Key Medical Resources - First Aid Training
Tracheal Intubation Self-Study Module
5.0 Contact Hours
Compiled by Terry Rudd, RN, MSN
|[pic] |
|Tracheal intubation being practiced on a mannequin (orotracheal technique) using a conventional |
|laryngoscope |
It is best to complete this module while on a computer to access the various links on the internet.
California Board of Registered Nursing CEP#15122
Key Medical Resources, Inc.
2235 E. Fourth Street, Unit E, Ontario, CA 91764
951 520-3116 FAX: 951 739-0378 Educate100@
See for other Key Medical Resources programs
Disclaimer: Much of this information was obtained from various internet sources and integrated in to this learning module. The information is not intended in any way to be medical advice or to replace facility policies and procedures. Please refer to your facility protocols and current textbooks to guide your practice. Note that intubation may only be performed by practitioners who have intubation in their scope of practice AND have facility policies to perform this procedure. Developed 10/2010.
Tracheal Intubation Self Study Module
It is best to complete this module while on a computer to access the various links on the internet.
Available at – self study module tab
Compiled by Terry Rudd, RN, MSN
Key Medical Resources, Inc. 2235 E. Fourth Street, Suite E, Ontario, CA 91764
5.0 C0NTACT HOURS CEP #15122 70% is Passing Score
Please note that C.N.A.s cannot receive continuing education hours for home study.
1. Please print or type all information.
2. Complete answers and return answer sheet with evaluation form via fax or email to Key Medical Resources, Inc. Email: Educate100@ FAX: 951 739-0378.
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After completion of the self-study module, Promise Hospital Respiratory Therapy practitioners will be required to successfully complete a skills validation with intubation of a manikin.
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Tracheal Intubation Self-Study
It is best to complete this module while on a computer to access the various links on the internet.
Available at – self study module tab
Self Study Exam 5.0 C0NTACT HOURS
After completion of the self-study module, Promise Hospital Respiratory Therapy practitioners will be required to successfully complete a skills validation with intubation of a manikin.
Choose the Single Best Answer for the Following Questions and Place Answers on Form:
1. The best purpose of tracheal intubation is to:
a. Provide a means to deliver oxygen.
b. Maintain an open airway.
c. Provide complete control of ventilation.
d. Allow for more efficient bagging.
2. The most widely used route for tracheal intubation is:
a. Orotracheal
b. Nasotracheal
c. Circothyrotomy
d. Tracheotomy
3. Intubation should be considered for which Pa02 level and situation?
a. Pa02 less than 70 mm Hg on room air.
b. Pa02 less than 60 mm Hg with Fi02 of 50% or greater.
c. Pa02 less than 80 mm Hg with Fi02 of 70% or greater..
d. Pa02 less than 80 mm Hg on room air.
4. In which of the following situations should intubation be considered?
a. Diminished spontaneous ventilation for opiods.
b. Inability to maintain oxygenation using face mask oxygen supplementation.
c. ARDS
d. All of the above.
5. Physical examination is important prior to considering intubation. Which factors would be of particular importance to assess?
a. Range of motion of the cervical spine.
b. The thryromental distance.
c. The size and shape of the tongue and palate.
d. All of the above.
6. The appropriate curved laryngoscope blade for a large adult is the:
a. Miller 3.0
b. Miller 4.0
c. Macintosh 2.0
d. Macintosh 4.0
7. The best choice to help the endotracheal tube conform better to the patient’s anatomy is the use of:
a. A backboard
b. A tube stabilization device
c. A stylet
d. A straight blade
8. Which of the following statements is TRUE?
a. A cuffed endotracheal tube is the most common device inserted through the mouth.
b. Tracheostomy tubes may be inserted through the mouth.
c. Most endotracheal tubes are made from latex.
d. Most endotracheal tubes are uncuffed.
9. Which would be a contraindication for endotracheal intubation?
a. Patient weights over 300 pounds.
b. Airway can be managed less invasively.
c. Patient is awake and responsive.
d. Pa02 is above 50% on room air.
10. Which endotracheal tube size is most appropriate for an average sized adult?
a. 6.0 mm
b. 6.5 mm
c. 7.5 mm
d. 9.0 mm
11. Which technique is recommended as part of the endotracheal intubation procedure?
a. Open airway, suction if necessary.
b. Preoxygenate with 100% non-rebreather or BVM
c. Place the patient’s head in the “sniffing” position.
d. All of the above.
12. Which technique IS NOT acceptable to confirm proper tube placement?
a. Bilateral breath sounds.
b. End tidal C02 monitor.
c. Chest X-ray.
d. Abdominal auscultation.
13. Which procedure may help prevent gastric contents from leaking into the pharynx during intubation?
a. Heimlich maneuver
b. Head tilt, chin lift
c. Sellick maneuver
d. Suctioning prior to intubation
14. The best was to avoid breaking teeth during intubation is:
a. Use a guide wire.
b. Adjust fulcrum of the laryngoscope blade away from the teeth.
c. Use a paralytic medication prior to intubation.
d. Spray vocal cords with 2% Lidocaine
15. Prior to placing the endotracheal tube, it is essential that the person placing the tube:
a. Visualize the vocal cords.
b. Place the laryngoscope blade in the vallecula.
c. Apply cricoids pressure.
d. Hold the laryngoscope in the right hand.
16. Rapid-sequence induction and intubation (RSI) is utilized to:
a. Intubate while under anesthesia.
b. Minimize the possibility of aspiration of gastric contents during anesthesia.
c. Intubate without the need to preoxygenate.
d. Avoid the use of Sellick maneuver.
17. Cricothyrotomy is utilized to:
a. Help with insertion of a tracheostomy tube.
b. Assist proper placement of an endotracheal tube.
c. An emergency procedure where orotracheal and nasotracheal intubation cannot be done.
d. Provide a quick, first-choice technique for airway management.
