1.09 (Surgery-CK) Orotracheal Intubation

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Surgery

Orotracheal Intubation
ClinicalKey
August 10, 2020

OUTLINE Failure of airway maintenance or protection


- Sufficient oxygenation and ventilatory effort are reassuring but do not
PRE-PROCEDURE ........................................................................................1
Indications ..............................................................................................................................1 necessarily provide information about airway patency or protection.
Contraindications ..................................................................................................................2 - Decreased mental states place patients at risk for aspiration of
Equipment ..............................................................................................................................2
Anatomy..................................................................................................................................4 gastric and oropharyngeal secretions, a precursor to chemical
pneumonitis and pneumonia.
PROCEDURE ................................................................................................5
Assessment ............................................................................................................................5
- Airway obstruction can occur in the form of foreign bodies,
Preparation.............................................................................................................................5 angioedema, neck hematomas, or simply relaxed hypopharyngeal
Sellick maneuver ...................................................................................................................6 soft tissue
Laryngoscopy & Intubation..................................................................................................6
Troubleshooting ....................................................................................................................8 o The latter can occur in patients who are not alert enough to
keep this passage open.
POST-PROCEDURE ......................................................................................8
Post-procedure Care ............................................................................................................8 - Initial measures to open an airway include a jaw thrust, chin lift, and
Complications ........................................................................................................................9 removal of foreign bodies.
- Oropharyngeal and nasopharyngeal airways may bypass select
upper airway obstructions, but in patients with impending airway
- Endotracheal intubation is a critical, often lifesaving procedure for closure or loss of airway protective reflexes, intubation is
severely ill or injured patients who cannot maintain adequate required.
oxygenation, perform effective ventilation, or maintain a protected - Clinically, a patient who can phonate and swallow has a patent,
airway protected airway.
- is also often used when a patient is at risk of serious deterioration or - Clinical Pearls:
is considered unstable and needs a procedure or transfer that o presence of gag reflex should not be equated with airway
requires leaving the resuscitation room environment protection and is neither sensitive nor specific for the need
- obtaining a secure, definitive airway is the primary consideration for intubation
during any resuscitative effort o absent gag reflexes may be found in up to 25% of healthy,
awake patients
o additionally, checking a gag reflex may induce vomiting and
aspiration and is not advised

Failure to oxygenate
- The lung’s primary function is to oxygenate pulmonary arterial
blood
- All vital organs in the body require oxygen to perform cellular
respiration. Certain specialized tissues, such as neuronal tissue,
undergo irreversible damage if deprived of oxygen for only a few
minutes.
- Patients with head injury, hypoxia, and hypotension experience
accelerated secondary brain injury and worse neurologic outcomes.
- Clinical Pearls:
Figure 1. Orotracheal intubation o With rare exception, persistent hypoxia despite maximum
supplemental O2 requires intubation.
- This procedure is commonly performed in the prehospital setting, o Acute cardiogenic pulmonary edema often may be
emergency departments, critical care units, and electively in effectively managed with continuous positive noninvasive
operating suites ventilation, thus avoiding the need for intubation.
- Proper airway management requires a thorough understanding of
the indications for tracheal intubation, the pharmacology of sedative Failure to ventilate
and neuromuscular blocking (NMB) agents, and the proper methods - A by-product of cellular metabolism is CO2.
for endotracheal tube (ETT) placement - Ineffective ventilation results in CO2 retention, acidosis, and
- Clinical Pearls: ultimately altered mental status.
o The use of rapidly-acting sedatives and neuromuscular - Although CO2 diffuses across alveolar membranes with greater
blocking agents helps to create the best possible intubating ease than oxygen, airway obstruction, toxic ingestion, or muscular
conditions weakness can result in hypopnea and CO2 accumulation.
o However, use of such is beyond the scope of the video shown - Clinical Pearls:
o Patients with acute ventilatory failure, unless immediately
PRE-PROCEDURE reversible, require intubation.
Indications o Opioid overdose resulting in respiratory depression or arrest
- There are four principal scenarios in which intubation is required may be effectively managed with naloxone.
and should be done immediately if initial corrective measures fail. o In select patients with acute exacerbations of chronic
obstructive pulmonary disease (COPD), bi-level positive
airway pressure (BiPAP) can obviate intubation
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Surgery | Orotracheal Intubation
o however, close observation is required because many - Standard direct laryngoscope
patients fail BiPAP trials and will require intubation. o Laryngoscope blades
o Laryngoscope handle with batteries
Expected need for intubation
- This criterion for intubation is less straightforward and requires the
most judgment.
- Frequently, severely ill or injured patients do not meet one of the
first three indications for intubation. However, the underlying
pathophysiologic process or its treatment may result in hypoxia,
hypoventilation, or intense pain; or require the patient to travel
outside a monitored setting (e.g., to the CT scanner).
- Clinical Pearls
o One example may be a trauma patient with an open femur
fracture and pelvic fracture, complicated by substantial
hypotension.
o The patient arrived awake and talking with normal oxygen
saturation but has significant hypotension and incipient
shock.
o In addition to the need for fracture fixation, the patient requires
imaging and possibly interventional radiology procedures, Figure 2. Intubating equipment.
both of which require the patient to leave the relatively safe
confines of the resuscitation bay. - ETTs and accessories
o The increasing metabolic burden of the persistent hypotension
and the need for prolonged time outside the resuscitation area o ETTs, variable sizes
argue that the patient should have his/her airway protected o Malleable ETT stylet
early to avoid a crisis later. o 10-mL syringe
o ETT tape or commercial ETT holder
Contraindications
- Basic airway equipment
Do Not Resuscitate Order o Bag and mask ventilation device
- Endotracheal intubation is lifesaving for many patients and has only o Oropharyngeal and/or nasopharyngeal airways
one absolute contraindication. o Oxygen source and tubing
- Patients, often elderly or chronically ill, who have an advanced
directive with a Do Not Resuscitate (DNR)/Do Not Intubate (DNI)
order should not be intubated.

