Intubation
Kashmira Purbhoo
Indication
Any situation in which a GA may compromise the
safety of a patient with a difficult / potentially
difficult intubation and/or facemask ventilation
Contraindications:
Patient refusal
Inexperience
LA hypersensitivity
Non-compliant / uncooperative patient e.g. children
Significant airway bleeding
Critical airway (patient with severe stridor e.g. acute
epiglottitis)
Informed Consent
The procedure must be explained to the
patient and consent obtained
If conscious sedation is to be used the
patient must understand that some degree
of recall is possible
Anti-sialogogue
Glycopyrolate 4 g/kg iv when patient
arrives in theatre (can also be given s/c or
imi 60 min before intubation also 4
g/kg)
OR
Patient positioning
Usually supine with anaesthetist behind
the patient at the head of the table
If patient cannot tolerate supine position:
semi-Fowlers (sitting) position with
anaesthetist in front of patient (image will
be inverted on screen)
Supplemental Oxygen
Should always be used
facemask still allows access if performing nasal
intubation
small size oral RAE ETT placed in adjacent nostril
Conscious Sedation
Contraindicated if it may compromise
patient safety
Patient must be able to follow verbal
commands
Many techniques are available
Dexmeditomidine or propofol &
remifentanil preferred by most
Topical vasoconstriction
Applied nasally
Decreases localized blood flow
Prolongs effect of local anaesthetic
Oropharynx
The oropharynx & the posterior third of the tongue are
innervated by the glossopharyngeal nerve
atomized lignocaine 4% 4-6 ml (use 2% if 4% not available) or
gargle with lignocaine
Translaryngeal block
20G cannula advanced through cricothyroid membrane until air
aspirated
Remove needle and leave cannula
Patient asked to exhale fully
Inject 3 ml 2% lignocaine inspiration & coughing will allow LA to
spread
Post Procedure
At the end of surgery , before extubation, ensure that
The patient has been oxygenated with high FiO2 for 3-5
mins
Any muscle relaxants have been adequately reversed
The upper airway is free of all secretions the airway may
still be anaesthetised and laryngeal reflexes are not intact.
Pulmonary aspiration a risk
The patient is breathing spontaneously with adequate tidal
volumes
The patient is awake
Have all possible equipment for possible re-intubation at
hand
Cleaning of equipment
Follow proper cleaning protocols to ensure
longevity of equipment
Scope must ready to be used
Thank You