1. Tracheal Intubation

2. Proper Positioning Flexion of the neck
Elevation of head approximately 10 cm
Goal: Alignment of the three axis

3. Proper Position of Laryngoscope Blade

4. Glottic opening during a direct laryngoscopy (elevated epiglottis)

5. Choose a Blade

6. Direct Laryngoscopy Mac vs Miller Confirmation of ETT placement
Advantages with each
Disadvantages with each
Confirmation of ETT placement
Simulation: Demonstrate intubation with MAC and Miller Blades

7. Choose a Tube

8. Optimal External Laryngeal Manipulation

9. Lehane McKormick Scale: document view for next person in a standard manner

10. Confirmation of Tube Placement
End-tidal PCO2
Symmetric bilateral chest movements
Bilateral breath sounds
Feel of compliance while manually inflating the lungs
Presence of expiratory refilling of bag
Condensation of water in the tube lumen
Arterial hemoglobin oxygen saturation

11. Securing the Tube

12. Nasal Intubations Indications: Contraindications: Complications:
Oral surgery
Emergent intubations (blind nasal)
Prolonged intubation
Contraindications:
Basilar skull fracture
Lefort II or Lefort III fractures
Complications:
Nasal necrosis
Posterior pharyngeal wall tear
Nasal/turbinate injury
Epistaxis
Adenoidectomy
Perforation of piriform sinus
Bactermia
Retropharyngeal abscess

13. Nasal Endotracheal Tubes
Nasal Rae
Advantage is tube contour facilitates stability
Endotrol Tubes
Soft
Ability to flex tip of tube

14. Equipment Necessary for Nasal Intubation
Vasoconstrictor (afrin, phenylephrine drops)
Local anesthetic (lidocaine jelly)
Lubricant
Magills forceps
Possible Fiberoptic if ‘blind’ nasal fails
Simulation: Demonstration of nasal intubation with Magill forceps

15. Common Complications of Intubation
Bronchospasm
Esophageal Intubation
Dental trauma
Aspiration
Laryngospasm
Endobronchial Intubation
Laryngeal/Tracheal Trauma
Hypertension
Tachycardia
Myocardial ischemia
Cardiac dysrhythmias
Pulmonary barotrauma

16. Bronchospasm
Increased airway resistance probably related to reflex response to endotracheal intubation
Accounts for approximately 5.3% of fatal or near-fatal peri-inducation complications
Extensive list for differential diagnosis

17. Evaluation of Bronchospasm
Auscultate while manually ventilating patient (evaluate compliance)
Bilateral vs Unilateral
Location of wheezing in lung fields (foreign body; cardiogenic)
Determine patency of ETT (suction catheter; fiberoptic scope)
Sequence of Events (induction; central line placement; surgical considerations, extubation)

18. Differential Diagnosis of Bronchospasm
Reactive Airway Disease
Chronic Obstructive Pulmonary Disease
Endobronchial intubation
Aspiration/foreign body
Pneumothorax
Light anesthesia
Obstructed ETT (kinked; foreign body)
Cardiogenic
Pulmonary Edema
Pulmonary embolus
Vascular rings
Drug induced histamine release
Anaphylaxis

19. Signs of Bronchospasm Increased Peak Inspiratory Pressures (PIP)
Decreased Tidal volumes (pressure ventilation)
Decreased Compliance to manual ventilation
Audible wheezing noted
Obstructed wave forms on Capnogram
Simulation: Demonstration of Bronchospasm (wheezing)

20. Treatment Supportive and determine cause Increased Inspired oxygen
Bronchodilators
Beta-2 Agonists
Anticholinergics
Steroids
Epinephrine
Treat underlying cause: pass suction catheter, deepen anesthetic, call attending for help----do not panic

21. Aspiration Risk Factors Risk Reduction Full stomach Hiatal Hernia GERD
Trauma
Narcotics
Gastroparesis
Uremia
Hypothyroidism
Risk Reduction
Avoid Mask Ventilation
Cricoid Pressure
Rapid Sequence Induction
Consider placing NG/OG tube and evacuate stomach contents

22. Management of Patient who Aspirates on Induction
Maintain Cricoid pressure
Turn head
Suction
Trendelenberg
Broncscopy
Intubation
Supportive Measures (A-line; Oxygen, PEEP)

23. Training Exercise:
Practice direct laryngoscopy and intubation with feedback from facilitator until advanced beginner
Practice nasotracheal intubation using Magil forceps
Demonstrate how to secure an endotracheal tube
Practice laryngoscopy with a Miller blade