Tracheal transection
- Orotracheal intubation is relatively contraindicated in patients with
known or suspected partial transection of the trachea because
the procedure may cause complete transection and subsequent
loss of the airway.
- Emergent consultation with a thoracic surgeon or
otorhinolaryngologist should be obtained if available because
surgical airway management may be necessary.

Cervical spine injury


- Orotracheal intubation is not contraindicated in patients with
cervical spine injuries
- however, strict in-line immobilization of the cervical spine must be
performed by an assistant. Figure 3. Basic airway equipment

Difficult airway - Sedative and NMB agents


- Difficult orotracheal intubation may arise in a variety of clinical - Water-based lubricant (i.e., Surgilube)
scenarios, including: - Yankauer suction catheter and tubing
o Patients with oropharyngeal tumors, trauma, or infection - General resuscitation equipment
o Patients with limited neck mobility, small mandibles, inability to o Peripheral IV (in place)
open the mouth, or pharyngeal structures that are difficult to o Cardiac monitor
visualize through an open mouth o Oxygen saturation probe
- If difficult intubation is suspected, then contingency plans, including o Blood pressure cuff
preparation for an alternative airway control technique (e.g., - End-tidal CO2detector
laryngeal mask airway insertion, surgical airway management, or - Rescue devices
fiber optic airway technique) and emergent specialist consultation, o Laryngeal mask airway or laryngeal tube
should be made. o Intubating stylet (Frova or bougie)
- Ventilator
Equipment
- Equipment for universal precautions (mask, gloves, etc.)
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o A 20- to 30-degree angle (hockey-stick bend) should be
introduced proximal to the cuff. This is done to facilitate
passage of the tube into the trachea
- Clinical pearls:
o Angles greater than 35 degrees have been associated with an
increased rate of difficult or impossible intubation

Figure 4. End-tidal CO2 detector

Types of Laryngoscope Blades


- Macintosh/curved blades
o This blade has a gentle curve and is designed to have its tip
placed in the vallecula.
o With gentle forward and upward pressure, the epiglottis is
Figure 6. Place a 20-30-degree bend just proximal to the cuff of the tube.
elevated indirectly to expose the vocal cords.
- Miller/straight blades
- Prior to intubation, assure that all equipment is in good working order,
o This blade is straight and should be placed under the
and ready to use
epiglottis and lifted directly to expose the vocal cords.
- Check the light at the tip of the laryngoscope
- Clinical Pearls:
- Temporarily inflate the balloon on the endotracheal tube to assess its
o The choice of blade is based on operator preference and
integrity
experience. Pediatric patients are often easier to intubate
- Lubricate the stylet and place it into the endotracheal tube
using a straight blade because of the pliability of the tissues of
o The tip of the stylet must not protrude beyond the end of the
the upper respiratory tract, but either blade can be used. For
tube in order to avoid iatrogenic injury
infants, use a straight blade.

