Endotracheal intubation Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. DCA, Dip. Software statistics- PhD ( physiology), IDRA, FICA

Indications Provides a patent airway 2. Protects the airway against aspiration of secretions, blood, and gastric contents 3. Allows positive-pressure ventilation 4. Allows removal of tracheobronchial secretions 5. Decreases the anatomic dead space 6. Oxygenation—provides a controlled FiO2 to 100% 7. Route for emergency drug administration during cardiac arrest

Same indications , but a different eye

Oral , pharyngeal and laryngeal axis

Three axes theory Sniffing the morning air ( bannister ) 10 cm thickness cushion Adnet challenged – neutral postion beneficial in many cases with imaging and clinical comparisons But keep the pillow , any problem , easy to remove

Correct patient positioning Ventilation with 100% oxygen Preparation of necessary equipment (including suction devices) Sometimes drugs

best aid to inexperienced operators learning laryngoscopy would be a 10-pin bowler's wrist brace, which would immobilize the wrist. Don’t lever

In or out ? straight or curved ! Pharyngeal surface of epiglottis – glossopharyngeal nerve Laryngeal surface – superior laryngeal nerve Laryngospasm Identification of epiglottis ! Essential

Curved blades are also thought to be less traumatic to the teeth and to provide more room for passage of the tracheal tube through the oropharynx. On the other hand, straight blades provide a better view of the glottis in a patient with a long, floppy epiglottis or an anterior larynx. Therefore, straight blades are preferred in infants, pediatric patients, and patients with an anterior larynx.

Problem number 1 – too deep

Problem number 2 important to keep the tongue completely to the left side of the mouth with the flange of the laryngoscope blade. Many unsuccessful or difficult intubations result from the tongue protruding over the flange of the blade toward the right side of the mouth

Problem number 3 in an effort to keep the tongue to the left, displacement of the blade tip to the right of the midline. This position obscures the view of the epiglottis and may precipitate trauma and bleeding from friable tissue in the tonsillar bed

Problem number – 4 In barrel-chested, obese, or large-breasted patients, it may be difficult initially to insert the blade of a laryngoscope correctly into the mouth and avoid obstruction to movement of the handle of the laryngoscope by the chest wall. In these patients, further initial neck extension or a 45-degree rotation of the laryngoscope handle to the right permits easier introduction of the blade of the laryngoscope into the mouth. Alternatively, a short laryngoscope handle

Obese patients may often require more extensive padding (planking) starting at the midpoint of the back to the head in order to assume an optimal position for laryngoscopy. (Rapid airway management position – RAMP )

Jackson position

Intubation Correct size From the lateral side Assistant can retract lips ! Tip to enter on vision Don’t do along the blade Cuff disappears - insertion Inflation and check

Moderate tension in the pilot balloon

The use of optimal external laryngeal pressure can improve the laryngoscopic view. may reduce the incidence of a grade III view from 9% to a range from 5.4% to 1.3%. Optimal external laryngeal pressure is usually backward, upward, and to the right (BURP) on the thyroid cartilage, What is the best ? He himself ! Bimanual laryngoscopy

Is it not endobronchial ? 21 cm in women and 23 cm in men – may be OK 3 times the endotracheal tube size in children (for a 4.0-mm endotracheal tube, 12 cm; for a 5.5-mm endotracheal tube, 16.5 cm). Auscultate both sides. Palpate for pulsed pressures in suprasternal notch with and the cuff simultaneous Fiberoptic bronchoscopy. Outside the operating room – Xray - Ideally, the tip of the tube should be 2 to 4 cm above the carina at the clavicular (midtracheal) level.

Fixation Ideal is maxilla Tincture benzoin ( alcohol + benzoin) Fan the alcohol out Wire with upper incisor if movement is possible Change every two days prolonged intubation Beards – umbilical tape around the neck – careful about venous compression

Previoulsy used for cases of mechanical ventilation Nasal intubation Previoulsy used for cases of mechanical ventilation But now possible bacteremia and sepsis goes against nasal intubation for long time ET tubes dental procedures, mandibular fixation Rarely in pediatrics Oral procedures

Vasoconstrictors Well gelled Deflate the cuff maximum Floor below the inferior turbinate Resistance - withdrawal, rotation, and reinsertion of the tube. Extension of the neck may help Usually the right nares !

Concavity anterior Concavity posterior

The laryngoscopy Similar

Nasopharynx Guide through the tip in front of glottis An assistant can push the tube Macgill forceps Hold the tube – not in cuff – swinging movement – backhand of a ping pong ball Hinging ? Flexion of the neck may help Put some air in the cuff – direct it and deflate

Length 24 to 25 cm for women and 26 to 27 cm for men 3 cm more Fixation in maxilla Suture to nose ! Checking – similar

Success tips Readiness with equipments Position Lubricate Hold the handle close to the blade Use force , at least delicate Don’t bend the wrist ( prying) every action has an equal and opposite reaction!

To put the tube what do we need ? Can we put the tube in you ? – NO Afferents pass on a big motor reaction( efferents) comes Nerve blocks Local spray Muscle relaxants

Summary Indications Axes Position Laryngoscopy Four problems Length Nasotracheal