18. Indications for tracheotomy in the chronic long-term setting includes:
a. Long term mechanical ventilation.
b. Removal of tracheal secretions.
c. Consistent airway management.
d. All of the above.
19. In the child, inserting a tube that is too large relative to the diameter of the trachea can cause:
a. Inflammation
b. Inability to talk
c. Edema
d. Inability to achieve positive pressure ventilation
20. The most fatal complication of improperly performed tracheal intubation is:
a. Esophageal intubation
b. Increased positive pressure in the airwary
c. Right main stem intubation
d. Pneumothorax
This is the end of the exam. Complete answers and return answer sheet with evaluation form via fax or email to Key Medical Resources, Inc.
Email: Educate100@ FAX: 951 739-0378.
[pic]
Tracheal Intubation
From Wikipedia, the free encyclopedia
It is best to complete this module while on a computer to access the various links on the internet.
Available at – self study module tab
I. Indications
II. Predicting Difficulty
III. Equipment
a. Laryngoscopes
b. Stylets
c. Tracheal tubes
IV. Methods to confirm tube placement
V. Special situations
a. Intubation in emergency circumstances
b. Rapid-sequence induction and intubation
VI. Cricothyrotomy
VII. Tracheotomy
VIII. Pediatric patients
IX. Complications
Tracheal intubation, usually referred to as intubation, is the placement of a flexible plastic tube into the windpipe to maintain an open airway or to serve as a conduit through which to administer certain drugs. This invasive medical procedure is frequently performed in critically injured, ill or anesthetized patients to facilitate positive pressure ventilation of the lungs, including mechanical ventilation, and to prevent the possibility of asphyxiation or airway obstruction. The most widely used route is orotracheal, in which an endotracheal tube is passed through the mouth and vocal apparatus into the trachea. In a nasotracheal procedure, an endotracheal tube is passed through the nose and vocal apparatus into the trachea. Other routes include cricothyrotomy (used almost exclusively in emergency circumstances) and tracheotomy, used primarily in circumstances where a prolonged need for airway support is expected.
After the trachea has been intubated, a high-volume, low-pressure cuff is typically inflated near the distal tip of the tube to help secure it in place and protect the tracheobronchial tree against leakage of respiratory gases and pulmonary aspiration of acid from the stomach and other undesirable material. The tube is then secured to the face or neck and the proximal end of the tube is connected to a T-piece, anesthesia breathing circuit, bag valve mask device, or a mechanical ventilator. Once there is no longer a need for ventilatory assistance and/or protection of the airway, the tracheal tube is removed; this is referred to as extubation of the trachea (or decannulation, in the case of a surgical airway such as a cricothyrotomy or a tracheotomy).
For centuries, tracheotomy was considered the most reliable (and most risky) method for intubation of the trachea. By the late 19th century, advances in the sciences of anatomy and physiology, as well as the beginnings of an appreciation of the germ theory of disease, had reduced the morbidity and mortality of tracheotomy to a more acceptable rate. Also in the late 19th century, advances in endoscopic instrumentation had improved to such a degree that direct laryngoscopy had finally become a viable means to secure the airway by the non-surgical orotracheal route. Nasotracheal intubation was not widely practiced until the early 20th century.
The 20th century saw the transformation of the practices of tracheotomy, endoscopy and non-surgical tracheal intubation from rarely employed procedures to essential components of the practices of anesthesia, critical care medicine, emergency medicine, gastroenterology, pulmonology and surgery. Today, tracheal intubation is usually performed after administration of general anesthesia and a neuromuscular-blocking drug, but can be performed in the awake patient with local or topical anesthesia, or in an emergency without any anesthesia at all. It is normally facilitated by visualizing the glottis with a conventional laryngoscope, flexible fiberoptic bronchoscope or video laryngoscope, though other devices and techniques are available.
See this Link for a good overview of intubation:
Note: inflate the balloon until a seal is achieved. Use a manometer or auscultate the neck to verify seal. Do not place a predetermined amount of air in to the balloon.
Indications
Tracheal intubation (orotracheal, nasotracheal, cricothyrotomy, or tracheotomy) is indicated under a variety of circumstances. One indication is in comatose or intoxicated patients with a depressed level of consciousness (defined as a Glasgow Coma Scale ≤ 8).[62] In such cases, dynamic collapse of the laryngopharyngeal muscles frequently results in obstruction of the hypopharynx, impeding the free flow of air into the lungs. Furthermore, protective airway reflexes such as coughing and swallowing, which serve to protect the airways against pulmonary aspiration of gastric contents and foreign bodies, may be diminished or absent. In such situations, tracheal intubation restores patency (the relative absence of blockage) of the airway and protects the lower airways from aspiration.[63]
In the setting of hypoxemia, intubation should be considered if the arterial partial pressure of oxygen (PaO2) is less than 60 millimeters of mercury (mm Hg) while breathing an O2 concentration (FiO2) of 50% or greater. For hypercapneic patients, a PaCO2 greater than 45 mm Hg in the setting of acidemia should prompt intubation, especially if serial measurements demonstrate a worsening respiratory acidosis. Regardless of the laboratory values, these guidelines should always be put in the clinical context.[64]
Anesthetic agents, opioids, or neuromuscular-blocking drugs may diminish or even abolish spontaneous ventilation. Diagnostic or therapeutic manipulation of the airway (such as bronchoscopy, laser therapy or stenting of the bronchi) may intermittently interfere with the ability to breathe. Under such circumstances, tracheal intubation is often employed to facilitate control of the airway.[65] Other specific indications include situations in which there is inability to maintain oxygenation using face mask oxygen supplementation. Examples include apnea or hypoventilation that often occurs in the setting of closed head injury, intoxication or poisoning, cervical spine injury, flail chest, severe pneumonia, acute respiratory distress syndrome (ARDS), or near-drowning. Impending or existing airway obstruction as commonly occurs in the setting of sustained seizure activity, facial fractures, expanding neck hematoma, laryngeal or tracheobronchial injury, airway burns, inhalation injury), or in critically ill patients with multisystem disease or injuries.[65]
Predicting difficulty
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[pic]
Tracheal intubation is anticipated to be difficult in this child with a massive ameloblastoma
Due to the grave consequences of failed tracheal intubation, the potential for difficulty or complications is carefully evaluated before undertaking tracheal intubation. The medical history is helpful in this respect. The diagnosis and/or proposed surgical procedure may offer clues to a potentially difficult airway. The subject is questioned about any significant signs or symptoms, such as dysphonia or dyspnea. Such signs and symptoms may suggest obstructing lesions in various locations within the pharynx, larynx, or tracheobronchial tree. A history of previous surgery (e.g., previous cervical fusion), trauma, radiation therapy, or tumors involving the head, neck and mediastinum can also provide clues to a potentially difficult intubation. Previous experiences with tracheal intubation, especially difficult intubation, intubation for prolonged duration (e.g., intensive care unit) or prior tracheotomy should also be documented.[66]
A detailed physical examination of the airway is also important. Of particular importance are:[67]
1. the range of motion of the cervical spine: the subject should be able to tilt the head back and then forward so that the mentum touches the chest.
