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ENDOTRACHEAL TUBE
EN,
GROUP 2
GROUP MEMBERSCHESTER MAKHUWIRACHIKONDI CHALANDACHRISTINA NGULUBEDALITSO SODALAELESTINA GONDOLONIETHEL CHIKADZAGRENA MTAWALIMARIA NGULUBETIONGE SISYAVYNIDA NYIRENDA
Endotracheal tubeDefinition Endotracheal tube is a specific type of
tracheal tube that is nearly inserted through the mouth(oraltracheal) or nose(nasaltracheal).
Functions of Endotracheal Tube:
It provides a patent airway when the patient is having respiratory distress that can not be treated with simpler methods.
It is a method of choice in emergency care i.e. used for administration of drugs.e.g.atropine.
It is a mean of providing an airway for patients who can not maintain an adequate airway on their own.
Cont..The are of different sizes ranges from 2 to
10.5mm in internal diameter.The size is chosen based on the patient’s
body size with the smaller sizes being used for pediatric and neonatal patients.
indicationsComaShallow or slow respirationsCyanosisGastric lavage. Surgical patients where body positioning or
facial contours preclude the use of a mask To prevent loss of airway at a later time, i.e. a
burn patient who inhales hot gases may be intubated initially to prevent his airway from swelling shut
contraindicationsObstruction of the upper airway due to
foreign objectCervical injuries
Caution
Esophageal disease Mandibular diseaseLaryngealThermal chemical burns
ENDOTRACHEAL INTUBATION
REQUIRED EQUIPMENT:1. Endotracheal tube Size of tube is dependent on size of patient 7.5 mm is the “Universally Accepted” size for
an unknown victim Men are usually larger, therefore an 8.0 mm
tube may be appropriate Females are usually smaller, therefore a 7.0
mm tube may be appropriate
Cont…2. 10 cc Syringe – used to fill the cuff at the end
of the endotracheal tube.3. Stylet – a wire inserted into the endotracheal
tube in order to stiffen it during passage4. Water soluble lubrication – KY Jelly or
Surgilube5. Stethoscope – to check for proper placement
of the endotracheal tube6. Magill forceps – May be used to help guide an
endotracheal tube from the pharynx into the larynx
Cont..7. Laryngoscope handle8. Laryngoscope blade9.Miller blade (straight blade)10. Macintosh blade (curved blade)11. Oropharyngeal airway (bite block) – to
prevent the patient from biting down on the endotracheal tube
12. Tape – to secure the endotracheal tube in place
13. Gloves
Cont..14. Ambu-bag – to facilitate positive pressure
ventilations15. Suction Device – to clear the airway of
debris (blood, mucous, saliva)
PROCEDURAL STEPS:
Endotracheal intubation (ETI) is a rapid, simple,safe and non surgical technique that achieves all the goals of airway management, namely, maintains airway patency,protects the lungs from aspiration and permits leak free ventilation during mechanical ventilation, and remains the gold standard procedure for airway management
Cont..a. Maintain the patient’s ABC’s b. Determine that the patient requires
endotracheal intubation c. Assemble required equipmentd. Position the patient’s head – three axes,
those of the mouth, the pharynx, and the trachea must be aligned to achieve direct visualization of the vocal cords
e. Sniffing Position – the head is extended and the neck is flexed
Cont..
f. A folded towel may be placed under the patients shoulders and neck to assist with positioning
g. Suction the patient (no longer than 30 seconds) h. Oxygenate patient for 1 minute with 100%
Oxygen i. Insert the laryngoscope blade and place
endotracheal tube
Cont..j. Laryngoscope handle is held with the left
hand k. Insert the laryngoscope blade in the
patients right side of the mouth and sweep to the center of the mouth.
When a curved blade is used, the tip of the blade is advanced into the vallecula (i.e. the space between the base of the tongue and the pharyngeal surface of the of epiglottis)
Cont..When a straight blade is used, the tip of the
blade is inserted under the epiglottisl. Lift the laryngoscope blade in an upward
motion m.The handle must not be used with a prying
motion, and the upper teeth must not be used as a fulcrum
n.Visualize the vocal cords
Cont..o. Using the right hand, insert the
endotracheal tube until you see the cuff pass through the vocal cords. Advance the tube an additional ½ to 1 inch for proper placement.
p. Remove the laryngoscope carefully from the patients mouth
q. Remove the stylet from the endotracheal tube
Cont..** NOTE: The insertion of the endotracheal
tube should be no longer than 30 seconds from the time you stop ventilating the patient until the time you remove the stylet. If you are unable to place the endotracheal tube within 30 seconds, withdraw the endotracheal tube and laryngoscope, ventilate the patient (Step f.) and start again
Cont.r. Ventilate the patient with two breaths s. Check for proper placement with these
first two ventilation’s by: t. Observing the chest rise and fall with
each ventilation: Proper placement will cause both lungs to
inflate with each ventilation
Cont..Auscultating for bilateral breath sounds:Breath sounds will be completely absent if
placed within the esophagus. Remove the endotracheal tube and attempt placement after 1 minute of oxygenation and ventilation.
