1. Endotracheal Intubation of Dogs and Cats (Anesthetist)
This set of notes is for practical use in the surgery suite at VTI
There are no gold stars because this whole power point is a
There is a second set of notes that are more detailed and comprehensive regarding the process and importance of intubation, the risks associated with it, and items we do not have at VTI (VTNE information)
Reading assignment: A&A pages covers the equipment needed & pages covers the process
During lab, be sure to familiarize yourself with where to find intubation supplies and where to clean them
Recovery job also

2. Endotracheal Intubation
Flexible tube, placed inside trachea of an anesthetized (induced/unconscious) patient, used to transfer gases directly from the anesthesia machine to the patient’s lungs, therefore securing the airway.
Please know the definition of/be able to locate the following:
Larynx
Trachea
Arytenoids
Epiglottis
Soft palate
Tracheal bifurcation
Bronchus
Alveoli
Swallow reflex absent (Stage 3, Plane 1); after induction
Can maintain Ax on a mask, why intubate?

4. Anatomy Review

5. Supplies: Laryngoscope
Identify all parts
Ensure light is functioning properly
Curved vs. straight
Aids in direct visualization of the trachea
Miller vs. macintosh
Handle must match blade
Avoid touching epiglottis

6. Supplies: Secure Tube in Place
You have options:
Roll gauze
IV line tubing *usually best option
You will tie it around the tube first, and then around the patient’s head
Tie should be placed as far back as possible, without occluding the inflation line
Use a bow tie, not a knot
Tie around tube first
Do not include small tube for cuff inflation
Use a bow tie, not a knot

7. Supplies: Stylet Stylet is placed inside of the ET tube
Made of strong wire/metal
What is the purpose?
Stylet should be longer than ET tube
Why?
*Usually only used for cats
Stiffens and molds the tube
Do not lose it down the trachea!
Should not come out the distal end
GUIDE TUBES- soft plastic, placed in trachea before ET tube

8. The Endotracheal Tube ET tubes are made of polyvinyl chloride
View silicone demo tube
They have a Murphey eye and a cuff
You will prepare the size you think will be appropriate & 1 tube smaller and 1 tube larger
Type of cuff and a leak test

9. Selecting an Appropriate ET Tube
DIAMETER
Measured in _______________
Should be a snug, but smooth fit
Should not “fall” in OR be forced into trachea
“Largest that will comfortably accommodate patient”
DOGS = based on weight (table in A&A book)
Remember: 20 kg = mm
millimeters; half sizes until 11.0

10. Selecting an Appropriate ET Tube
LENGTH
Should extend from the _________________ to
cranial to the ___________ _______________.
Can use shoulder as a
landmark
Centimeters
Nose to thoracic inlet
One lung receives gas- hyperventilation, not enough inhalant waking up
One lung doesn’t- hypoventilation, atelectasis hypoxemia

11. Preparation is Key Immediately before intubating:
The night before surgery:
Check several tubes for loose connectors, excessive wear, cuff leaks, debris, etc.
Perform a cuff leak check:
Immediately before intubating:
Apply lubrication to cuff
Water or sterile lube depending on tube size
Very small amount and this is optional
Check patient ______ tone and __________ reflex
Inflate fully and let sit for 10 mins
Don’t allow lube to dry on tube
Water for <4.0mm

12. Intubation Techniques Procedure 8-6 on Page 260
1. Visual
Direct visualization of larynx minimizes possibility of traumatic or improper intubation
RESTRAINT/positioning IS KEY!

13. Visual Technique: Restrainer
Restrainer holds hand placed on the muzzle with fingers behind front canine teeth (like you would for pilling) pulling upward to open the mouth
Neck should be straight in line with body and fully extended
Adjust to the wishes of the
person intubating
Extended and in line with body
Use gauze to hold tongue

14. Visual Technique: Intubation
During intubation:
Hold laryngoscope in hand
Hold ET tube in other hand
Gently pull tongue forward, and press the blade to the base of tongue to expose trachea
Try to avoid touching the epiglottis
Soft palate may be obstructing your view
Blade too far forward can obstruct your view
Flange is made for humans, which is done upside down

15. Once it’s in to desired depth, confirm presence in trachea
Visualize tracheal opening (confirm by presence of arytenoids and epiglottis)
Epiglottis closed?
*May need to use blade to push down on tongue or push up on soft palate
Once epiglottis lies flat/open, slide ET tube past it and down into the trachea
Aiming caudally may cause esophageal intubation
Once it’s in to desired depth, confirm presence in trachea
Secure into place
Laryngoscope

16. How Do You Know You’re In?
Condensation seen in ET tube with each breath
Feel air through tube with each breath
Palpate throat for one firm structure
Patient can not vocalize
Only feel one tube

17. How Do You Know You’re In?
Using Machines:
Provide PPV= chest should rise (stomach should NOT)
Auscultate BOTH lung fields
Parts of Ax machine should move with respirations
Which parts?
Capnometer should give appropriate readings
Unidirectional valves and reservoir bag

18. Cuff Inflation- Patient Leak Test
Cuff is attached to a pilot balloon with a spring loaded inflation valve
Must depress the spring in order to inflate!
1. Manually ventilate and listen for air escaping around the tube
If you hear air escaping (most likely will), inflate cuff slowly until you don’t
Balloon should not feel taught or be fully inflated
Once no air sounds are heard, you’re good!
You will also feel resistance while squeezing the reservoir bag if the cuff is inflated appropriately
*Inflating the cuff fully should not take the place of using a larger tube!

19. After Intubation
Move the patient into desired position for the procedure
Hook up anesthesia machine to patient
Set flow meter first
Set vaporizer (if needed) once hoses are in place
MUST DISCONNECT PATIENT from breathing hoses anytime the patient is repositioned
*Never let breathing hoses hang off of the table
Most important with small ET tubes
*Do not move the endotracheal tube without deflating the cuff first!

20. Recovery Period You’re ready to wake them up!
Patient will remain on oxygen for about 5 minutes
Recumbency: _______________________
Head and neck ____________
Check oral cavity
Watch for signs of waking up:
RR and TV increase; HR increase
Eyes move central
Reflexes: palpebral, muscle tone, ear flick, back legs, tongue

21. Recovery Period- Extubation
1. After 5 minutes, oxygen can usually be discontinued
2. Disconnect breathing hoses and then untie ET tube tie
3. Deflate cuff completely and remove ET tube only when:
DOGS: Once swallowing reflex has returned
CATS: Earliest sign of regaining consciousness
(any voluntary movement- whiskers, head, tail flick, brisk palpebral)
4. Prevent obstruction of airway with tongue by pulling tongue forward during AND after removing the tube
5. Patient should react to removal of ET tube
Swallowing, licking/moving tongue, raising head, extending legs
Upper airway obstruction, respiratory distress likely

22. ET Tube Cleaning Inflate cuff and leave inflated until dry
Wash inside AND outside of endotracheal tube
Use bottle brushes and pipe cleaners to remove all debris
Use warm soapy water to get mucus off
Rinse
Disinfect in DILUTE chlorhexidine solution
Rinse VERY well
Hang upright to dry over night
Deflate cuff and replace in correct location