1. Unit 3 Lesson 3 Endotracheal Intubation

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An endotracheal tube (ET) is a tube designed to be inserted into the trachea. Oxygen, medication, or a suction catheter can be directed into the trachea through an ET tube. The markings on the ET tube indicate the internal diameter of the tube in millimeters. The tubes are available in graduated sizes from 2.5 to 10 mm. The proximal end of the ET tube has a 15 mm adapter that connects to various oxygen delivery devices.

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The distal end of the tube is beveled to facilitate placement between the vocal cords. The distal end also has a balloon cuff that when inflated wedges the tube inside the trachea. This cuff prevents aspiration of vomitus around the tube and minimizes air leaks during ventilation.

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Endotracheal intubation allows direct ventilation of the lungs through the ET tube, bypassing the entire upper airway. The ET tube is placed through the vocal cords with direct visualization of the process. A laryngoscope is an illuminating instrument that is inserted into the pharynx and larynx and allows you to visualize those structures. A laryngoscope is made up of two components, the handle and the blade.

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In most laryngoscopes, the handles and the blades are in two separate pieces. Some disposable laryngoscopes are preassembled with the handle and the blade as a single fixed unit.

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There are two general types of blades, straight and curved. Both types of blades come in assorted sizes from 0 to 4 – with 4 being the largest. The size of the blade used depends on the size of the patient. Each blade is designed to enable visualization of the vocal cords by taking advantage of the different anatomical mechanisms.

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The straight blade is designed so that the tip of the blade is place under the epiglottis in order to lift the epiglottis upward and bring the glottic opening and the vocal cords into view. The curved blade is designed so that the tip of the blade is inserted into the vallecula (the space between the base of the tongue the pharyngeal surface of the epiglottis) so that lifting the laryngoscope handle brings the vocal cords into view.

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Before intubtion, hyperventilate the patient’s lungs with 100% O2 for at least 1 minute. With the laryngoscope held in the left hand, insert the blade into the right side of the mouth, displacing the tongue to the left. Advance the ET tube through the right corner of the mouth and, under direct vision, through the vocal cords. Never use a prying motion with the handle and do not use the teeth as a fulcrum.

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Observe the depth markings on the ET tube during intubation. In the average adult, the tube is properly positioned when the patient’s teeth are between the 19 and 23 cm marks on the tube. Using a syringe, inflate the balloon cuff with about 10 mL of air through the one- way inflating tube.

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Confirm proper tube placement by auscultating over the mid-anterior chest line on the right and left sides of the chest. If stomach gurgling is present or chest expansion is absent, immediately remove the ET tube and reattempt intubation after oxygenating the patient’s lungs with 100% O2 for 15 to 30 seconds.

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When appropriate tube placement has been confirmed, secure the ET tube to the patient’s head and face and provide ventilatory support with supplemental O2. Be especially careful not to disturb the ET tube. If the tube is pushed in, it will most likely enter the right bronchus preventing O2 from entering the patient’s left lung. If the tube is pulled out, it can easily slip into the esophagus sending all of the O2 to the patient’s stomach. This is a fatal complication if it goes unnoticed!

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The advantages of endotracheal intubation of the apneic patient include complete control of the airway. The ET tube prevents the tongue, blood, or debris that may be present in the upper airway from interfering with the passage of air into the trachea and lungs.

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It minimizes the possibility of aspiration of vomitus or other foreign matter into the airway. It allows for better oxygen delivery. And endotracheal intubation allows for deep suctioning of the airway (a flexible suction catheter can be passed through the ET tube to suction the trachea to the level of the carina).

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Endotracheal intubation is considered to be an invasive technique because it requires placement of equipment inside a body cavity. Whenever you perform an invasive procedure, you must be aware of the potential complications and be prepared to recognize and treat them should they arise. Stimulation of the airway can lead to slowing of the heart. The patient’s heart rate should be monitored throughout the intubation.

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Prolong attempts at intubation may also lead to hypoxia. To prevent this, the patient should be hyperventilated with high flow O2 prior to intubation and the entire intubation procedure should only take about 30 to 45 seconds to perform. Stimulation of the airway may also cause the patient to gag and vomit. Because of the high risk of splattering of sputum or blood during intubation, it is essential that body substance isolation precautions (BSI precautions) be taken when intubating a patient.