Tracheal intubation

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Tracheal intubation

Summary

Procedure
Allow air to enter the lungs
Artificial ventilation or mechaniccal ventilation
Prevent from obstruction
Protect airway from aspiration

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Tracheal intubation

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Anatomy of airway

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Tracheal intubation

1 Indications

2 Airway assessments

3 Equipments

4 Steps of intubation

5 Complications
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1 Indications

1) For supporting ventilation in patient with

some pathologic disease:

 Upper airway obstruction;

 Respiratory failure;
 Loss of conciousness.

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1 Indications

2) For supporting ventilation during general

anesthesia:

 Type of surgery;
 Operative site near the airway;
 Abdominal or thoracic surgery;
 Prone or lateral position;
 Long period of surgery.

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1 Indications

3) For supporting ventilation under other

circumstances :

 Inability to maintain oxygenation using face

mask oxygen supplementation;
 Apnea, hypoventilation, intoxication(globefish),
poisoning, cervical spine injury, flail chest,
severe pneumonia, ARDS;

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Objectives of Mechanical Ventilation

Physiologic Objectives
 Support pulmonary gas exchange ;
 Reduce metabolic cost of breathing;
 Minimize ventilator associated lung injury.
Clinical Objectives
 Reverse hypoxemia;
 Optimize ventilation;
 Prevent or treat atelectasis;
 Overcome upper airway obstruction;
 Manage secretions(lung lavage);
 Protect airway from aspiration;
 Permit sedation/anesthesia and neuromuscular blockade;
 Reduce ICP;
 Stabilize chest wall.
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2 Airway assessments

Difficult airway:

① Difficult facemask or supraglottic airway

(SGA) ventilation;
② Difficult SGA placement;
③ Difficult laryngoscopy;
④ Difficult tracheal intubation;
⑤ Failed intubation.
American Society of Anesthesiologists(ASA) 2013

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2 Airway assessments

Condition that associated with difficult intubation:

① Congenital anomalies: Pierre Robin syndrome ,

Down’s syndrome;
② Infection in airway: Retropharyngeal abscess,
Epiglottitis;
③ Tumor in oral cavity or larynx.

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2 Airway assessments

Condition that associated with

difficult intubation:

④ Enlarge thyroid gland;

⑤ Trachea shift to lateral or
compressed tracheal lumen;
⑥ Maxillofacial ,cervical or
laryngeal trauma;

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2 Airway assessments

Condition that associated with difficult intubation:

⑦ Temperomandibular joint dysfunction;

⑧ Burn scar spasm at face and neck;
⑨ Morbidly obese or pregnancy.

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2 Airway assessments

General appearance of the neck, face, maxilla

and mandible;
Jaw movement;
Head extension and neck movement;
The teeth and oropharynx;
The soft tissues of neck;
Recent chest and cervical spine X-rays;
Previous anaesthetic records.

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2 Airway assessments

Interincisor gap :
Normal---more than 3.5-5.5 cm (Big Mac)

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2 Airway assessments

Thyromental distance :
Normal---more than 6.5 cm

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2 Airway assessments

Flexion and extension of neck

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2 Airway assessments

Movement of temperomandibular joint (TMJ)

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2 Airway assessments

Mallampati classification:

Soft
palate
Uvula

Class 3,4---may be difficult intubation

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2 Airway assessments

Laryngoscopic view

Grade 3,4---risk for difficult intubation

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3 Equipment
1) Laryngoscope : handle and blade

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3 Equipment
Macintosh (curved) and Miller (straight) blade
Adult : Macintosh blade;
Small children : Miller blade

Miller Macintosh
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3 Equipment
2) Endotracheal tube

atelectasis
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3 Equipment

2) Endotracheal tube

Murphy’s law
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3 Equipment

2) Endotracheal tube Low volume High pressure

High volume Low pressure

Uncuffed tube

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3 Equipment

2).1 Size of endotracheal tube:

internal diameter (ID)
=3.0 (NEW BORN-3MONTHS)
=3.5 (3-9MONTHS)
=4.0 (9-18MONTHS)
=AGE(y)/4 + 4 (cm) (Children)
=7.7-8.0 (MALE)
=7.0-7.5 (FEMALE)

