Artificial Airways Et Tube And Intubation

Front 1

Indications for an Endotracheal tube

Back 1

1. Risk of aspiration

2. Upper airway obstruction

3. Access for suctioning

4. Need for Mechanical ventilation

Front 2

ET tube markings and measurements

Back 2

- 21 to 25 cm mark at the lips

- 19 to 23 cm at the teeth

- distal end should be 3-6 cm above the carina

Front 3

Radiopaque line on the ET tube

Back 3

Allows to see the placement of the tibe on a Chest Xray

Front 4

Bevel tip

Back 4

Minimizes mucosal damage during insertion

Front 5

Murphy eye

Back 5

Side ports opposite to the bevel that assures gas flow if tip becomes occluded

Front 6

Tracheal cuff

Back 6

Seals lower airway to protect airway and facilitate positive pressure ventilation. Cuff is high volume, low pressure.

Front 7

Pilot balloon and valve

Back 7

Spring loaded valve allows for cuff inflation and monitoring cuff pressures.

Front 8

ET tube sizes

Back 8

Adult female - 7.5 - 8.0

Adult male - 8.0 - 8.5

Front 9

Equipment for intubation

Back 9

- Manual resuscitator and mask

- Laryngoscope handle and blade

- Stylet (oral intubation)

- Light wand

- Magill Forceps (nasal intubation)

- Syringe for cuff inflation

- EZ cap CO2 monitor

- Tape of ET tube holder

- Suction equipment (yankeur and catheter)

- CDC barrier precautions

Front 10

Light wand

Back 10

A flexible stylet with a light buld on the tip. Glow under the skin indicates tracheal placement. No glow means tube is in esophagus.

Front 11

Laryngoscope: Macintosh

Back 11

- Size 3 for adults.

- Curved.

- Fits into vallecula and indirectly raises the epiglottis.

Front 12

Laryngoscope: Miller

Back 12

- Size 3 for adults

- Straight

- Fits directly under the epiglottis

- infant intubation

Front 13

Laryngoscope troubleshooting if loght on blade does not work.

Back 13

- Tighten bulb

- Check handle attachment

- Change blades

- Check batteries

Front 14

Video Laryngoscope

Back 14

Video camera on the blade of a Laryngoscope for better view of the larynx. Ex: Glidescope.

Front 15

Stylet

Back 15

Provide ridgidity and shape to the ET tube for easier insertion. Placement is 1 cm above tip of ET tube to prevent puncture.

Front 16

Magill forceps

Back 16

Only for nasal intubation. To guide ET tube to the opening of trachea.

Front 17

Mallampati score

Back 17

Use to predict the ease of intubation.

Class 1 and 2: easy intubation

Class 3: Difficult

Class 4: Extremely Difficult

Front 18

Intubation Procedure

Back 18

1. Test Laryngoscope and ET tube cuff.

2. Position head in sniffing position.

3. Hyperoxygenate.

4. Hold Laryngoscope in left hand; ET tube in right hand.

5. Advance blade into the right side of mouth and sweep tongue to the left.

6. Advance Macintosh or Miller blade.

7. Visualize cord

Front 19

Intubation procedure cont.

Back 19

8. Insert tube (single attempt should not exceed 30 secs. Withdraw blade and bag pt before making another attempt)

9. Inflate cuff

10. Assess tube position

11. Manually ventilate and oxygenate and secure tube

12. Obtain chest x-ray

Front 20

Sellick maneuver

Back 20

Cricoid pressure to help visualize the cord.

- It moves trachea to a more posterior position for easier visualization.

- It also prevents vomiting during the intubation procedure by occluding the esophagus.

Front 21

Assessing tube position post intubation

Back 21

1. Visualize chest expansion on inspiration (Quickest)

2. Auscultate

* presense of bilateral BS

* absense of gastric sounds

3. Detection of end-tidal CO2 (purple to yellow)

* false negative in case of cardiac arrest or significant decreased CO

Front 22

Assessing tube position post intubation cont.

