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