2. the range of motion of the temporomandibular joint: three of the subject's fingers should be able to fit between the upper and lower incisors.
3. the size and shape of the maxilla and mandible, looking especially for problems such as maxillary hypoplasia, micrognathia, or retrognathia.
4. the thyromental distance: three of the subject's fingers should be able to fit between the thyroid cartilage and the mentum.
5. the size and shape of the tongue and palate relative to the size of the oral cavity.
6. the teeth, especially noting the presence of prominent maxillary incisors, any loose or damaged teeth, or crowns.
Besides the physical examination, many classification systems have been developed in an effort to predict difficulty of tracheal intubation, including the Cormack-Lehane grading system,[68][69] the Intubation Difficulty Scale (IDS),[70] and the Mallampati score.[71] The Mallampati score is determined by looking at the anatomy of the mouth and based on the visibility of the base of palatine uvula, faucial pillars and the soft palate. Such medical scoring systems correlate to some extent with the degree of difficulty of laryngoscopy and tracheal intubation, and may aid in the evaluation of factors linked to difficult tracheal intubation. However, no single score or combination of scores can be trusted to detect all patients who are difficult to intubate.[72][73] No system has yet been devised that has 100% positive predictive value, or 100% sensitivity and specificity.[74] Furthermore, one recent study has demonstrated that even among experienced anesthesiologists, only 25% could correctly define all four grades of the widely used Cormack–Lehane classification system, and intra-observer reliability (reproducibility of results) was poor.[75] Under certain emergency circumstances (e.g., severe head trauma or suspected cervical spine injury), it may be impossible to fully utilize these the physical examination and the various classification systems to predict the difficulty of tracheal intubation.[76] In such cases, alternative techniques of securing the airway must be readily available.[77]
Many individuals have unusual airway anatomy, such as those who have limited range of motion of the cervical spine or temporomandibular joint, or who have oropharyngeal tumors, hematomas, angioedema, micrognathia, retrognathia, or excess adipose tissue of the face and neck. Using conventional laryngoscopic techniques, intubation of the trachea can be difficult or even impossible in such patients. This is why all persons performing tracheal intubation must be familiar with alternative techniques of securing the airway. Use of the flexible fiberoptic bronchoscope and similar devices has become among the preferred techniques in the management of such cases. However, these devices require a different skill set than that employed for conventional laryngoscopy and are expensive to purchase, maintain and repair.[78][79]
Equipment
Laryngoscopes
[pic]
[pic]
Laryngoscope handles with an assortment of Miller blades (large adult, small adult, pediatric, infant and neonate)
See this Link for a virtual tour of various intubation devices and techniques:
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Laryngoscope handle with an assortment of Macintosh blades (large adult, small adult, pediatric, infant and neonate)
The vast majority of tracheal intubations involve the use of a viewing instrument of one type or another. Since its introduction by Kirstein in 1895,[37] the conventional laryngoscope has been the most popular device used for this purpose. Today, the conventional laryngoscope consists of a handle containing batteries and a set of interchangeable blades. Two basic styles of laryngoscope blade are commercially available: the straight blade and the curved blade. The Macintosh blade is the most widely used of the curved laryngoscope blades,[55] while the Miller blade[80] is the most popular style of straight blade.[81] Both Miller and Macintosh laryngoscope blades are available in sizes 0 (neonatal) through 4 (large adult). There are many other styles of straight and curved blades (e.g., Phillips, Robertshaw, Sykes, Wisconsin, Wis-Hipple, etc.) with accessories such as mirrors for enlarging the field of view and even ports for the administration of oxygen. These specialty blades are primarily designed for use by anesthetists, most commonly in the operating room.[82]
Besides the conventional laryngoscopes, many other devices have been developed as alternatives to direct laryngoscopy. These include a number of indirect fiberoptic viewing laryngoscopes such as the flexible fiberoptic bronchoscope, Bullard scope,[83] UpsherScope,[84][85] and the WuScope.[86] These devices are widely employed for tracheal intubation, especially in the setting of the difficult intubation (see below). Several types of video laryngoscopes are also currently available, such as the Glidescope,[87][88] McGrath laryngoscope,[89] Daiken Medical Coopdech C-scope VLP-100,[90] the Storz C-Mac,[91] Pentax AWS,[92][93][94][95] Video Macintosh Intubating Laryngoscope System (VMS)[96] and the Berci DCI.[97] Other "noninvasive" devices which can be employed to assist in tracheal intubation are the laryngeal mask airway[98][99][100][101][102][103][104] (used as a conduit for endotracheal tube placement), the lighted stylet,[105][106] and the AirTraq.[107] Due to the widespread availability of such devices, the technique of blind digital intubation[108] of the trachea is rarely practiced today, although it may still be useful in emergency situations under austere conditions such as natural or man-made disasters.[109]
See this Link for the airway cam view of direct laryngoscopy:
Stylets
An intubating stylet is a malleable metal wire which can be inserted into the endotracheal tube to make the tube conform better to the laryngopharyngeal anatomy of the specific individual, thus facilitating its insertion. Stylets are commonly employed under circumstances of difficult laryngoscopy. Just as with laryngoscope blades, there are also several types of available stylets.[110] The Verathon Stylet is a rigid stylet that is curved to follow the 60° angulation of the blade of the GlideScope® video laryngoscope.[87]
[pic]
[pic]
An endotracheal tube stylet, useful in facilitating orotracheal intubation