Back 22

4. Chest x-ray (BEST)* 3-6 cm above the carina* below clavicles, at level of aortic knob (between T2-T4)5. Mist in the ET tube during exhalation

Front 23

Advantages of Oral endotracheal intubation

Back 23

1. Quick insertion

2. A larger airway can be used

Front 24

Disadvantages of oral endotracheal intubation

Back 24

1. More poorly tolerated by conscious patients

2. Easier accodental extubation

3. Poor mouth care

Front 25

Rapid sequence intubation (RSI)

Back 25

1. Patient is NOT bag mask ventilated before procedure.

2. Preferred method of intubation in the ED

3. Reduces the chance of aspiration because no air enters the stomach.

Front 26

5 essential P's of RSI

Back 26

1. Preparation

2. Pre-oxygenate

3. Paralysis and induction

4. Placement of tube5. Post intubation management.

5. Post intubation management.

Front 27

Pre-oxygenate

Back 27

5 mins before sedationa and paralytics, pre-oxygenate via 2 methods:

- NRB for 3 min

- 15 lpm NC for 5 mins

* If BVM is necessary, be gentle and apply cricoid pressure.

Front 28

RSI paralysis and induction

Back 28

- IV opioid

- Hypnotic: etomidate

- Paralytics:

Succinylcholine or Rocuronium(common, long lasting, and doesn't cause hyperkalemia)

Front 29

RSI placement of tube

Back 29

1. Place pt in sniffing position

2. Sellick maneuver or cricoid pressure

3. Laryngoscope to visualize glottis

4. ET is passed between vocal cords

5. BMV (Bag Mask Vent) to verify position

Front 30

If you can't get tube in?

Back 30

- Provide 100% O2 with BMV

- Consider back up device

- Surgical airway (cricothyroidotomy)

Front 31

Naso-tracheal intubation indication

Back 31

Access to mouth is unavailable due to oral surgery or oral Trauma

Front 32

Naso-tracheal Disadvantages

Back 32

1. Nasal tissue and septum damage

2. Sinusitis and otitis (middle ear infection) due to obstruction of drainage.

Front 33

Naso-tracheal advantages

Back 33

1. More suitable because mandibular movement is bot an issue.

2. May be better tolerated by patient once placed.

Front 34

Naso-tracheal Method

Back 34

1. Performed blindly oray use fiberoptic Laryngoscope for visualization.

2. Pre lubricate with water soluble gel

3. Bevel up towad the septum

4. Advance tube

5. Depth of tube is 26-28 cm for adult

6. When tip is at oropharynx, a Laryngoscope is used to visualize the glottis

7. Magill forceps are used to grasp above the cuff and guide past the vocal cords.

Front 35

Complications of intibation procedure

Back 35

1. Right mainstem intubation

* suspect with tube inserted > 28 cm orally, unequal chest expansion, unequal BS, or increased ventilating pressures.

2. Oral, nasal and/or laryngeal trauma

3. Aspiration

4. Esophageal intubation

Front 36

Laryngeal injuries

Back 36

- Glottic edema (can worsen >24hrs after extubation)

- Vocal cord inflammation/paralysis

- Laryngeal or vocal cord lesions

*Tracheomalacia

*Tracheal stenosis

*Tracheoesophageal fistula

- Vocal cord polyps and granulomas

Front 37

Primary symptoms

Back 37

1. Hoarseness

2. Stridor

- Indicates significant reduction in airway diameter

- Treated with racemic epinephrine, steroids and cool aerosol.

- Steroids may be given 24 hrs in advance if the pt has failed an extubation attempt.

Front 38

Tracheoesophageal fistula

Back 38

Cause:

- tracheal erosion from the cuff qnd tube

- esophageal erosion from NG tube

Diagnosis:

- history of recurrent aspiration

- direct endoscopic examination

Treatment:

- surgical closure of fistula

Front 39

Cuff

Back 39

Use low pressure, high volume cuff to minimize damage.