Pharmacologic Agents
- Sedatives
o In the absence of a planned “awake” intubation of a patient with
an identified difficult intubation, an induction agent (potent
sedative given in a dose capable of inducing general
anesthesia) is administered before intubation, using a rapid
sequence technique. Rapidly acting agents, such as
etomidate or propofol, are excellent induction agents.

- Neuromuscular-blocking agents
o Depolarizing:
▪ Succinylcholine is the only depolarizing NMB agent
approved in the US and is the most commonly used
paralytic during emergent airway management.
▪ At a dose of 1.5 mg/kg, it induces paralysis within 45 to
60 seconds by maintaining open ion channels at the
neuromuscular junction.
▪ This prevents repolarization and further muscular
activity.
▪ It should NOT be used in patients at risk for
succinylcholine-induced hyperkalemia such as:
Figure 5. Macintosh and Miller Laryngoscope Blades.
• patients with burns
• recent high-spinal paralysis
Endotracheal Tubes and Accessories
• neuro-muscular disease
- ETTs
• Guillian-Barre
o Various sizes are available depending on the patient’s size,
• known history or family history of malignant
weight, or length
hyperthermia
o A 7.0 or 7.5 ETT will suffice for most normal-sized adult patients
• end-stage renal disease
▪ Most adult: size 8.0
o Nondepolarizing (competitive):
• 7.0 may be required for smaller adults
▪ Vecuronium and rocuronium are commonly used in
o A smaller backup tube cannot navigate the laryngeal inlet
patients with contraindications to succinylcholine.
- Malleable stylets
▪ They can be used as first line agents as well. Rocuronium
o should be used during intubation to provide shape and
in a dose of 1 mg/kg provides relaxation times
strength to the ETT
approaching those achieved with succinylcholine.
o It is inserted into the lumen of the tube with the tip inside the
▪ Disadvantages to vercuronium and rocuronium,
ETT, 1 to 2 cm from the end of the ETT.
however, are significant:
o Do not let the stylet protrude beyond the ETT tip, because this
• longer time to achieve intubation conditions
can cause airway trauma.

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• longer time for return of spontaneous ventilation in - The oral cavity extends superiorly to meet the posterior nasopharynx
the case of failed intubation and blends inferiorly with the laryngeal inlet and superior
▪ A recent Cochrane Database review comparing esophageal space.
rocuronium versus succinylcholine concluded that
succinylcholine was superior to rocuronium in providing Larynx
excellent intubation conditions for rapid sequence - The larynx is a complex structure composed of fibrous membranes,
induction and intubation. cartilages, and discrete muscle bands. It is richly innervated and
responsible for phonation and airway protection.
Rescue Devices - Anterior structures include the hyoid bone, epiglottis, thyrohyoid
- Intubating stylets membrane, and the thyroid cartilage.
o Intubating stylets, either a Frova catheter (Cook Ltd, - The small space between the epiglottis and base of the tongue is the
Letchworth, UK) or an Eschmann stylet (gum elastic bougie), vallecula.
should be immediately available for use when direct - Anterior and upward pressure pushes on the hyoepiglottic ligament
laryngoscopy provides suboptimal (partial) view of the cords, and moves the epiglottis out of view during laryngoscopy.
because they can serve as an effective adjunct for difficult - Posteriorly, the arytenoid cartilages are responsible for vocal cord
airways. movement. These become contiguous with the aryepiglottic folds
o An intubating stylet is a thin, hard, plastic rod angled anteriorly that form the lateral wall of the laryngeal inlet and are connected
at the distal tip. anteriorly to the epiglottis.
o When placed in the trachea, the curved tip runs along the - In the floor of the larynx are the vocal cords.
tracheal rings, providing tactile feedback that confirms its - Inferior and behind the larynx are the left and right piriform recesses,
location. which in the midline are contiguous with the upper esophagus.
o An ETT can then be placed over the stylet using a Seldinger
type of technique.

