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Intubation and Extubation

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					Endotracheal Intubation/Extubation

Upper Airway Anatomy (p. 158)

Visualization of Vocal Cords

Indications for Intubation
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In conditions of, or leading to resp. failure, such as; - trauma to the chest or airway - neurologic involvement from drugs myasthenia gravis, poisons, etc. -CV involvement leading to CNS impairment from strokes, tumors, infection, pulmonary emboli -CP arrest

Indications (cont’d)
Relief of airway obstruction  Protection of airway (I.e. seizures)  Evacuation of secretions by tracheal aspiration  Prevention of aspiration  Facilitation of positive press. ventilation
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Relieving Airway Obstruction
Obstruction classified as upper ( above the glottis and includes the areas of the nasopharynx, oropharynx, and larynx) or lower (below the vocal cords)  Can also be classified as partial or complete obstruction  Causes include trauma, edema, tumors, changes in muscle tone or tissue support
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Hazards of tracheal tubes & cuffs
Infection  Trauma  Dehydration  Obstruction  Trauma
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Hazards (cont’d)
Accidental intubation of the esophagus or right mainstem bronchus  Bronchospasm, laryngospasm  Cardiac arrhythmias resulting from stimulation of the vagus nerve  Aspiration pneumonia  Broken or loosened teeth
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Later Complications of Intubation
Paralysis of the tongue  Ulcerations of the mouth  Paralysis of the vocal cords  Tissue stenosis and necrosis of the trachea
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Routes for Intubation
Orotracheal  Nasotracheal  Tracheotomy
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Oral Intubation

Advantages of Oral Intubation
Larger tube can be inserted  Tube can be inserted usually with more speed and ease with less trauma  Easier suctioning  Less airflow resistance  Reduced risk of tube kinking
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Disadvantages of Oral Intubation
Gagging, coughing, salivation, and irritation can be induced with intact airway reflexes  Tube fixation is difficult, self-extubation  Gastric distention from frequent swallowing of air  Mucosal irritation and ulcerations of mouth (change tube position)
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Nasal Intubation

Advantages of Nasal Intubation
More comfort long term  Decreased gagging  Less salivation, easier to swallow  Improved mouth care  Better tube fixation  Improved communication
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Disadvantages of Nasal Intub.
Pain and discomfort  Nasal and paranasal complications, I.e., epistaxis, sinusitis, otits  More difficult procedure  Smaller tube needed  Increased airflow resistance  Difficult suctioning  Bacteremia
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Intubation Equipment
Endotracheal Tube and stylet  Laryngoscope  Sterile water-soluble jelly  Syringe to inflate cuff  Adhesive tape or tube fixation device  Bite block to prevent biting oral ET tube  Suction Equipment, bag- mask, O2  Local anesthetic
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Endotracheal Tube

Endotracheal Tube
ET tube size and depth of insertion (see p. 594)  For children older than 2 years - tube size = age/4 + 4 - depth = age/2 + 12  Adult - tube size female = 8.0, male = 9.0 - depth female = 19-21 and 24-26 male = 21-23 and 26-28
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Stylet

Light stylet (light wand)

Laryngoscope

Laryngoscope
Blade and handle  Blade - has a flange, spatula, light, and tip - curved blade (Macintosh) - straight blade (Miller, Wisconsin)  Fiber optic vs. traditional laryngoscope  Blade size: 0 - 1 infant, 2 from 2-8 years 3 from age 10 - adult, 4 large adult
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Straight blade (Miller)

Curved blade (Macintosh)

Oral Intubation Procedure
Assemble and check equipment - suction equipment - laryngoscope - select proper size tube, check tube  Position patient - align mouth, pharynx, larynx - “sniffing” position
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Patient Positioning

Oral Intubation Proced. (cont’d.)
Preoxygenate the patient - bag-valve mask - *intubation attempt should take no longer than 30 sec, if unsuccessful, then ventilate again with bag and mask for 3-5 minutes  Insert laryngoscope - hold laryngoscope in left hand & insert in right side of mouth, displace tongue toward center
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Oral procedure (cont’d.)
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Visualize glottis and displace epiglottis

Oral proced. (cont’d.)
Insert ET tube - do not use laryngoscope blade to guide tube - once you see the tube pass the glottis, advance the cuff passed the cords by 2 -3 cm  Hold tube with right hand and remove laryngoscope & stylet - inflate cuff with 5 - 10 cc of air - ventilate with bag
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Oral proced. (cont’d)
Inflate cuff with 5 - 10 cc of air  Ventilate with “bag”  Assess tube position - auscultation of chest & epigastric - cm mark at teeth - capnometry/colorimetry - light “wand”  Stabilize tube/Confirm placement - chest x-ray
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Extubation
Guidelines for extubation (see table, p. 613)  Cuff-leak test
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Extubation Procedure
Assemble Equipment - intubation equipment - in addition to intubation equipment, O2 device and humidity, SVN with racemic epi  Suction ET tube  Oxygenate patient  Unsecure tube, deflate cuff
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Extubation proced. (cont’d.)
Place suction catheter down tube and remove ET tube as you suction  Apply appropriate O2 and humidity  Assess/Reassess the patient
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