The Eschmann tracheal tube introducer (often incorrectly referred to as a gum elastic bougie) is another specialized type of stylet, which can also be used to facilitate difficult intubation.[111][112][113] This flexible device is 60 cm (24 in) in length, 15 French (5 mm diameter) with a small "hockey-stick" angle at its distal tip. Unlike the stylet, the Eschmann tracheal tube introducer is typically inserted directly into the trachea and then used as a guide over which the endotracheal tube can be passed (in a manner analogous to the Seldinger technique). As the Eschmann tracheal tube introducer is considerably less rigid than a conventional stylet, this technique is considered to be a relatively atraumatic means of tracheal intubation.[114][115][116][117][118][119]
The concept of using a stylet for replacing or exchanging orotracheal tubes was introduced by Finucane and Kupshik in 1978, using a central venous catheter.[120] The modern tracheal tube exchanger is a hollow catheter, 56 to 81 cm (22.0 to 31.9 in) in length, that can be used for removal and replacement of tracheal tubes without the need for laryngoscopy.[121] The Cook Airway Exchange Catheter (CAEC) is another example of this type of catheter; this device has a central lumen through which oxygen can be insufflated.[122]
Tracheal tubes
[pic]
Diagram of an endotracheal tube (blue, A; Cuff inflation tube B) that has been inserted into the airway (C). D: Esophagus
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A cuffed endotracheal tube, constructed of polyvinyl chloride
A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent airway. Tracheal tubes are frequently used for airway management in the settings of general anesthesia, critical care, mechanical ventilation and emergency medicine. Many different types of tracheal tubes are available, suited for different specific applications. An endotracheal tube is a specific type of tracheal tube that is nearly always inserted through the mouth (orotracheal) or nose (nasotracheal). It is a breathing conduit designed to be placed into the airway of critically injured, ill or anesthetized patients in order to perform mechanical positive pressure ventilation of the lungs and to prevent the possibility of aspiration or airway obstruction.[123] The proximal end of the endotracheal tube has a fitting designed to be connected to a source of pressurized gas such as oxygen. The distal end has an orifice through which such gases are directed into the lungs and may also include a balloon (referred to as a cuff). The distal tip of the endotracheal tube is positioned above the carina and sealed within the trachea such that the lungs can be ventilated equally.[123] A tracheostomy tube is another type of tracheal tube; this 2–3-inch-long (51–76 mm) curved metal or plastic tube may be inserted into a tracheostomy stoma to maintain patency of the lumen.[124]
Tracheal tubes can be used to ensure the adequate exchange of oxygen and carbon dioxide, to deliver oxygen in higher concentrations than found in air, or to administer other gases such as helium,[125] nitric oxide,[126][127] nitrous oxide, xenon,[128][129] or certain volatile anesthetic agents such as desflurane, isoflurane, or sevoflurane. They may also be used as a route for administration of certain medications such as bronchodilators, inhaled corticosteroids, and drugs used in treating cardiac arrest such as atropine, epinephrine, lidocaine and vasopressin.[130]
Originally made from red latex rubber,[34][44] most modern endotracheal tubes today are constructed of polyvinyl chloride. Tubes constructed of silicone rubber, wire-reinforced silicone rubber or stainless steel are also available for special applications. For human use, tubes range in size from 2 to 10.5 mm (0.1 to 0.4 in) 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. Most endotracheal tubes have an inflatable cuff to seal the tracheobronchial tree against leakage of respiratory gases and pulmonary aspiration of gastric contents, blood, secretions and other fluids. Uncuffed tubes are also available, though their use is limited mostly to pediatric patients (in small children, the cricoid cartilage, the narrowest portion of the pediatric airway, usually provides an adequate seal for mechanical ventilation).[61]
[pic]
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A Carlens double-lumen endotracheal tube, used for thoracic surgical operations such as VATS lobectomy
In addition to cuffed or uncuffed, preformed endotracheal tubes are also available. The oral and nasal RAE tubes (named after the inventors Ring, Adair and Elwyn) are the most widely used of the preformed tubes.[131]
Various types of endotracheal tubes are available that have endobronchial as well as endotracheal lumens (Carlens,[132] White and Robertshaw tubes). There is also the Univent tube, which has a single tracheal lumen and an integrated endobronchial blocker.[133][134] These tubes enable one to ventilate both lungs, or either lung independently. Single-lung ventilation (allowing the lung on the operative side to collapse) can be useful during thoracic surgery, as it can facilitate the surgeon's view and access to other relevant structures within the thoracic cavity.[135][136]
The "armored" endotracheal tubes are cuffed, wire-reinforced silicone rubber tubes. They are much more flexible than polyvinyl chloride tubes, but yet difficult to compress or kink. This can make them useful for situations in which the trachea is anticipated to remain intubated for a prolonged duration, or if the neck is to remain flexed during surgery. Most armored tubes have a Magill curve, but preformed armored RAE tubes are also available. Another type of endotracheal tube has four small openings just proximal to the inflatable cuff, which can be used for suction of the trachea or administration of intratracheal medications if necessary.[137] Other tubes (such as the Bivona® Fome-Cuf® tube) are designed specifically for use in laser surgery in and around the airway.[138]
Technique for Endotrachal Intubation
See this link for Basic Airway Management & Endotracheal Intubation
Indications:
1. Treatment of symptomatic hypercapnia.
2. Treatment of symptomatic hypoxemia.
3. Airway protection against aspiration.
4. Pulmonary toilet.
Contraindications:
Airway can be managed less invasively.
