Endotracheal Intubation

1. See Also
1. Rapid Sequence Intubation
2. Endotracheal Tube
3. Advanced Airway
2. Indications
1. See Advanced Airway
3. Preparation: Consider extraglottic devices
1. Extraglottic devices
1. Esophageal Tracheal Combitube (ETC
2. !aryngeal "as# Airway (!"A
2. Anticipate di$$icult extraglottic device ("nemonic% R&'S
1. Restricted mouth opening
2. &bstruction o$ the upper airway or !arynx
3. 'istorted or disrupted airway
4. Sti$$ lungs requiring increased (entilatory pressures (Asthma)
C&*') AR'S) term pregnancy
3. Resources
1. 'i$$icult Airway Course
+, http%--www,theairwaysite,com
4. Preparation: Consider aira! visuali"ation devices
1. #ideo lar!ngoscopes
1. .lidescope video laryngoscope
1. http%--verathon,com-products-glidescope/video/laryngoscope
2. C/"AC video laryngoscope
1. http%--www,#arlstor0,com-cps-rde-xchg-SI'/122+134'/
5267'48+-#arlstor0/en-hs,xsl-9:59,htm
3. *entax A;S video laryngoscope
1. http%--us,pentaxmedical,com-index,php<
page=shop,product>details?@62A$lypage=$lypage,tpl?@62Apr
oduct>id=:2?@62Acategory>id=15?@62Aoption=com>virtuem
art?@62AItemid=+52
4. "c.rath video laryngoscope
1. http%--www,covidien,com-rms-pages,aspx<
page=&ur*roducts-"c.rath(ideo!aryngoscopy
$. Co*ilot video laryngoscope
1. http%--copilotvl,com-
%. (ividTrac
1. http%--vividmed,com-products-adult/vividtrac/+33
&. Clarus (ideo system ($iberoptic
+, http%--clarus/medical,com-airway-products-cvs/clarus
2. 'oest cost solutions
1. Airtraq Avant (optical prism device
1. http%--www,airtraq,com-index,php<
option=com>content?@62Atas#=view?@62Aid=+99?@62AItemi
d=612
2. Bing (ision (ideo !aryngoscope
+, http%--www,owntheairway,com-
$. Preparation
1. (ne)onic: S*AP+(E
1. Suction
2. &xygen
3. Airway equipment
4. *harmacologic agents
$. "onitoring Equipment
2. Prepare ,or -apid Se.uence Intubation
1. Indicated i$ not crash airway or awa#e intubation needed $or di$$icult
airway
3. (onitoring Pulse *xi)etr! /0!poxe)ia1 2rad!cardia3
1. *retreatment with Atropine 3,31 mg-#g is no longer recommended
2. Cowever many providers have it ready at the time o$ intubation in
case o$ symptomatic 7radycardia
4. Chec4 lar!ngoscope ,or light and blade si"e /See above3
1. (ideo laryngoscope is $ar superior to 'irect !aryngoscope $or
success$ul intubation (by odds ratio D+1
+, Sa#les (13+1 Ann Emerg "ed) "ay 5 (pre/publication
$. Chec4 suction
%. Select E5 si"e and length /See Endotracheal 5ube3
1. Cu$$ed ET Tubes may be used in in$ants and children
&. St!let should 6*5 extend be!ond distal ET
1. .lide scope intubation requires glide scope stylet with deep
hoc#ey/stic# bend
7. Intubation atte)pts should not last 839 seconds
1. !imit intubation attempt to 13 seconds in newborns
:. *pti)i"e ,irst atte)pt at intubation
1. Encourage strategies that increase li#elihood o$ $irst intubation
attempt success (e,g, video laryngoscope) bougie
2. 4irst pass attempt has the lowest complication rate and mar#ed
complication rate a$ter 1 intubation attempts
3. "ort (1335 Anesth Analg 99(1% E38/+6
19. Preox!genate ith 199; *x!gen
1. See Rapid Sequence Intubation $or preoxygenation pointers
2. In$ants and children desaturate very quic#ly
1. Intubation attempts should be brie$ and stopped as &xygen
Saturation drops below 93F
1, Stop and re/oxygenate prior to another attempt
11. Consider using an *ral Aira! in in,ants and !oung children
1. In$ants have a large Tongue $or their small "andible
2. &ral Airway may help #eep the Tongue out o$ the way $or the
intubation
%. Preparation: 'ar!ngoscope
1. Esti)ated blade si"e selection
