1. Intubation Techniques
Presented By Tom Beers

2. Overview Airway Anatomy Advantages of Intubation Indications
Contraindications
Complications
Equipment
Intubation Techniques
Nasal Intubation
Rapid Sequence Intubation

3. Airway Anatomy
Laryngoscope view of the vocal cords

4. Advantages of Intubation
A cuffed endotracheal tube protects the airway from aspiration
Access is gained to the tracheobronchial tree for the suctioning of secretions
Ventilations via an entotracheal tube do not cause gastric distention
Maintains a patent’s airway and assists in avoiding further obstruction
NO LONGER DO WE ADMINISTER MEDS VIA ETT

5. Indications
Inadequate oxygenation (decreased arterial PO2) that is not corrected by supplemental oxygen
Inadequate ventilation (increased arterial PCO2)
Need to control and remove pulmonary secretions
Any patient in cardiac arrest
Ant patient in deep coma who cannot protect his airway (without a gag reflex?????)
Remember: “Less than 8…Intubate”

6. Indications, cont...
A patient in immediate danger of upper airway obstruction (i.e. burns of the upper airways)
A patient with a decreased level of consciousness
A patient with severe head and facial injuries with a compromised airway
A patient in respiratory failure or respiratory arrest

7. Contraindications A patient with an intact gag reflex (Really????)
Patients likely to react with laryngospasm (i.e. children with epiglottitis)
Basilar skull fracture (during nasal intubation)

8. Complications
Trauma to the teeth, vocal cords, soft tissues of the larynx and related structures
Nasotracheal tubes can damage the turbinates, cause severe bleeding, and even perforate the nasopharyngeal membranes
Hypertension and tachycardia can occur from the intense stimulation of intubation. This is potentially life-threatening in the cardiac patient

9. Complications, cont...
Cardiac arrhythmias related to vagal stimulation or sympathetic nerve stimulation may occur
Damage to the endotracheal tube cuff, resulting in a cuff leak and/or poor seal
Intubation of the esophagus, resulting in gastric distention and regurgitation upon attempting ventilation
Trauma resulting from over ventilating with a BVM without a pressure release valve (pneumothorax)

10. Complications, cont more...
Over stimulation of the larynx resulting in laryngospasm, causing a complete airway obstruction
Inserting the tube to deeply resulting in right main stem bronchus intubation
Tube obstruction due to foreign material, dried respiratory secretion and/or blood

11. Equipment Body Substance Isolation (BSI)
Face shield/mask, protective glasses and latex examination gloves

12. Equipment Laryngoscope with relevant size blades, 10cc syringe
Miller (straight) Blade
MacIntosh (curved) Blade
Laryngoscope with blades and 10cc syringe

13. Equipment Magill Forceps,flexible ET tube, and stylet Magill Forceps
Flexible ET tube stylet
Stylet with ET tube

14. Equipment Relevant size ET tubes, tube holder and/or cloth tape
Cuffed and uncuffed ET tubes
Various sizes and styles of ET tubes
ET tube holder

15. Equipment
BVM with oxygen, suction unit with Yankauer and french ET catheter
French ET catheter
BVM connected to oxygen
Yankauer suction tip

16. Intubation Techniques
Position yourself at the patient’s head
Inspect the oral cavity for secretions or foreign material. Suction if necessary
Hyperventilate the patient with 100% oxygen for 2 minutes prior to intubation attempt (important!)

17. Intubation Techniques
Place the patient’s head in the sniffing position
Open the patient’s mouth with the fingers of the right hand

18. Intubation Techniques
With the laryngoscope held in the left hand, insert the blade into the right side of the mouth displacing the tongue to the left
When using a curved blade, advance the tip of the blade into the vallecula (the space between the base of the tongue and the pharyngeal surface of the epiglottis)

20. Intubation Techniques
When using a straight blade, insert the tip under the epiglottis. The glottic opening is exposed by exerting upward traction on the handle
To allow full visulization of the vocal cords, it may be helpful for an assistant to employ the Selleck’s Maneuver (applying moderate pressure to the cricoid cartilage)

22. Intubation Techniques
Resist the urge to use a prying motion with the handle. Lift only upward to avoid damaging the patient’s bottom teeth
Advance the ET tube through the right corner of the mouth
Under direct vision, continue advancing the tube through the vocal cords

23. Intubation Techniques
Holding the tube firmly in place, quickly remove the laryngoscope blade
Observe the depth markings on the the ET tube in relation to the patient’s teeth (19 to 23cm in an adult)
Inflate the cuff with 5 to 10 cc of air via the pre-drawn syringe

24. Intubation Techniques
Attach the tube to a mechanical ventilation device such as a BVM and begin ventilating and oxygenating the patient
Ensure distal cuff is inflated correctly and observe for any air leaks
Observe end-tidal CO2 monitor and fogging of the tube

25. Intubation Techniques
During ventilation, confirm proper tube placement
First auscultate the abdomen while visualizing chest expansion
Then auscultate the chest bilaterally ensuring equal breath sounds

26. Intubation Techniques
Secure the tube in place using a tube holder and cloth tape
If no tube holder is available, the tube may be secured using cloth tape and an oropharyngeal airway
Continue with ventilating the patient

27. Confirm Airway Placement

28. Digital Intubation
Insert your middle and index fingers into patient’s mouth.
Walk your fingers and palpate the patient’s epiglottis.

31. Nasal Intubation
Nasal intubation may be indicated for any of the following:
Endotrachael intubation has proven difficult
C-spine motion must be limited (c-spine injury)
If the patient’s jaw is clenched
Obese patients
No other means of airway security are available

32. Nasal Intubation
Hyperventilate the patient with 100% oxygen for 2 minutes prior to intubation attempt (use of lidocaine?)
Select a cuffed ET tube 1mm smaller than that used for normal endotracheal intubation
Lubricate the end of the tube with a sterile, water-soluble jelly (lidocaine?)

34. Nasal Intubation Select the right tube style
Select the nostril that is largest and most direct
With the bevel of the tube toward the septum, advance the tube along the nasal floor

35. Nasal Intubation
If the nostril is impassible, attempt the other nostril. If unsuccessful, reduce the size of the tube by 0.5mm
The curve of the tube should follow the natural curve of the airway

36. Nasal Intubation
Gently advance the tube while rotating it medially 15 to 30 degrees
Continue advancing until airflow is heard through the tube
Quickly and gently advance the tube early during the next inspiration (in a non-apnic patient)
Use of magill forceps?
Use of the ET blade in obese pateints?

37. Nasal Intubation
Observe for fogging of the tube while advancing. This indicates exhaled breath
If no fogging or breath sounds are are noted, then placement may be in the esophagus. Withdraw and another attempt will be required

38. Nasal Intubation
Attach the tube to a mechanical ventilation device such as a BVM and begin ventilating and oxygenating the patient
Ensure distal cuff is inflated correctly and observe for any air leaks
Secure the tube with cloth tape

39. Nasal Intubation
During ventilation observe end-tidal CO2 monitor and confirm proper tube placement
First auscultate the abdomen while visualizing chest expansion
Then auscultate the chest bilaterally ensuring equal breath sounds

40. Post Intubation Issues
Studies find that it is perceived that most ETT’s are missed pre-hospitally
Progressive FD/EMS departments are adressing issue
Hospitals can do their part too!
New backup airway devices are on the market

42. Conclusion
Airway security is one of the primary “bread and butter” operations of EMS
Basic airway maneuvers should always be done first and if effective and safe for the patient…continued
There is less emphasis on “early airway with endotracheal intubation” in ACLS
Best practices include continuous airway confirmation

43. THE END