Tracheal Intubation
Proper Positioning
• Flexion of the neck
• Elevation of head
approximately 10
cm
• Goal: Alignment of
the three axis
Proper Position of Laryngoscope Blade
Glottic opening during a direct
laryngoscopy (elevated epiglottis)
Choose a Blade
Direct Laryngoscopy
• Mac vs Miller
– Advantages with each
– Disadvantages with each
• Confirmation of ETT placement
• Simulation: Demonstrate intubation
with MAC and Miller Blades
Choose a Tube
Optimal External Laryngeal Manipulation
Lehane McKormick Scale: document
view for next person in a standard
manner
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
Securing the Tube
Nasal Intubations
• Indications:
– 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
Nasal Endotracheal Tubes
• Nasal Rae
– Advantage is tube
contour facilitates
stability
• Endotrol Tubes
– Soft
– Ability to flex tip
of tube
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
Common Complications of Intubation
• Bronchospasm
• Esophageal
Intubation
• Dental trauma
• Aspiration
• Laryngospasm
• Endobronchial
Intubation
• Laryngeal/Tracheal
Trauma
• Hypertension
• Tachycardia
• Myocardial
ischemia
• Cardiac
dysrhythmias
• Pulmonary
barotrauma
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
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)
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
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)
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
Aspiration
• Risk Factors
–
–
–
–
–
–
–
–
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
Management of Patient who
Aspirates
on
Induction
• Maintain Cricoid pressure
•
•
•
•
•
•
Turn head
Suction
Trendelenberg
Broncscopy
Intubation
Supportive Measures (A-line; Oxygen,
PEEP)
Training Exercise:
1. Practice direct laryngoscopy and
intubation with feedback from
facilitator until advanced beginner
2. Practice nasotracheal intubation
using Magil forceps
3. Demonstrate how to secure an
endotracheal tube
4. Practice laryngoscopy with a Miller
blade