1. A&A Pages 97-99 & 245-251

2. Page2  Flexible tube, placed inside trachea of an anesthetized patient, used to transfer gases directly from anesthesia machine to patient’s lungs.

3.  Patient airway is assured  Artificial ventilation can be provided  Dead air space reduced  increase efficiency of gas exchange with inhalation anesthetics ◦ Anatomic dead space – This is good for two reasons: 1. 2. 3

4.  Reduces the risk of pulmonary aspiration ◦ What is this? ◦ What is being aspirated?  Secretions can be removed with suction catheter through the ET tube  Drugs can be easily administered in emergency (route = ____) ◦ Dosage =

6.  Technical difficulty  Overzealous efforts to intubate can damage anatomy  Esophageal intubation  Tube can be inserted too far cranial  Pressure necrosis from over inflation

8.  Cole tubes  Murphy tubes: cuffed or non-cuffed ◦ Cuff-  Laser specific tubes Murphy Eye

9.  Positive pressure ventilation  Efficient delivery of inhalant anesthetics ◦ P isn’t breathing in room air too ◦ Less waste gases in room  Prevent foreign material from entering lungs

10. Responsible for maintenance: batteries/charging and light bulbs

11.  http://www.youtube.com/watch?v=cK8fdHHy CPY&NR=1 - visual of epiglottis http://www.youtube.com/watch?v=cK8fdHHy CPY&NR=1  http://www.youtube.com/watch?v=3EDRvvGp OZk&NR=1 - intubation of a dog http://www.youtube.com/watch?v=3EDRvvGp OZk&NR=1  http://www.youtube.com/watch?v=CGjGTfP_ Bs0 – intubation with cuff http://www.youtube.com/watch?v=CGjGTfP_ Bs0

12. DIAMETER  Should be a snug, easy fit ◦ Should not “fall” in OR be forced into trachea  General ideas: CATS = 3.0-4.5mm DOGS = based on weight (table in A&A book) Remember: 20 kg = 9.5-10 mm

13.  Weight based is a guideline  Always prep 3 tubes  Brachycephalics may need smaller than you think Use width of space between the nostrils as a guide

15. LENGTH  Extend from:  If you extend into only one bronchus:  If tube extends too far past patient’s nose:  Increased mechanical dead space

16.  Check several tubes for loose connectors, excessive wear, cuff leaks, debris Cuff leak check: Immediately before intubating:  Apply lubrication- very small amount and optional  Check patient jaw tone ◦ Swallow reflex?

17. 1. Visual  Direct visualization of larynx minimizes possibility of traumatic or improper intubation  Position: ◦ Position is preference

19.  Assistant 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:  Pull out tongue to visualize back of throat 19

20.  Move soft palate up and out of the way with ET tube and at the same time…  Move epiglottis down and out of the way with the ET tube (or blade of laryngoscope)  Under direct vision, ET tube is passed through tracheal opening Tech note: You may need to wait for a breath or stimulate animal’s body to inhale to see opening

21.  Hold laryngoscope w/ non-dominant hand  Hold ET tube in dominant hand  Press blade against pulled out tongue, exposing trachea  Can be used to hold epiglottis down ◦ Lightly!  Blade too far forward can obstruct view

23. Page23

24.  Stylette runs inside the ET tube  Made of strong wire/metal ◦ Purpose?  Stylet should be longer than ET tube! ◦ Why?

25. 2. Blind  Used in dogs and horses  NOT suitable for cats, very small dogs, or patients with edema, swelling or trauma 3. Tactile  Cattle, large exotics, a few large dogs  Finger holds down the epiglottis  Slide tube into trachea using your finger as a guide

26.  Small mouth and sensitive larynx  Vocal cords tend to quickly close and push tube to side  Swallowing reflex or contact with end of ET tube causes: ◦ Can be reduced by application of topical anesthetic Apply 0.1 cc of 2% Lidocaine on glottis *With or w/o the needle

34.  Condensation seen in ET tube  Feel air through tube  Palpate throat  Normal breathing sounds  Patient can not vocalize

35. Using Machines:  Give a breath = chest should rise (stomach should NOT) ◦ Listen to BOTH lung sounds  Parts of Ax machine should move with respirations  Capnometer should give appropriate reading  Radiographs

36. Page36

37.  Cuff is attached to a pilot balloon with a spring loaded inflation valve  Must depress spring in order to inflate  Cuff should inflate, but not be maximally full of air *If more than 10 cc of air needed:  Leaky cuff or need a larger ET tube

38.  Recheck: ◦ Every 30 min of surgery AND ________________________  Most important for which type of procedure??  If you are running anesthesia for longer than 2 hours, you can reposition the tube slightly so pressure necrosis does not happen. Important note:

39.  Roll gauze  Rubber Band  IV line tubing  Paper tape-birds/reptiles Things to remember: 1. 2. 3. ALWAYS disconnect the patient from the anesthetic tubes when moving OR repositioning

40. Page40

41.  Your patient will be in recovery ◦ Recumbency? ◦ Head and neck ____________ Deflate the cuff when the patient shows signs of waking up  such as??  Remove ET tube after ______________________  Prevent obstruction of airway with tongue by pulling tongue forward during and after pulling the tube  Downside of waiting too long?

42.  Brachycephalic animals – should be head up, chewing on tube before it is pulled

43.  Patients may cough for 1 – 2 days post-op ◦ Should not be severe or continue to get worse  Advising owner will avoid phone calls and later explanations!

44.  Inflate cuff and leave inflated until dry  Wash inside AND outside of endotracheal tube  Use warm soapy water to get mucus off ◦ Commercial brushes available, cotton swabs, pipe cleaners  Rinse  Disinfect in Ultra Sonic Cleaning soln. or DILUTE chlorhexidine  Rinse VERY well  Hang upright to dry over night  Deflate cuff

45.  Unclean equipment (we reuse ET tubes!)  Leaky cuff ◦ Check before use, during surgery, and while cleaning

46.  Tube too small ◦ Not getting enough inhalant ax  ◦ Like breathing through a straw  ◦ Easily become blocked with mucus   Tube too large ◦ Damage to anatomy  Tube is too long ◦ Hypoxemia and atelectasis  decreased tissue perfusion and difficulty breathing on recovery

47.  Over-inflation of cuff  Under inflating cuff = No seal created ◦ Breathing room air  ◦ Staff breathing iso  ◦ Aspiration likely  Vagus nerve stimulation: ◦ Parasympathetic response  bradycardia, apnea, cardiac arrhythmias ◦ What class of premed can help prevent this response?

48.  Dislodged tube ◦ Not tied securely ◦ Coughs out (cats) ◦ Not disconnected while repositioning ◦ Weight of hoses & machine pulls out  Restricted air flow ◦ Bevel against wall of trachea  What can help with this? ◦ Kinks- extreme head position, over edge of table, floppy tube used