1. <ith lar!ngoscope blade held next to patient=s ,ace
1. 7lade should reach between lips and !arynx (or lips to angle
o$ Gaw
1, Similar distance as with si0ing &ral Airway
2. 2etter to choose a blade too long than too short
1. Esti)ate 1 c) longer than needed
3. #ideo 'ar!ngoscop! 2lade /e.g. >lidescope3
+, Si0e 6 .lidescope disposable blade $its most adults (even
large adults
1, Si0e 5 .lidescope disposable blade is typically di$$icult to $it
inside the mouth
2. 2lade si"e guidelines b! age
1. Adult% @6 to @5 "acintosh 7lade (curved
2. Child at age 2% @1 "acintosh 7lade (curved
3. Consider a wider laryngoscope blade in syndromic children (e,g,
"acroglossia
4. Child
+, "iller blade (straight blade used most o$ten
+, Beeps the large $loppy epiglottis out o$ the way
1, "iller blade @3
+, *remature In$ant
6, "iller blade @+
+, Term in$ant
5, "iller blade @1
+, Age 1 years old
:, "iller blade @6
+, Third grade (age 9 years old
&. 5echni.ue
1. See -apid Se.uence Intubation
2. 0ead and 6ec4 Position
1. Simple maneuvers (e,g, Haw Thrust are most e$$ective in children
2. Beep head position in midline to prevent so$t tissue $rom obscuring
view when head turned to side
3. Children age D 1 years (;ithout C/Spine InGury
+, Cead extension with pillow under occiput
1, Chin li$ted into sni$$ing position
4. In$ants age I 1 years
+, &cciput naturally extends the large head
1, Chin li$ted to sni$$ing position
3. In$ants may need a small towel roll under the Shoulders to
align the head
$. Trauma
+, Assistant holds head down on bed) with little $ingers applied
to each ear to prevent side to side motion
1, Remove cervical collar completely $or intubation
6, !oad elastic bougie in side o$ mouth
5, Re$erences
+, &rman and ;eingart in "aGoews#y (13+6 E"%Rap
+6(5%
3. 0and Position: In,ant /reverse ,or le,t hand do)inant3
1. !e$t Thumb and +st $inger hold laryngoscope
2. !e$t 1nd and 6rd $inger hold chin
3. !e$t :th $inger pushes down on !arynx
4. Right hand inserts ET Tube
4. Ad?uncts: Elastic 2ougie
1. Consider holding elastic bougie) placed by right molars while
positioning laryngoscope
2. Allows $or quic# placement o$ elastic bougie in di$$icult airways
without losing sight o$ the cords
3. Jo help$ul in young children due to an incomplete calci$ication o$
tracheal rings
4. Re$erence
+, http%--emcrit,org-wee-bougie/prepass/and/criccon-
5. Endotracheal 5ube insertion
1. Insert lar!ngoscope into the right mouth
1. At the tonsillar pillars sweep Tongue to midline
1, Exception% .lidescope enters midline and without Tongue
sweep
2. Extend blade over base o, 5ongue and
+, Curved blade% Tip into vallecula
1, Straight 7lade% Tip over the epiglottis
6, Avoid entering esophagus $irst
+, Ris# o$ laryngeal trauma
5, *ointers in young children (typically straight blade
1. Insert the blade midline (does not require sweeping
Tongue except possibly in syndromic children
1, Avoid inserting the laryngoscope blade too $ar and
then pulling bac#
+, !andmar#s are di$$icult to interpret (esopagus
may appear similar to trachea in children
3. Insert the blade only to the Tongue base and then li$t
at a 5: degree angle
5, "ay insert the blade slightly $urther (millimeter i$ the
epiglottis still in way
3. Exert traction upard along axis o, handle
+, Straightens the airway $or a direct line o$ intubation
1, 'o not use teeth or gums as a $ulcrum
+, Results in signi$icant oral-dental trauma
6, Exception% .lidescope intubation requires no upward traction
+, Cowever airway is not straightened) so must use the
