Airway Management - Intubation
1. Rapid sequence intubation:- a technique of intubation using induction & paralytic agents
to induce LOC & paralysis of vocal cord and to facilitate
tracheal intubation & prevent aspiration
2. Indication:①failure of oxygenation
②failure of ventilation
③To maintain airway patency
- Intraluminal:- foreign body
- Luminal:- angioedema, anaphylaxis, haematoma
- Extraluminal:- haematoma, trauma
④To protect airway
⑤clinical deterioration that leads to ① & ③
7 P’s of intubation
a) Preparation – MEALS
Medication, mask
Endotracheal tube
Adjust airway
Laryngoscope
Stylet, suction, syringe, stethoscope, staff, self
Male ETT size = 7-8
Female ETT size = 6-7
Prepare ETT + 0.5
Secure ETT at 3times the size of
ETT (eg size 7 – secure at 21cm)
b) Preoxygenation – high flow mask/ bag valve mask with 100% O2
 For nitrogen washout for around 3-5 mins depending on patient’s body weight
 So when patient becomes apneic, there is no oxygen entering lung & thus 100% O2 will
provide as store in lungs
*Short duration >> obese, pregnant
*Bag only when patient desaturate/ apneic
*Do not bag if patient can self-ventilate
c) Pre-medication:- LOAD
Lignocaine [obtund cough/ gag reflex, reduce pain, obtund sympathetic reflexes (BP,
HR, ICP ↓)]
Opiod (fentanyl) 1mcg/kg
Atropine (when BP ↓)  used in paeds
Defasciculating agent
Prepared by Leow Zhe Eu Group 4 Year 5 2014/2015
d) Paralytic agent
Induction agent (PROF KETAM)
 Propofol 1mg/kg (cardiorespitatory ↓)
 Ketamine 1mg/kg (able to ↑ BP)
 Etomidate 0.3mg/kg (maintain BP)
 Thiopental 1mg/kg –(cardiorespiratory ↓)
 Midazolam 0.1mg/kg – (cardiorespiratory
↓)
e)
-
Muscle Relaxant
 Succinylcholine 0.6-1.2mg/kg –dangerous
with hyper-K,but can be used in acute
burn
 Rocuronium 1mg/kg
 Vecuronium
*if unsure, use rocuronium
*C/I for succinylcholine
 h/o of maligant hyperthermia
 burn/crush injury >5/7
 stroke/ spinal cord injury >5/7
 MS/ ALS/ inherited myopathy
 known hyperkalemia (absolute)
 renal failure (relative)
 suspected hyperkalemia (relative)
Positioning:- Sniffing position
Flexion of neck & extension of hand
Put pillow/ donut below head about 10cm
External auditory meatus must be of same plane with sternal angle
f) Placement & confirmation
① Direct visualization
② Symmetrical chest rise
③ Presence of vapour on ETT
④ 5 point auscultation (most important at epigastrium)
*remove if hand gurgling/bowel sound;
*other site bilateral infra-clavicular & upper axillary
⑤General well being of patient (cyanosis → pink)
⑥ ETCO2 waveform capnography (N : 35-45 mmHg)
Post-intubation assessment (Dr. Arif)
Subjective – Vapour at ET tube
- Symmetrical chest rise
- 5 point auscultation
Objective – ETCO2
- SpO2 in ABG
- CXR
g) Post-intubation care
① Secure ETT
② Connect to ventilator
③ Prop up 30-45°
④ Airway:- Ryle’s tube (gastric decompression)
⑤ Breathing:- Auscultate for complication (eg. Pneumothorax)
Prepared by Leow Zhe Eu Group 4 Year 5 2014/2015
⑥ Circulation:- Blood for investigation
- Fluid
- Analgesia
⑦ Disability – Sedation
⑧ Exposure/ Environment:- hypothermia – induced in ACS, do not induce in trauma
- hyperthermia
⑨ Gastric protection:- PPI (eg. Pantoprazole)
⑩ Continuous bladder drainage – Monitor I/O charting
⑪ Disposition:- ICU/ HDU
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Waveform Capnography
Factors affecting EtCO2
Hypercapnia (↑ EtCO2)
Metabolism
- pain
- hyperthermia
- shivering
Respiratory
- insufficiency
- depression
Prepared by Leow Zhe Eu Group 4 Year 5 2014/2015
Hypocapnia (↓ EtCO2)
Metabolism
- hypothermia
- metabolic acidosis
Respiratory
- hyperventilation
- bronchospasm
- COPD
- Analgesia/ sedation
Circulatory
- ↑ CO2
- Tourniquet release
-
mucus plug
Circulatory
- Hypotension
- sudden hypovolemia
- cardiac arrest
- Pulmonary emboli
- shock
Medications
- Bicarbonate administration
- Effective drug therapy for bronchospasm
CREDITS
I would like to express our gratitude and appreciation to Dr Zikri for his guidance and
teachings throughout resuscitation week for Year 5 2014/2015.
Thanks to all who had assisted directly and indirectly.
Prepared by Leow Zhe Eu Group 4 Year 5 2014/2015