is flexed because flexion of the head can advance the endotracheal tube as much as 2 cm deeper into the trachea.
Right mainstem bronchus intubation:
ET tube is advanced too deeply, and the tip enters the right main stem bronchus.
This can cause atelectasis of left lung because of lack of air entering the left lung.
Operator should confirm position of the tube through auscultation of equal breath sounds in the axillae and on the chest radiograph.
If more intense breath sounds are heard over right side of chest, the tube should be withdrawn while auscultating until equal breath sounds are heard.
Endotracheal tube is inadvertently placed into the esophagus.
Intense air movement is heard over the epigastric area while no breath sounds are heard in lung fields.
The patient’s vital signs will deteriorate.
Some physicians remove the misplaced tube and perform another attempt. Other physicians leave the misplaced tube in place and attempt endotracheal intubation using the misplaced tube to mark the esophagus.
Vocal cord trauma:
Attempting to force an oversized ET tube through narrow vocal cords may cause damage to the cords.
Selecting a smaller ET tube will allow easier passage of the tube.
Damage to the teeth and lips is common. This usually occurs when the operator attempts to improve visualization by pivoting the laryngoscope in the mouth (shown in Step 6). This will cause the handle to push against the teeth and lips. If all broken teeth and fragments cannot be accounted for, a chest radiograph must be obtained to determine their location.
To avoid oral trauma, the laryngoscope handle should be lifted in the “up and out” manner.
Tracheal perforation by the stylet: The stylet should not extend beyond the tip of the ET tube.
Aspiration: Positive pressure with the BVM may lead to gastric distention. Cricoid pressure and minimizing BVM use will decrease the amount of gas in the stomach.
Pneumothorax can occur with positive pressure ventilation especially if the patient has poor lung compliance or if the ET tube was placed in the right mainstem bronchus.
Arrhythmias may be caused by manipulation of the oropharynx by the laryngoscope. Also, prolonged attempts to place the ET tube may lead to hypoxia, bradycardia, or asystole. Premedication with atropine can blunt the bradycardic response to intubation.
Continuous mechanical ventilation (CMV) or assist/control. The ventilator delivers a minimum number of breaths per minute at a set tidal volume (control breath). If the patient takes a breath independently, the ventilator will deliver the preset tidal volume (assist breath). This mode is generally used for patients who are not breathing spontaneously.
Synchronized intermittent mandatory ventilation (SIMV). The ventilator delivers a minimum number of ventilations per minute with a set tidal volume as in CMV. However, the patient may breathe spontaneously at rate greater than the ventilator setting and at their own tidal volume. This mode is used when patients are being weaned from the ventilator to allow them to breathe some on their own without risk of respiratory failure due to fatigue.
Continuous positive airway pressure (CPAP). The ventilator assists with inhalation by delivering a predetermined pressure in the circuit. This pressure decreases the work of breathing by allowing the patient to overcome airway resistance with less effort. The tidal volume and respiratory rate are determined by the patient’s effort. This mode may be used when determining if the patient can be extubated or in various restrictive and obstructive lung diseases.
Pressure regulated volume control (PRVC). A form of CMV in which a target volume is set on the ventilator and the ventilator will vary the inspiratory flow of each breath to achieve the set volume at the lowest possible peak pressure. The ventilator adjusts pressure from breath to breath, as the patient’s airway resistance and compliance change, in order to deliver a set tidal volume. It also measures the tidal volume of each breath and compares it to the set tidal volume. If the measured volume is less than the set volume, the ventilator will increase the inspiratory pressure to deliver the set tidal volume. If the measured tidal volume is more than the set volume, the ventilator will decrease the pressure. This setting may increase inspiratory time to deliver the set volume without raising pressure above its set upper limit. The PRVC setting is not recommended in asthma or COPD because a longer inspiratory time may cause air trapping and auto-PEEP (positive end-expiratory pressure).
Tidal volume (VT):
VT is the volume of air inspired and expired during each breath.
In the past, many experts recommended 10 mL/kg as a good starting point. However, more recent data suggest a lower tidal volume of 6 to 8 mL/kg reduces the risk of barotrauma and ventilator-induced lung injury.
The rate should be adjusted to approach a minute ventilation of 100 mL/kg. This minute ventilation is required to remove carbon dioxide produced by metabolism.
The rate should be adjusted with the following considerations:
The febrile patient produces 25% more carbon dioxide and requires 25% more breaths.
A hypercapneic patient may transiently require an increased respiratory rate to remove excess CO2. However, providing adequate ventilations through intubation and mechanical ventilation to a previously hypoventilating patient may be sufficient enough to correct hypercapnea without the need for hyperventilation.
The rate should be adjusted based on blood gas analysis or end tidal CO2 monitoring.
Pressure is applied to the airway to increase alveolar pressure and keep the small airways open.
It may be increased and can improve oxygenation by preventing alveolar collapse.
Excess pressure may elicit barotraumas.
Most start at 5 to 10 cm H2O.
Fraction of inspired oxygen (FiO2):
Concentration of oxygen delivered to the lungs
Usually begins with 100% and is titrated down based on arterial blood concentration of oxygen or pulse oximetry