Equipment:
1. IV access, EKG, pulse ox monitors.
2. Suction apparatus.
3. Oropharyngeal, nasopharyngeal airways.
4. Non- rebreather mask.
5. Oxygen.
6. Bag valve mask.
7. Appropriate size endotracheal tube (7.5 mm – adult, child = diameter of little finger); with stylet and 10cc syringe.
8. Laryngoscope blade and handle (appropriate size).
9. Tape or tube stabilization device.
Endotracheal tube and laryngoscope sizes:
|Age: |Preemie |Neonate |6 mo. |1-2 yr. |4-6 yr. |8-12 yr. |Adult |
|Tube size: |2.5 |3-3.5 |3.5-4 |4-5 |5-5.5 |6-7 |7.5-8.5 |
|Blade size: |0 |0-1 |1 |1-2 |2 |2-3 |4-5 |
Procedure:
• Assess airway – note landmarks, swelling, deformities. Remove dentures. – Assess tongue size, dental obstruction, visibility of oropharynx, degree of neck mobility. - Maintain cervical spine stability as necessary.
• Open airway: suction or manually extract foreign material. – Chin lift, jaw thrust.
• Use artificial airways if needed: oropharyngeal, nasopharyngeal.
• Preoxygenate with 100% non-rebreather or bag-valve-mask. Keep pulse ox greater than 95% at all times.
• Position patient into “sniffing position” if possible; restrain as necessary.
• Standing at the supine patient’s head, gentle insert laryngoscope blade with left hand. Use suction as necessary with right hand. (See Figure 2)
• Visualize glottic opening/vocal cords.
• Advance ETT with right hand through cords. (See Figure 3)
• Remove stylet.
• Inflate ETT cuff with 5 – 10 cc air via syringe.
• Ventilate with bag and oxygen.
• Confirm tube placement with chest auscultation, CO2 monitor and chest x-ray.
• Secure tube with tape or a commercial-type tube stabilization device.
• [pic][pic]
Sellick Maneuver
[pic]
Sellick maneuver. This pressure prevents gastric contents from leaking into the pharynx
by extrinsic obstruction of the esophagus
See this link for Sellick Maneuver and other intubation videos
Complications: Prevention and Management
| Complication: |Prevention: |Management: |
|Missing/broken teeth: |Remove loose teeth prior; avoid using|Check chest x-ray to rule out aspiration. |
| |upper teeth as fulcrum for | |
| |laryngoscope blade. | |
|Clenched teeth: | |Paralytic medication. |
| | | |
|Air leak: |Check cuff prior to beginning |Inject more air or change tube over guide wire. |
| |procedure. | |
|Inability to visualize vocal cords: |Proper patient positioning, proper |Reposition, choose a different blade, adequate suction, |
| |laryngoscope blade size, proper |cricoid pressure by assistant. |
| |suctioning. | |
|Esophageal intubation: |Visualize cords. |Remove tube, re-oxygenate and reinsert. |
|Right lung intubation: |Avoid excessive tube advancement. |Deflate cuff, re-position and re-inflate. |
|Laryngospasm: |Spray vocal cords with 2% Lidocaine. |Benzodiazepine or paralytic medication. |
|Failure to intubate: |None. |Have alternative plan prepared: e.g., BVM, another type of |
| | |tube, cricothyrotomy. |
Methods to confirm tube placement
No single method for confirming tracheal tube placement has been shown to be 100% reliable. Accordingly, the use of multiple methods for confirmation of correct tube placement is now widely considered to be the standard of care.[66] Such methods include direct visualization as the tip of the tube passes through the glottis. With a properly positioned tracheal tube, equal bilateral breath sounds will be heard upon auscultation of the chest, and no sound upon auscultation of the epigastrium. Equal bilateral rise and fall of the chest wall will be evident with ventilatory excursions. A small amount of water vapor will also be evident within the lumen of the tube with each exhalation and there will be no gastric contents in the tracheal tube at any time.[138]
Ideally, at least one of the methods utilized for confirming tracheal tube placement will be a measuring instrument. Waveform capnography has emerged as the gold standard for the confirmation of tube placement within the trachea. Other methods relying on instruments include the use of a colorimetric end-tidal carbon dioxide detector, a self-inflating esophageal bulb, or an esophageal detection device.[139] The distal tip of a properly positioned tracheal tube will be located in the mid-trachea, roughly 2 cm (1 in) above the bifurcation of the carina; this can be confirmed by chest radiograph. If the tracheal tube is inserted too far into the trachea, the tip will often be located within the right main bronchus, because this bronchus has a less acute angle than the left.[140]
Special situations
Intubation in emergency circumstances
Tracheal intubation in the emergency setting can be difficult with the fiberoptic bronchoscope due to blood, vomit, or secretions in the airway and poor patient cooperation.[141][142] Patients with massive facial injury, complete upper airway obstruction, apnea, severe hypoventilation, or profuse upper airway bleeding are poor candidates for fiberoptic intubation.[143][144] Fiberoptic intubation under general anesthesia typically requires two skilled individuals.[145] Success rates of only 83–87% have been reported using fiberoptic techniques in the emergency department, with significant epistaxis occurring in up to 22% of patients.[146][147] These drawbacks limit the use of fiberoptic bronchoscopy somewhat in urgent and emergent situations.[141][142]
Personnel experienced in direct laryngoscopy are not always immediately available in certain settings that require emergency tracheal intubation. For this reason, specialized devices have been designed to act as bridges to a definitive airway. Such devices include the laryngeal mask airway, cuffed oropharyngeal airway and the esophageal-tracheal combitube (Combitube).[148][149] Other devices such as rigid stylets, the lightwand (a blind technique) and indirect fiberoptic rigid stylets, such as the Bullard scope, Upsher scope and the WuScope can also be used as alternatives to direct laryngoscopy. Each of these devices have its own unique set of benefits and drawbacks, and none of them is effective under all circumstances.[110]
Rapid-sequence induction and intubation
Rapid sequence induction and intubation (RSI) is a particular method of induction of general anesthesia, commonly employed in emergency operations and other situations where patients are assumed to have a "full stomach". The objective of RSI is to minimize the possibility of regurgitation and pulmonary aspiration of gastric contents during the induction of general anesthesia and subsequent tracheal intubation.[66] RSI traditionally involves preoxygenating the lungs with a tightly-fitting oxygen mask, followed by the sequential administration of an intravenous hypnotic agent and a rapidly-acting neuromuscular-blocking drug, before intubation of the trachea.[150]
One important difference between RSI and routine tracheal intubation is that the practitioner does not manually assist the ventilation of the lungs after the onset of general anesthesia and apnea, until the trachea has been intubated and the cuff has been inflated. Another key feature of RSI is the application of manual pressure to the cricoid cartilage, often referred to as the Sellick maneuver, prior to instrumentation of the airway and intubation of the trachea.[66]
Since the introduction of RSI, there has been controversy regarding virtually every aspect of this technique, including:[151]
• choice of induction drug, dose and method of administration.