glidescope stylet with the deep hoc#ey/stic# distal
bend
1, 'ue to unstraightened airway with glidescope) unbent
ET Tube will be di$$icult to target the trachea
4. E)plo! techni.ues to best visuali"e the cords
+, Insert ET Tube $rom the right corner o$ mouth (Avoids
obstructing view
2. Cricoid pressure /Sellic4 (aneuver3
+, "ay $acilitate glottis viewing i$ per$ormed correctly
1, &ptional in 13+3 ACC .uidelines
+, 'oes not prevent aspiration
1, "ay impede intubation i$ per$ormed incorrectly
3. 2@-P (aneuver
+, "ove thryoid cartilage 7ac#wards) Kpwards)
Rightwards
1, !ess e$$ective in young children
4. 2@-P Alternative in children
+, Intubator places their hand over an assistants hand
which is in turn held over the anterior nec#
1, Intubator moves the assistants hand (especially
bac#wards to align airway
6, ;hen cords are well visuali0ed) assistant holds
position and inubator removes their hand
5, Especially use$ul in in young children who typically
have an anterior positioned !arynx
$. Position E5 5ube
1. 7lac# mar#er on ET Tube at level o$ cords
1, Cu$$s should be placed Gust below cords
7. Evaluation: Assess 5ube Position
1. Symmetrical Chest "ovement
2. Auscultate $or equal breath sounds
3. 'ocument absent breath sounds over Stomach
4. (apor condenses on inside o$ tube with exhalation
$. End/tidal carbon dioxide (required by new guidelines
1. "ay be low i$ Cardiac &utput low (esp in$ants
:. (anage)ent: 5rouble+Shooting Inade.uate #entilation or *x!genation
1. "nemonic% '&*E
1. 'islodged tube
2. &bstructed tube
3. *neumothorax
4. Equipment $ailure
2. Con$irm tube positioned correctly as above
3. Is ET Tube too small) cu$$ (D2yo under/in$lated<
4. Is the pop/o$$ valve on Resuscitation bag depressed<
1. ;ith Jear/drowning) pulmonary edema) and Asthma
+, higher ventilation pressures are needed
$. Is the 7ag/(alve 'evice !ea#ing<
1. Compress the bag against an &ccluded ET connection
+, Air will be expelled $rom any lea#s
%. Is the operator providing adequate tidal breaths<
&. Is there a *neumothorax present<
19. (anage)ent: Secure the E5 5ube
1. Con$irm tube position again by auscultation
2. Tape ET Tube in place and $ix to chee# with ben0oin
3. Jote the distance mar#er at lips in chart
4. Commercial tube holder highly recommended
11. (anage)ent: Post+Intubation #entilator settings in children /under age 7
!ears
1. *recaution% Reduce rate and Tidal (olume $or Asthma Exacerbation (allow
$or permissive hypercapnia
2. Respiratory Rate % 13/1: breaths per minute
3. Tidal (olume % :/8 cc-#g
4. Set pea# inspiratory pressure to +1/13 cm C1& in in$ants
12. (anage)ent: *ther post+intubation )anage)ent
1. &rogastric Tube or Jasogastric Tube (i$ no 7asilar S#ull 4racture ris#s
1. Celps prevent aspiration
2. Reduces Stomach volume which can inter$ere with ability to
ventilate (especially in children
13. -esources
1. Airway ;orld (requires $ree registration to view videos
1. https%--amec,Econnex,com-portal-airwayworld-login
2. .lidescope Intubation technique
1. http%--www,youtube,com-watch<v=mL30M0ELA7A
3. .lidescope with E intubations
1. http%--www,youtube,com-watch<v=*6NNsJCwLB#
4. Elastic 7ougie Intubation
1. http%--www,youtube,com-watch<v=>N!abcsncwc
$. !aryngeal "as# Airway (!"A Insertion
1. http%--www,youtube,com-watch<v=9Ee5E*yARaK
%. CombiTube Insertion
1. http%--www,youtube,com-watch<v=c34gn(8+OIO
14. Re,erences
1. "aGoews#y (13+1 E"% RA*/C6 1(:% 6/5
2. .ausche/Cill and Claudius in "aGoews#y (13+1 E"/RA* +1(+1% E/8
3. ;alls (13+1 Emergency Airway "anagement) 6rd Ed) !ippincott)
*hiladelphia) p, E6/23