Endotracheal Intubation – Airway management is the evaluation, planning, and use of medical procedures and devices for the purpose of maintaining or restoring ventilation in a patient.
Endotracheal Intubation – Definition
” A procedure in which a tube is placed into the trachea through the mouth (orotracheal) or nose (nasotracheal) to maintain a patent airway. Used perioperatively for anesthetized patients and has various indications in emergency medicine, including acute respiratory failure, poor oxygenation or ventilation, and risk of airway compromise. “
IN SHORT : Orotracheally or nasotracheally placement of a cuffed tube below the vocal cords .
Endotracheal tube – Indications
- General anesthesia
- Failure (or pending failure) of ventilation or oxygenation
- Airway obstruction
- Severe acute asthma or COPD exacerbation (severe bronchoconstriction)
- Glasgow Coma Score ≤ 8
VERY IMPORTANT ==> “Patients with cervical spine injuries are at risk of respiratory compromise. Orotracheal intubation with manual stabilization of the cervical spine is recommended for initial airway management.”
Endotracheal Intubation – Procedure
1. Preoxygenation: administration of 100% oxygen via face mask prior to intubation to ensure sufficient time to perform intubation.
The functional residual capacity of the lung is filled with up to 80% nitrogen. The administration of 100% oxygen via a mask washes out nitrogen (denitrogenization) in alert patients breathing on their own and enriches the lungs with oxygen. As a result, the time period in which the patient can go without spontaneous breathing after anesthetic induction can be prolonged significantly.
2. Sedation (e.g., propofol)
3. Muscle relaxation (e.g., succinylcholine)
Muscle relaxation allows for smooth passage of the tube through relaxed vocal cords and decreases the risk of injury (e.g., vocal cord damage).
4. Positioning of patient with mild cervical flexion (sniffing position)
5. Placement of the endotracheal tube with the help of a laryngoscope: observe the tip of the tube passing into the larynx through the vocal cords (direct visualization).
Cricoid pressure may be applied to move the larynx posteriorly and facilitate visualization of the vocal cords. If orotracheal intubation is not feasible (e.g., small mouth opening) or oral or jaw surgery is performed, nasotracheal intubation can be performed instead.
6. Signs of proper tube placement
- Auscultation of bilateral breath sounds over lungs ( Breath sounds should not be audible over the epigastric area in adults. In pediatric patients, there may be referred breath sounds over the stomach. )
- Measurement of CO2 in the exhaled air (end-tidal CO2)
- Distal tip should be 2–6 cm above carina (check with chest x-ray and reposition if necessary)
7. Inflate the cuff to secure the tube if proper placement is ensured.
Rapid sequence intubation
- A method of endotracheal tube intubation used for emergency airway management that involves rapid induction of unconsciousness followed by administration of a paralytic agent.
- Differs from traditional intubation in that it uses weight-based doses of short-acting medications (rather than gradually titrating the dose) in order to forego bag-valve-mask ventilation and achieve more rapid intubation.
Complications of intubation
- Early complications
- Damage to the teeth
- Esophageal intubation
- Unilateral bronchial intubation ( If the tube is advanced too far, it will typically end up in the right main bronchus )
- Tracheal perforation
- Pulmonary aspiration
- Late complications after intubation: vocal cord injuries, vocal cord granuloma
- Complications of long-term intubation
- Tracheal stenosis , tracheomalacia
- Clinical features: respiratory distress and inspiratory stridor
- Treatment: correction of the affected tracheal region via laser, stenting, or surgical removal, depending on the extent
- Pulmonary fibrosis: prophylaxis with lung-protective ventilation
- Tracheal stenosis , tracheomalacia
- Suction airways prior to extubation to minimize risk of aspiration (e.g., of fluids, foreign material)
- Extubation criteria
- Sufficient spontaneous breathing
- Presence of protective reflexes (swallowing and coughing reflex)
- Adequate level of consciousness (e.g., opening the eyes, following requests)