• avoidance of manual ventilation before tracheal intubation.
• optimal position and whether the head-up, head-down, or horizontal supine position is the safest for induction of anesthesia in full-stomach patients.
• application of cricoid pressure (the Sellick maneuver).
Named for British anesthetist Brian Arthur Sellick (1918–1996) who first described the procedure in 1961,[152] the goal of the Sellick maneuver is to minimize the possibility of regurgitation and pulmonary aspiration of gastric contents, which can result in a severe and sometimes fatal chemical aspiration pneumonitis. Cricoid pressure has been widely used during RSI for nearly fifty years, despite a lack of compelling evidence to support this practice.[153] The initial article by Sellick was based on a small sample size at a time when high tidal volumes, head-down positioning and barbiturate anesthesia were the rule.[154] Beginning around 2000, a significant body of evidence has accumulated which questions the effectiveness of the Sellick maneuver. The application of cricoid pressure may in fact displace the esophagus laterally[155][156] instead of compressing it as described by Sellick. Cricoid pressure may also compress the glottis, which can obstruct the view of the laryngoscopist and actually cause a delay in securing the airway.[157][158][159][160]
The Sellick maneuver is often confused with the BURP (Backwards Upwards Rightwards Pressure) maneuver.[161] While both of these involve digital pressure to the anterior aspect of the laryngeal apparatus, the purpose of the latter is to improve the view of the glottis during laryngoscopy and tracheal intubation, rather than to prevent regurgitation.[162]
Cricothyrotomy
[pic]
[pic]
Cricothyrotomy kit
A cricothyrotomy is an incision made through the skin and cricothyroid membrane to establish a patent airway during certain life-threatening situations, such as airway obstruction by a foreign body, angioedema, or massive facial trauma.[163] Cricothyrotomy is nearly always performed as a last resort in cases where orotracheal and nasotracheal intubation are impossible or contraindicated. Cricothyrotomy is easier and quicker to perform than tracheotomy, does not require manipulation of the cervical spine and is associated with fewer complications.[164]
The quickest and easiest method to perform this technique is the needle cricothyrotomy (also referred to as a percutaneous dilational cricothyrotomy), in which a large-bore (12–14 gauge) intravenous catheter is used to puncture the cricothyroid membrane.[165] Oxygen can then be administered through this catheter via jet insufflation. However, while needle cricothyrotomy may be life-saving in extreme circumstances, this technique is only intended to be a temporizing measure until a definitive airway can be established.[62] In practice, needle cricothyrotomy is little better than apneic oxygenation inasmuch as the small diameter of an intravenous catheter allows for adequate oxygenation but not for elimination of carbon dioxide (ventilation). After one hour of apneic oxygenation through a needle cricothyrotomy, one can expect a PaCO2 of greater than 250 mm Hg and an arterial pH of less than 6.72, despite an oxygen saturation of 98% or greater.[166] A more definitive airway can be established by performing a surgical cricothyrotomy, in which a 5 to 6 mm (0.20 to 0.24 in) endotracheal tube or tracheostomy tube can be inserted through a larger incision.[167]
Several manufacturers (Cook Medical, Portex Medical, Pyng Medical, Teleflex Medical, etc.) market prepackaged cricothyrotomy kits. These kits enable one to use either a wire-guided percutaneous dilational (Seldinger) technique, or the classic surgical technique to insert a polyvinylchloride catheter through the cricothyroid membrane. The kits may be stocked in hospital emergency departments and operating suites, as well as ambulances and other selected pre-hospital settings.[168][169]
Tracheotomy
Tracheotomy consists of making an incision on the anterior aspect of the neck and opening a direct airway through an incision in the trachea. The resulting stoma can serve independently as an airway or as a site for a tracheostomy tube to be inserted; this tube allows a person to breathe without the use of their nose or mouth. Both surgical[167] and percutaneous[165][170][171] techniques are widely used in current practice. In order to limit the risk of damage to the recurrent laryngeal nerves (the nerves that control the vocal folds), tracheotomy is performed as high in the trachea as possible. If only one of these nerves is damaged, the patient will experience dysphonia; if both of the nerves are damaged, the patient will experience complete aphonia. British theoretical physicist Stephen Hawking lost his ability to speak after surgeons performed a tracheotomy in an effort to prevent recurrent pneumonia.[172] In the acute setting, indications for tracheotomy are similar to those for cricothyrotomy. In the chronic setting, indications for tracheotomy include the need for long-term mechanical ventilation and removal of tracheal secretions (e.g. comatose patients, or extensive surgery involving the head and neck).[163][173][174]
Pediatric patients
[pic]
[pic]
A premature infant weighing 990 grams (35 ounces), intubated and requiring mechanical ventilation in the neonatal intensive-care unit
There are significant differences in airway anatomy and respiratory physiology between children and adults. The smaller and younger the patient, the more significant these differences are; they must be taken into careful consideration before one undertakes tracheal intubation of any pediatric patient. These anatomical and physiological differences gradually become less significant as the human body approaches a mature age and body mass index.[175]
For infants and young children, orotracheal intubation is easier than the nasotracheal route. Nasotracheal intubation carries a risk of dislodgement of pharyngeal tonsils and epistaxis. Despite the greater difficulty, nasotracheal intubation route is preferable to orotracheal intubation in children undergoing intensive care and requiring prolonged intubation because this route allows a more secure fixation of the tube. As with adults, there are a number of devices specially designed for assistance with difficult tracheal intubation in pediatric patients.[176][177] Confirmation of proper position of the tracheal tube is accomplished as with adult patients.[178]