Front 40

Prevention of damage

Back 40

1. Limit tube movement

2. Correct airway size

3. Maintain acceptable cuff pressures

4. Sterile technique when cleaning

Front 41

Monitoring cuff pressures

Back 41

Keep cuff pressures between 20-25 mmHg or 25-35 cmH2O

Front 42

Excess cuff pressure will result in:

Back 42

1. Decreased lymphatic flow --- will result in edem

2. Decreased venous flow --- will result in edema

3. Decreased arterial flow --- will result in necrosis

*(Tracheo-Innominate Artery Fistula)

Front 43

Tracheo-Innominate Artery Fistula

Back 43

Innominate artery ruptures that causes massive bleeding in the airway. This is caused by overinflated cuff that caused to the tracheal wall.

Front 44

Tracheo-Innominate Artery fistula treatment

Back 44

1. Compress the TIF by overinflating the tracheal cuff (85% success)

2. If unsuccessful, insert finger into the pre-tracheal space to compress the innominate artery against posterior sternum to control the bleeding.

Front 45

Tracheo-Innominate Artery Fistula treatment cont.

Back 45

3. Move pt to OR quickly

4. Blood should be sent for cross-match

5. Continue control of bleeding during transport to OR

Front 46

Minimum Occluding Volume (MOV)

Back 46

1. Place stethoscope over trachea

2. Withdraw enough air so that you hear a small leak at peak inspiratory pressure of a mechanical or manual breath.

3. Slowly add air back until there is no leak at the end of the PIP

Front 47

Minimal Leak Technique (MLT)

Back 47

1. Perform a MOV

2. After MOV is achieved, withdraw a little air until there is a slight leak at PIP

3. Use manometer to measure the pressure at the end of exhalation.

(Not done clinically but still tested on Board)

Front 48

Cufflator (manometer)

Back 48

Measure the pressure at the end of exhalation.

* Could cause leak if checked too frequuently

Front 49

Troubleshooting problems with the cuff

Back 49

1. Cuff pressure registers 0 torr

- Check the connection between the manometer and pilot balloon are tight.

2. If air is inserted and there is still evidence of a leak, the cuff is ruptured.

- extubate and re-intubate with a different tube

Front 50

Troubleshooting problems with the cuff cont.

Back 50

3. If the cuff pressure exceeds that which is recommended

- Extubate and re-intubate with a larger tube

4. If the cuff pressure is measured at a specific PIP but the PIP subsequently changes.

- re-measure the cuff pressure using MOV

Front 51

Secure ET tube with:

Back 51

1. Cloth tape

- Holds best especially with moisture

2. Specially made tube holders

Front 52

Secure well to prevent:

Back 52

1. Accidental extubation

2. Tracheal damage

Front 53

Double lumen ET tubes (Endobronchial tube or Carlens Tube)

Back 53

1. ET with 2 independent lumens of different lengths

- Longer lumen is inserted into right or left main stem bronchus

- Shorter lumen is placed in the trachea above the carina

2. Each lumen can be ventilated independently or wye adaptor to connect two lumens and ventilate with one ventilator.

Front 54

Double lumen or Carlens Tube

Back 54

Has two cuffs:

- One is in the bronchus

- One is in the trachea

Front 55

Double lumen/Carlens tube Indications

Back 55

- Unilateral lung disease to improve oxygenation and ventilation

- Used in thoracic surgery

Front 56

CASS Tube (Continues Aspiration of Subglottic Secretions)

Back 56

Continues suction above cuff via seperate tube connected to vacuum pressure of 20 mmHg

- Used to reduce incidence of VAPS

Disadvantage:

High cost

Front 57

Tube Exchangers

Back 57

1. Cook airway exchange catheter

2. Gum Elastic Bougie

Front 58

Cook Airway Exchange Catheter

Back 58

- Small diameter tube

- Allows oxygenation and ventilation during exchange via a 15mm adapter

- Cm markings list the depth of the tube

- Acts as a stylet

- ET tube slides over it and into trachea

Front 59

Gum Elasric Bougie

Back 59

- Small diameter semi-flexible tube with angled tip

- Acts as a stylet

- NO central lumen so oxygenation and ventilation is NOT possible during exchange

- Angler tip at 30 degrees to facilitate intubation