Advanced Airway Management & Intubation The Difference Between Life and Death By: Norman Wilkinson, NREMT-P Flight Paramedic EMS/ECC Instructor

Topics For Discussion Basic anatomy and physiology. Advantages of endotracheal intubation. Indications of intubation. Contraindications of intubation. Complications of intubation. Equipment required for intubation. Technique of endotracheal intubation. Rules of endotracheal intubation. Tube sizes. Rules and principals of suctioning. Other airway adjuncts. Conclusion. 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 Intubation Cuffed E.T tubes protect the airway from aspiration. E.T tube provides access to the tracheobronchial tree for suctioning of secretions. 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 medication.

Indications for Intubation Inadequate oxygenation(decreased arterial PO2) that is not corrected by supplemental oxygen via mask/nasal. Inadequate ventilation (increased arterial PCO2). Need to control and remove pulmonary secretions. 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 tube.

Complications Associated With Intubation Trauma of the teeth, cords, arytenoid cartilages, larynx and related structures. Nasotracheal tubes can damage the turbinates, cause epistaxis, and even perforate the nasopharyngeal mucosa. 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 ventilation. Baro-trauma resulting from over ventilating with a bag without a pressure release valve( phneumothorax).

Complications Continued… Over stimulation of the larynx resulting in laryngospasm, causing a complete airway obstruction. 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

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 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.

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 stethoscope.

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 readings.(Spo2).

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.

Conclusion Always oxygenate patient before and after intubation. 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.