Because the airway of a child is narrow, a small amount of glottic or tracheal edema can produce critical obstruction. Inserting a tube that is too large relative to the diameter of the trachea can cause edema. Conversely, inserting a tube that is too small can result in inability to achieve effective positive pressure ventilation due to retrograde escape of gas through the glottis and out the mouth and nose (often referred to as a leak around the tube). An excessive leak can usually be corrected by inserting a larger tube or a cuffed tube.[179]
The tip of a correctly positioned tracheal tube will be in the mid-trachea, between the clavicles on an anteroposterior chest radiograph. The correct diameter of the tube is that which results in a small leak at a pressure of about 25 cm (10 in) of water. The appropriate inner diameter for the endotracheal tube is estimated to be roughly the same diameter as the child's little finger. The appropriate length for the endotracheal tube can be estimated by doubling the distance from the corner of the child's mouth to the ear canal. For premature infants 2.5 mm (0.10 in) internal diameter is an appropriate size for the tracheal tube. For neonates of normal gestational age, 3 mm (0.12 in) internal diameter is an appropriate size. For normally nourished children 1 year of age and older, one can apply the following formulas to estimate the proper diameter and depth of insertion for tracheal tubes:[138]
• Internal diameter of tube (mm) = (patient's age in years + 16) / 4
• Appropriate depth of insertion of orotracheal tube (cm) = 12 + (patient's age in years / 2)
Complications
Tracheal intubation is generally considered the best method for airway management under a wide variety of circumstances, as it provides the most reliable means of oxygenation and ventilation and the greatest degree of protection against regurgitation and pulmonary aspiration.[130] However, tracheal intubation requires a great deal of clinical experience to master[180] and serious complications may result even when properly performed.[181] When performed improperly, the associated complications (e.g., unrecognized esophageal intubation) may be rapidly fatal.[182] Without adequate training and experience, the incidence of such complications is unacceptably high.[130] For example, among paramedics in several United States urban communities, unrecognized esophageal or hypopharyngeal intubation has been reported to be 6%[183][184] to 25%.[182] Among providers at the basic emergency medical technician (EMT-B) level, reported success rates for tracheal intubation are as low as 51%.[185] In one study, nearly half of patients with misplaced tracheal tubes died in the emergency room.[182] Because of this, recent editions of the American Heart Association's Guidelines for Cardiopulmonary Resuscitation have de-emphasized the role of tracheal intubation in favor of other airway management techniques such as bag-valve-mask ventilation, the laryngeal mask airway and the Combitube.[130]
Complications associated with the performance of laryngoscopy and insertion of an orotracheal tube include dental trauma, laryngospasm, perforation of the trachea or esophagus, pulmonary aspiration of gastric contents or other foreign bodies, fracture or dislocation of the cervical spine, temporomandibular joint or arytenoid cartilages, hypoxemia, hypercapnia, cardiac dysrhythmias, hypertension, increased intracranial or intraocular pressure and vocal cord paresis.[181] In addition to these complications, tracheal intubation via the nasal route carries a risk of dislodgement of pharyngeal tonsils and potentially severe epistaxis.[146][147] Newer technologies such as flexible fiberoptic laryngoscopy have fared better in reducing the incidence of such complications, though the most frequent cause of intubation trauma remains a lack of skill on the part of the laryngoscopist.[181]
Complications more often associated with prolonged intubation and/or tracheotomy include tracheoinnominate or tracheoesophageal fistula, tracheomalacia, ventilator-associated pneumonia and stenosis of the glottis or trachea.[138] The cuff pressure must be monitored carefully in order to avoid complications from over-inflation, many of which can be traced to excessive cuff pressure causing ischemia of the tracheal mucosa.[186][187] A 2000 Spanish study of bedside percutaneous tracheostomy reported overall complication rates of 10–15% and procedural mortality of 0%,[171] which is comparable to those of other series reported in the literature from the Netherlands[188][189] and the United States.[170][190]
References
External links
1. Videos of direct laryngoscopy recorded with the Airway Cam (TM) imaging system -
2. Examples of some devices for facilitation of tracheal intubation -
3. Diagram of performance of the Sellick maneuver -
4. The CRIC™ Cricothyrotomy System from Pyng Medical Corporation -
5. The Rüsch QuickTrach® from Teleflex Medical Corporation -
6. The Portex® Cricothyroidotomy Kit (PCK) -
7. The Melker Emergency Cricothyrotomy Catheter Tray -
General
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INTUBATION POLICY
POLICY & PROCEDURE
CARDIOPULMONARY MANUAL
|PROMISE HOSPITAL OF EAST LOS ANGELES, L.P. |APPLIES TO: |No. |
|SUBJECT: INTUBATION |Hospital Wide | |
| |Date of Revision: |Date of Origin: 1/01/06 |
| |8/06 | |
| |Recommended By: PROMISE HEALTHCARE |
|DEPARTMENTAL INVOLVEMENT: | |
|( Administration ( Marketing ( Admitting |Administrative approval: |
|( Business Office ( Nursing ( Other: | |
|( Human Resources ( Therapies ( ___________ | |
|( Medical Records ( Medical Staff | |
| | |
| |Page 1 of 4 |
|REFERENCE: |
|ATTACHMENT: |
I. PURPOSE:
The establishment of a patent airway is one of the most essential steps in the emergency resuscitation scenario. Timing is one of the most crucial aspects in the procedure. It is imperative that intubation be performed in a specific timeframe without comprising the patients well being.