If the tube is placed too far down the tracheal tree, a right mainstem intubation can occur. This prevents air from going into the left lung.
Cont..To correct this problem, continue to ventilate
patient and slowly withdraw endotracheal tube ¼ - ½ inch or until bilateral breath sounds are heard.
Auscultating over epigastrium for gastric sounds: Placement of the endotracheal tube into the
stomach / esophagus will produce gurgling sounds in the epigastric area. Remove the endotracheal tube and attempt placement after 1 minute of oxygenation and ventilation.
Cont..u. Inflate the endotracheal tube’s cuff with
10 cc’s of air: v. Inflation of the balloon serves two
purposes: Holds tube in place Acts as a barrier and prevents fluids from
entering the lungs w. Ventilate the patient with two breaths x. Insert oropharyngeal airway
Cont..aa.Ventilate the patient with two breaths bb.Tape endotracheal tube securely in place cc.Continue to ventilate patient (1 breath
every 5 seconds) and suction as necessary
..\Desktop\ett visual aids\procedure on real person.flv
..\Desktop\ett visual aids\intubation procedure.flv
Immediate care of intubationA. Check symmetry of chest expansion : auscultate breath sounds of anterior and
lateral chest bilaterally. Obtain order for chest x-ray to verify
proper tube placement. Check cuff pressure every 8-12 hours. Monitor for signs and symptoms of
spiration
Cont…B. Ensure high humidity ; a visible mist
should appear in the T.piece or ventilator tube.
C. Administer oxygen prescribed by the doctors.
D. Secure the tube to the patient’s face with tape, and mark the proximal end for position maintance
Cut proximal end of tube if it islonger that 7.5cm(3 inches) to prevent kinking.
Cont..• Insert an oral airway or mouth device to
prevent the patient from biting and obstructing the tube.
E.Use sterile suction technique and airway to prevent iatrogenic contamination and infection .
F.Continue to reposition patient every 2 hours and as needed to prevent atelectasis and to optimize lung expansion.
Cont..G. Provide oral hygiene and suction the
oropharynx whenever necessary.H. Explain to the patient and family the
purpose of the tubeI. Distract the patient through one to one
interaction with the nurse and family.J. Close monitoring of the patient is
essential to ensure safety and prevent harm.
Extubation1. Determine that endotracheal intubation is no
longer required 2. Patient begins spontaneous respiration’s3. Explain procedure to patient to gain
cooperation4. Have a self inflating bag and mask ready in
case ventilator assistance is required immediately after extubation.
5. Suction the endotracheal tree and oropharynx,remove tape and then deflate the cuff.
Cont.4. Withdraw the endotracheal tube with one smooth
motion 5. Monitor the patient for signs / symptoms of
respiratory distress or difficulty 6. Give 100% oxygen for a few breaths, then insert a
new, sterile suction catheter inside tube.7. Have the patient inhale at peak inspiration, remove
the tube, suctioning the airway through the tube as it is pulled out.
Care of patient following extubation• Give heated humidity and oxygen by face
mask and maintain the in a sitting or high fowler’s position.
• Monitor respiratory rate and quality of chest excursions, note stridor ,color change and change in mental alertness or behavior.
• Monitor the patient’s oxygen level using a pulse oximeter.
• Keep NPO or give only ice chips for next few hours.
Cont.Provide mouth care.Teach patient how to perfom coughing and
deep breting exercises.
ADVANTAGES OF ENDOTRACHEAL INTUBATION
Provides an unobstructed airway when properly placed
Prevents aspiration of secretions (blood, mucous, stomach / bowel contents) into the lungs
Can be easily maintained for a lengthy period of time
Decreases anatomic dead space by approximately 50%
Cont..Facilitates positive pressure breathing
without gastric inflation Facilitates body positioning and movement
of the patient May be utilized to pass medications
Atropine Epinephrine Lidocaine
DISADVANTAGES OF ENDOTRACHEAL INTUBATION:
Need advanced training to properly perform procedure
By passes the nares function of warming and filtering the air
Increased incidence of trauma due to neck manipulation when spinal cord injury is suspected
May increase respiratory resistance Improper placement
complications1. Due to high cuff pressure: Tracheal bleeding Ischemia Pressure2. Due to low cuff pressure: Aspiration pneumonia Trauma Missed intubation Failed intubation
HaemorrhageAirway obtructionDisconnection and dislocationSwallowed ETT
Prevention of complications 1. Administer adequate humidity2. Maintain cuff pressure at appropriate
level.3. Auscultate lung sound4. Monitor for signs and symptoms of
infection including temperature and WBC5. Administer prescribed oxygen and
monitor oxygen saturation.6. Monitor for cynanosis
Cont..7. Maintain adequate hydration of the
patient.8. Use sterile technique when suctioning
Reference
Brunner and Suddaths a text book for medical surgical nursing 2009
Indian journal for Anesthesia, 2005