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
Complications of Other airway adjuncts.
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
Any patient in respiratory arrest
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
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 .
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(
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
Laryngoscope with relevant size blades.
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
Technique of Endotracheal
Intubation (in a ideal setting)
Position the patient supine, open the airway with
a head-tilt chin-lift maneuver.(Suspected spinal
injury, attempt naso-tracheal intubation, spine in
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.
This brings the epiglottis into view.” DO NOT LOOSE
SIGHT OF IT!”
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.
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
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
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).
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
Other Airway Adjuncts
Always oxygenate patient before and after
Do not attempt intubation unless you are
totally skilled, rather perform bag-valve-
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.