The Respiratory Care Practitioner (RCP) may perform endotracheal intubations after meeting all specified requirements.
II. CONDITIONS FOR INTUBATION:
The Cardiopulmonary Department will perform endotracheal intubation only when the following conditions warrant it:
• During a cardiopulmonary resuscitation scenario when requested by the attending physician in charge. In the event that the attending physician is not available, and that delays would compromise the patients well being, the Respiratory Care Practitioner would immediately perform the procedure.
• During a cardio/respiratory arrest and when requested by an attending physician in charge.
• If requested by the patient’s primary physician due to severe respiratory distress or when cardiopulmonary arrest is imminent.
III. RCP REQUIREMENTS AND QUALIFICATIONS:
1. The RCP must have a minimum of 1 (ONE) year experience in the critical care setting.
2. The RCP must be BLS and ACLS certified.
3. The RCP will be required to attend and pass an intubation course consisting of anatomy, physiology, equipment use, hazards of intubation and contraindications. The RCP must successfully be able to intubate a mechanical Intubation Head using proper Intubation techniques. This course will go step to step on the complete proper use and procedure of intubation .
4. The RCP must complete and pass the Intubation Competency Criteria for intubation.
5. After the RCP has attended and passed the above criteria, he/she will be required to be proctored by a physician or a certified RCP before being allowed to perform intubations.
IV. RECERTIFICATION:
The RCP must re-certify every year. If the RCP does a minimum of THREE (3) intubations within the 12 month period, they will automatically be re-certified. If the RCP does not meet this criteria, he/she may be required to go through the Intubation Course again.
The Department Director/Manager at his own discretion will determine this.
V. EQUIPMENT:
Each RCP will be knowledgeable in the use and function of the equipment listed below:
• Endotracheal Tubes of various sizes
• Laryngoscope handles (Straight/Curved)
• Laryngoscope blade and bulbs
• 10 cc syringes
• KY Jelly or water based lubricant
• Taping of ET Tubes/Methods of Taping
• Suction equipments
• Manual resuscitation device (Ambu-bag)
• Stylette
• Laryngeal Mask (LMA)
• Endotracheal Tube Introducer (Gum-Elastic Bougie)
• Bite block
• Airways
• Patient teeth protector
• End Tidal C02 detector or esophageal detector
• Stethoscope
VI. SETTING UP:
• Contact/Notify Physician for standing orders.
• Explain procedure to patient and/or family members (if applicable).
• Obtain and set-up all required equipment:
➢ Suction set-up
➢ Choose type of blade and attach to handle
➢ Verify light on the handle is functioning
➢ Select appropriate size of endotracheal tube
➢ Insert stylette into the tube and secure the tube so that the stylet tip is ½ inches inside end of the ET tube
➢ Inflate the cuff with the syringe and observe for leaks. If no leak is present, deflate and lubricate the cuff.
➢ Position head using the ‘sniffing’ technique. You may want to roll a towel and place it under the back of the neck for better positioning and alignment.
VII. PROCEDURE:
• Hyperventilate and oxygenate the patient with a manual resuscitator device prior to intubation.
• Holding the laryngoscope, insert the blade into the oral pharynx until the tip of the blade is just past the uvula. If you are using a curve blade, sweep the tongue to the left when inserting the blade. If you are using a straight blade, insert the blade directly on top of the tongue.
• Advance the blade forward and upward as to point the end of the blade towards the larynx while lifting the lower jaw to bring the larynx into view. Avoid putting any pressure on the patients teeth. When using a curve blade, the tip of the of the blade should be in the vallecula. When using a straight blade, the tip must be holding up the epiglottis.
• When the vocal cords are visualized, insert the ET tube until the cuff is just beyond the vocal cords.
• Remove the stylette, inflate the cuff with 4-8cc of air, attach the end tidal C02 monitor and check for tube placement by observing the following:
▪ Auscultate for air movement in the lateral lung fields.
▪ Verify equal chest movement and verify bilateral breath sounds.
▪ Verify the absence of air movement in the epigastric region.
▪ Confirm tube placement with a chest x-ray immediately.
▪ Secure ET tube.
VIII. UNSUCCESFUL INTUBATION:
If the RCP has 3 unsuccessful intubation attempts, manually ventilate the patient with a manual resuscitator device and have a physician or another qualified RCP attempt intubation. If no other qualified personnel are available, keep calm and try again.
VIX. IMPORTANT NOTES:
• Endotracheal Intubation is a dangerous procedure and should only be attempted by a trained and qualified individual.
• Remember to always have suction available before attempting to visualize the vocal cords.
• Use the ‘When in Doubt, Pull Out’ approach if you are unsure of proper tube placement.
• Intubation attempts should not go past 20 seconds.
• Exercise extreme caution during the intubation procedure as to not traumatize the patient’s airway.
• Document intubation on RT Progress notes to include:
▪ Respiratory status prior, during and after intubation.
▪ Use of hyperventilation and hyperoxygenation techniques
▪ Method of insertion
▪ Tube size used, position, lip line marker and breath sounds
▪ Confirmation of ET tube placement
▪ Any difficulties or complications you might have encountered.
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