Orotracheal intubation

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CONTENTS

INDICATION AIRWAY ASSESSMENT PREPARING THE PROCEDURE THE PROCESS OF OROTRACHEAL

INTUBATION

WHY DO WE INTUBATE PATIENTS

1.maintenance of a clear airway 2.protection of the trachea and lungs 3.tracheobronchial toilet 4.controlled mechanical ventilation

AIRWAY ASSESSMENT

Airway anatomy

AIRWAY ASSESSMENT

History taking

AIRWAY ASSESSMENT

Physical examination

Difficult to Bag (MOANS)

Mask Seal Obesity or Obstruction

Age > 55 No Teeth

Stiff

Physical examination

AIRWAY ASSESSMENT

Difficult Airway Assessment

4 D’s Distortion, Disproportion, Dysmobility, Dentition

BONES Beard, Obese, No teeth, Elderly, Snores (sleep apnea)

SHORT Surgery (head/neck/jaw), Hematoma, Obese, Radiation, Tumor

LEMON MALLAMPATI Always have a “Rescue Airway” technique ready

60-SECOND EXAM “LEMON”

Look for external difficulty Evaluate using 3=3=2 rule Mallampati (Class I & II) Obstruction Neck Mobility

3 fingers fit in mouth 3 fingers fit from mentum to hyoid cartilage 2 fingers fit from mandible to top of thyroid cartilage

AIRWAY ASSESSMENT

Laboratory data

chest x ray : tracheal deviation

Preparing the procedure 1.performer

Lion heart , lady hand , fully brain

Protect yourself-risk infection

Team provider

Preparing the procedure 2. the patient

Monitors : NIBP, EKG , pulse oximeter

Position : the height of the table –adjust the patient’s face is at the level of the xiphoid of the standing person

Preparing the procedure 2. the patient

sniffing positionsniffing position

Sniffing the morning air:

Neck slightly flexed and the head

Extended, a pillow under the head

And neck(10 cm.) but NOT under

the shoulders-serve to align the oral

pharyngeal,and laryngeal axis

Preparing the procedure 3. equipment

SALT : SALT : suction, airway, laryngoscope, tubesuction, airway, laryngoscope, tube

*1.self-refilling bag-valve combination (Ambu bag),

connector, tubing and oxygen source

*2.laryngoscope with curved (Macintosh) and straight (Miller)

*3.ET-T( several different sizes)

Preparing the procedure 3. equipment*4.oral airways

*5.tincture of benzoin and precut tape

*6.introducer (stylets or Magill forceps)

*7.suction apparatus

*8.syringe 10 ml. to inflate the cuff

*9.mucosal anesthetics (lidocaine spray)

*10.water-soluble sterile lubricant (K-Y jelly)

Preparing the procedure 3. equipment

ET-T : For most women ---PVC c cuff no. 7.5 mm. For most man ---PVC c cuff no. 8 mm.

For most laryngoscopes the blade is curved(Macintosh no.3)

The process of intubation

* place the patient in the sniffing position

* check the laryngoscope and blade for proper fit, and make sure that the light works

* make sure that all materials are assembled and close at hand

The process of intubation * select the proper-sized tube

* with the 10 ml syringe, inflate the balloon with 5-8 ml. of air. Make sure that the balloon is functional and intact. Lubricate the end

* insert the stylet, and bend the tube and stylet gently into a crescent shape, tip of stylet is at least 1 cm proximal to the end of the tube

The process of intubation

*Topical anesthesia: anesthetize the mucosa of the oropharynx, and upper airway with lidocaine spray, if time permit and the patient is awake

The process of intubation A. Mask ventilation 1.select the proper-sized mask, place the mask over the pt.mouth

and nose with the Rt. Hand

2.with the Lt.hand, place the small and ring fingers under the pt.mandible, and lift up to open the airway . Grasp the mask with the thumb and index finger, and press it to the pt.face while lifting the mandible with the ring and small fingers

3.compress the bag with the Rt.hand and begin ventilation 1-2 mins with 100%oxygen at rate of 10-15 L/min

THE PROCESS OF INTUBATION

B. Direct laryngoscopy 1. open the pt.mouth with the Rt.hand, and remove any

dentures.

2. grasp the laryngoscope in the Lt.hand, the laryngoscope is introduced into the Rt.hand side of the mouth

3. spread the pt.lips, and insert the blade between the teeth.

THE PROCESS OF INTUBATION

B. Direct laryngoscopy 4. pass the blade to the Rt. of the tongue, and advance

the blade into the hypopharynx, pushing the tongue to the Lt.

5. lift the laryngoscope upward and forward, without changing the angle of the blade, to expose the vocal cords.

Laryngoscopic View Grades

Grade 1: Full aperture visible

Grade 2: Lower part of cords visible

Grade 3: Only epiglottis visible

Grade 4: Epiglottis not visible

THE PROCESS OF INTUBATION

C. orotracheal intubation 1.when visualizing the glottis and vocal cords, gently

pass the tube next the laryngoscope blade through the vocal cords into trachea, far enough so that the balloon is just beyond the cord

*for most women the tube is sited at 19-20cm

*for most man this is 21-23 cm at lip level

2.withdraw the stylet

THE PROCESS OF INTUBATION

C. orotracheal intubation 3.connect the bag-valve combination, begin ventilation

with 100%oxygen confirm the tube is properly and inflate the cuff with the 10 ml syringe until there is no air leak around the tube when positive pressure is applied

4.apply tincture of benzoin, wrap adhesive tape around the tube where it comes out of the mouth

THE PROCESS OF INTUBATION

D. check tube placement **subjective

1. visualize

2. listening

3. chest movement

THE PROCESS OF INTUBATION

D. check tube placement ** objective

1. vital signs

2. pulse oxymetry

3. ET-co2

4. fiberoptic bronchoscopy

5. chest x ray

IFEndotracheal Intubation Endotracheal Intubation fails, you must have a back-up plan...