Oral Endotracheal Intubation

**Intubation done wrong can be increadibly harmful - do not attempt without qualified training!**

 

 

 

Indications

Entotracheal intubation is used:

 

 

Procedure

 

 

 

 

 

 

 

 

 

 

Filmed at the Dalhousie Learning Resource Centre, used with permission.

 

  • Equipment Required
  • Preparations
  • Placing the Tube
  • Confirming Placement

Equipment Required

Endotracheal tubes are available in various sizes, the larger equipped with inflatable cuffing to seal the tube against the tracheal wall. A good rule of finger is to choose tube size according to the patient's pinkie diameter.

 

Blades

The rigid laryngoscope is designed to lift the tongue and epiglottis, allowing visualization of the vocal cords.

 

Blades come in different shapes and sizes. The straight Miller blade is useful for children, while the curved MacIntosh blade works best in adults. Blade size can be estimated by measuring the length from the patient's lips to the angle of the mandible.

 

Other Equipment

  • gloves, mask, protective eye wear
  • laryngoscope handle, plus a spare
  • selection of laryngoscope blades
  • suction (have this handy)
  • endotracheal tubes (at least one size above and below your best selection)
  • 10 cc syringe (ET Cuff inflation)
  • flexible intubating stylette (Figure 5.26)
  • Magill forceps
  • water soluble lubricant
  • lidocaine jelly and spray
  • Selection of O.P.A.’s and N.P.A.’s
  • 3 ft Twill Tape - for securing ET to patient.
  • Scissors
  • B.V.M. Apparatus

Preparations

Have a colleague present to assist.

 

Ventilate patient with BVM with 100% oxygen, or pre-oxygenate with 100 oxygen.

 

Observe univeral precautions and clean technique.

 

Choose sedation: light sedation or rapid sequence intubation

 

Preparation is everything. Select and check all equipment. Check suction, laryngoscope light, test inflate baloon and check for leaks, lubricate ETT tip and spray lidocaine on outside and inside.

 

If desired, a malleable stylet may be used to provide form to the ETT. Ensure inside of tube is lubricated to facilitate stylet removal.

 

Placing the Tube

Place patient on back, with head tilted back if no spinal injury is suspected. remove dentures. Place a pillow under the head, bringing ear to the level of the sternum.

 

Hold the blade handle with your hands to avoid tooth damage.

Aim laryngoscope handle upwards at ~45 degrees and advance along handle axis, being careful not to pinch lips or lever against teeth.

 

Visualize vocal cords.

 

Gently pass ETT between vocal cords, advancing cuff completely through.

 

If unsucessful within 20-30 seconds, remove laryngoscope and re-oxygenate patient before continuing.

 

Inflate cuff with 10 cc of air, remove syringe, and attach O2/CO2 meter before ventilating.

Confirming Placement

Do 5 point ausculation first over the epigastrium and then 2x each lung while ventilating. Bubbling sounds over the epigastrium suggests esophageal intubation - deflate cuff and repeat intubation.

 

If breath sounds are heard more clearly in one lung, mainstem bronchus intubation is likely. deflate cuff, withdraw ETT by 1-2 cm, and reassess.

 

A CO2 meter should be applied to the ETT, with colour change observed.

 

Once placement is satisfactory, secure tube with twill tape and continue ventilating.

 

Confirm ETT placement with CXR.

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Possible Complications

Hemodynamic insufficiency is very common due increased intrathoracic pressure and decreased vascular return. Be prepared to respond to hypotension!

 

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