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3 Equipment

2).2 Depth of endotracheal tube :

Depth of oral endotracheal tube(cm)
=23 cm (Male)
=21 cm (Female)
=Age(y) /2 + 12 (cm) (Children)
Depth of nasal endotracheal tube
= Depth of oral endotracheal tube+3

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3 Equipment
3) Stylet :

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3 Equipment

Nasal airway

4) Other equipments :
① Oropharyngeal Oral airway

And
Nasopharyngeal
airway;

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3 Equipment
4) Other equipments :
② Suction catheter;
③ Face mask;
④ Magill forceps;
⑤ Syringe;
⑥ Stethoscope;
⑦ Adhesive plaster.

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Thank you

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4 Steps of intubation

1) Preoxygenation for denitrogenation

Sniffing position:
Flexion at lower cervical spine
Extension at atlanto-occipital joint

pillow under head

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4 Steps of intubation

2) Insert the laryngoscope

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4 Steps of intubation

3) Visually examine the epiglottis and the vocal

cords
Vareculla

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4 Steps of intubation

4) Insert the ETT into the trachea

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4 Steps of intubation

5) Conform the location of endotracheal

① Visually;
② Air flow;
③ Stethoscope;
④ Rime fog;
⑤ EtCO2 .

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5 Complications

5.1 During intubation

① Trauma to lip, tongue or teeth;
② Hypertension and tachycardia or arrhythmia;
③ Pulmonary aspiration;
④ Laryngospasm;
⑤ Bronchospasm;

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5 Complications

5.1 During intubation

⑥ Laryngeal edema;
⑦ Arytenoid dislocation;
⑧ Increased intracranial pressure;
⑨ Spinal cord trauma in cervical spine
injury;
⑩ Esophageal intubation.

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5 Complications

5.2 During remained intubation

① Obstruction;
② Accidental extubation or endobronchial
intubation;
③ Disconnection from breathing circuit;
④ Lib or nasal ulcer in case with prolong period
of intubation .

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5 Complications

5.3 During extubation

① Laryngospasm;
② Pulmonary aspiration;
③ Edema of upper airway.

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5 Complications

5.4 After extubation

① Sore throat;
② Hoarseness;
③ Tracheal stenosis (Prolong intubation);
④ Laryngeal granuloma;

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6 Nasal intubation

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6 Nasal intubation

Advantages
① Comfortable for prolong intubation in
postoperative period;
② Suitable for oral surgery : tonsillectomy ,
mandible surgery;
③ For blind nasal intubation;
④ Can take oral feeding;
⑤ Resist for kinking and difficult to accidental
extubation;

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6 Nasoendotracheal intubation

Disadvantages
① Trauma to nasal mucosa;
② Risk for sinusitis in prolong intubation;
③ Risk for bacteremia;
④ Smaller diameter than oral route -> difficult
for suction.

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Endotracheal Intubation

NASAL
ORAL
Indications  Elective intubation
 Emergency airway
 Cervical spine injury

 Oral trauma/surgery
 Larger tube
Advantages  More comfortable
 Less resistance
 Good oral hygiene
 Less kinking
 Less gagging
 Easier to insert
 Less sedation

Disadvantages  Less comfortable  More difficult to place

 Smaller tube
 Patient may bite on tube
 Epistaxis or turbinectomy
 Oral hygiene difficult
 Sinusitis, otitis media
 Tube less secure
 Basal skull fracture
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6 Nasal intubation

Contraindication for nasoendotracheal intubation

① Fracture base of skull;
② Coagulopathy;
③ Nasal cavity obstruction;
④ Retropharyngeal abscess;

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