Document Sample
					   Advanced Airway
Management & Intubation

   The Difference Between
       Life and Death
          Don Hudson, D.O., FACEP, ACOEP
Topics For Discussion
   Basic anatomy and               Technique of
    physiology.                      endotracheal intubation.
   Advantages of                   Rules of endotracheal
    endotracheal intubation.         intubation.
   Indications of intubation.      Tube sizes.
   Contraindications of            Rules and principals of
    intubation.                      suctioning.
   Complications of                Other airway adjuncts.
    intubation.                     Conclusion.
   Equipment required for          Difficult intubations.
Anatomy and Physiology
 The airways can be divided in to parts namely:
  The upper airway.

  The lower airway.
The Upper Airway
The Lower Airway
Advantages of Endotracheal
   Cuffed E.T tubes protect the airway from
   E.T tube provides access to the
    tracheobronchial tree for suctioning of
   E.T tube does not cause gastric distention and
    associated danger of regurgitation.
   E.T tube maintains a patent airway and assists
    in avoiding further obstruction.
   E.T tube enables delivery of aerosolized
Indications for Intubation
   Inadequate oxygenation(decreased arterial
    PO2) that is not corrected by supplemental
    oxygen via mask/nasal.
   Inadequate ventilation (increased arterial
   Need to control and remove pulmonary
   Any patient in cardiac arrest.
Indications for Intubation
   Ant patient in deep coma who cannot protect his
    airway.(Gag reflex absent.).
   Any patient in imminent danger of upper airway
    obstruction (e.g. Burns of the upper airways).
   Any patient with decreased L.O.C, GCS <= 8.
   Severe head and facial injuries with
    compromised airway.
Indications Cont…
   Any patient in respiratory arrest
   Respiratory failure
                      1. Hypoventilation/Hypercarbia
                           A. Paco2 > 55mmhg
                       2. Arterial hypoxemia
                          refractory to O2
                           A. Paco2 < 70 on 100% O2
Contraindications for Intubation
   Patients with an intact gag reflex.
   Patients likely to react with laryngospasm
    to an intubation attempt. e.g. Children
    with epiglottitis.
   Basilar skull fracture – avoid naso-tracheal
    intubation and nasogastric/pharyngeal
Complications Associated With
   Trauma of the teeth, cords, arytenoid cartilages, larynx
    and related structures.
   Nasotracheal tubes can damage the turbinates, cause
    epistaxis, and even perforate the nasopharyngeal
   Hypertension and tachycardia can occur from the
    intense stimulation of intubation; This is potentially
    dangerous in the patient with coronary heart disease.
   Transient cardiac arrhythmias related to vagal
    stimulation or sympathetic nerve traffic may occur .
Complications Continued…
   Damage to the endotracheal tube cuff, resulting
    in a cuff leak and poor seal.
    Intubation of the esophagus, resulting in gastric
    distention and regurgitation upon attempting
   Baro-trauma resulting from over ventilating with
    a bag without a pressure release valve(
Complications Continued…
   Over stimulation of the larynx resulting in
    laryngospasm, causing a complete airway
   Inserting the tube to deep resulting in unilateral
    intubation (right bronchus).
   Tube obstruction due to foreign material, dried
    respiratory secretion and/or blood.
Equipment Required for
Successful Intubation
Equipment Cont…
   Laryngoscope with relevant size blades.
   Magill forceps.
   Flexible introducer.
   10-20 ml syringe.
   Oropharangeal airways – all sizes.
   Tape or adhesive plaster.
   E.T tubes – relevant sizes.
   Bag-valve-mask with oxygen connected.
   Suction unit with Yankauer nozzle and endotracheal
    suction catheter.
Technique of Endotracheal
Intubation (in a ideal setting)
Technique Cont…
   Position the patient supine, open the airway with
    a head-tilt chin-lift maneuver.(Suspected spinal
    injury, attempt naso-tracheal intubation, spine in
    neutral position.).
   Open mouth by separating the lips and pulling
    on upper jaw with the index finger.
   Hold laryngoscope in left hand, insert scope into
    mouth with blade directed to right tonsil.
   Once right tonsil is reached, sweep the blade to
    the midline keeping the tongue on the left.
Technique Cont…
   This brings the epiglottis into view.” DO NOT LOOSE
   Advance the blade until it reaches the angle between the
    base of the tongue and epiglottis.( volecular space)
   Lift the laryngoscope upwards and away from the nose –
    towards the chest. This should bring the vocal cords into
    view. It may be necessary for a colleague to press on
    the trachea to improve the view of the larynx.
    Place the ETT in the right hand. Keep the concavity of
    the tube facing the right side of the mouth.
   Insert the tube watching it enter through the cords.
Technique Cont…
    Insert the tube just so the cuff has passed the
    cords and then inflate the cuff.
   Listed for air entry at both apices and both
    axillae to ensure correct placement using a
Rules of Intubation
   Always have a suction unit available.
   An intubation attempt should never exceed
    30 seconds.
    Oxygenate the patient pre and post
    intubation with a bag-valve-mask.(100% O2).
   Have sedative medication available if
    needed.    (e.g. Midazolam 15mg/3ml)
   Always recheck tube placement manually
    guided by oxygen saturation
Tube sizes
   Newborn – to 4 kg - 2.5 mm (uncuffed).
   1-6 months 4-6 kg – 3.5 mm (uncuffed).
   7-12 months 6-9 kg – 4.0 mm (uncuffed).
   1 year 9 kg – 4.5 mm (uncuffed).
   2 years 11 kg – 5.0 mm (uncuffed).
   3-4 years 14–16 kg - 5.5 mm (uncuffed).
   5-6 years 18–21 kg – 6.0 mm (uncuffed).
   7-8 years 22-27 kg – 6.5 mm ( uncuffed).
Tube Sizes
  9-11 years 28-36 kg – 7.0 mm(cuffed).
 14 to adults 46+ kg – 7.0 – 80 mm (cuffed).
 Adult female 7.0 – 8.0mm (cuffed).
 Adult male 7.5 – 8.5 mm (cuffed).
 The size of the tube may also be determined by
  the size of the patients little finger.
N.B patients below the age of 8 require uncuffed
  ETT due to damage caused by the cuff in
  younger patients. Always monitor the ECG
  activity during intubation.
4 Rules of Suctioning
   Never suction further than you can see.
   Always suction on the way out.
   Never suction for longer than15 seconds.
   Always oxygenate the patient before and
    after suctioning.
Other Airway Adjuncts
   Kombi-tube.
   Oropharangeal airways/tubes.
   Nasopharyngeal airways/tubes.
   Oro-tracheal tubes.
   Naso-tracheal tubes.
   Always oxygenate patient before and after
   Do not attempt intubation unless you are
    totally skilled, rather perform bag-valve-
    mask ventilation.
   Always monitor the spo2 readings.
   Always reconfirm tube placement from
    time to time.
   This is some information as a base line
   The additional Power Points will expand
    on this information.