- Laryngeal mask airway/laryngeal tubes


o When intubation is unsuccessful but ventilation is possible, an
extraglottic rescue device, such as a laryngeal mask airway
(LMA) or Combitube, may be used to ventilate the patient
until assistance can be obtained, or a plan can be made to
place a definitive airway. Both devices are easy and quick to
place, even in the hands of a novice.
o The Combitube has the advantage of higher leak pressures
compared to a standard LMA, so it may be more effective in
patients with high ventilatory resistance, such as those with
acute asthma or chronic obstructive pulmonary disease
(COPD).
Figure 8. External Anatomy
Anatomy
Oral cavity & Oropharynx

Figure 9. Laryngeal anatomy, as seen during orotracheal intubation

Figure 7. Oral Cavity


- Clinical Pearls:
o Curved laryngoscope blades are designed to be placed in this
- The oral cavity is bound superiorly by the hard and soft palates,
recess.
inferiorly by the tongue and floor of the mouth, and laterally by the
buccal mucosa.
- Anteriorly, it is bound by the lips, gingiva, and teeth. Trachea
- During laryngoscopy, the blade is inserted along the right side of the - The trachea begins after the cricoid cartilage and consists of a series
tongue in the perilingual gutter. The tongue is displaced leftward and of stacked, incomplete rings.
upward into the floor of the mouth and mandibular fossa to expose - The trachealis muscle forms the posterior wall of the trachea.
the larynx. - The trachea extends 12 to 15 cm to the carina, then splits into the
- Posteriorly, at the palatoglossal arch the oral cavity merges with the right and left main-stem bronchi.
pharynx, a muscular tube composed of pharyngeal constrictor and - The average tracheal diameter is 10 to 12 mm and on average can
pharyngeus muscle groups. accommodate an 8.0 ETT.
- Clinical Pearls:
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o The tip of a correctly positioned ETT should rest about midway o Mallampati et al., correlated the number of posterior
between the inferior border of the cricoid ring and the trachea. pharyngeal structures viewed through the patient’s mouth
with failed intubation rates and developed four classes
PROCEDURE ranging from class 1 (full view) to class 4 (tongue only).
- Explain the procedure o Mallampati class 4 was found in preoperative patients to be
- If the patient is conscious, explain in plain terms the reason for associated with a 10% failed airway rate. Although this has
intubation and that he/she will be asleep and kept comfortable until subsequently been shown to be a crude estimate at best, a
the breathing tube can be removed. Mallampati class 4 should raise your suspicion for a difficult
- Inform any family members present, and exclude DNR/DNI status. airway.
- Consent is not required in emergency situations. - Clinical Pearls:
o If difficulty with either bag and mask ventilation or intubation is
Assessment likely, an individual with expertise in airway management
should be called, if available, for assistance.
Airway
- Before intubation, perform an airway assessment.
Preparation
- Patients who exhibit certain characteristics can be both difficult to
ventilate with a bag-mask and/or intubate. Numbers in bold are steps enumerated by the video shown.
- Clinical Pearls:
o Difficult airway assessment must be performed before 1) Position the patient supine in the stretcher
undertaking intubation, especially when using neuromuscular 2) Raise the stretcher so that the patient’s head is at the level of
blocking agents your sternum
o Predicted difficulty with bag and mask ventilation changes the
approach, such that muscle relaxants should be used only
Position the patient
with great care and consideration or avoided altogether
(because of the potential for inability to intubate a patient who - Position the patient so that his head is at the end of the bed. The bed
is paralyzed and sedated) height should be comfortable for the operator
o Failed placement of an endotracheal tube after paralysis results o generally, the patient’s head should be at the level of your
in one of two subsequent scenarios: you can't intubate but sternum.
can ventilate, or you can't intubate and can't ventilate. The - Just before intubation, place the patient into the “sniffing position”
latter is obviously a potentially fatal occurrence. o Flex the neck on the body and extend the head on the neck to
achieve the sniffing position.
o This maneuver aligns the axes of the oral cavity, pharynx, and
Difficult bag-valve-mask ventilation.
larynx and facilitates direct visualization of the glottic
- Use the “MOANS” acronym to outline characteristics that may herald structures.
difficulty with ventilation. - Clinical pearls:
o M: Difficulty with Mask seal (e.g. bearded, abnormal facial o Remember, a difficult airway exam should be performed prior
structure or trauma) to intubation
o O: Obesity (due to redundant upper airway tissue)
o A: Advanced Age
o N: No teeth (poor mask seal results)
o S: Stiffness with ventilation (resistance to ventilation)

Figure 11. Place the patient into the sniffing position and preoxygenate.

3) Prepare the equipment


Figure 10. Mallampati classification a) Gather and check the working status of all the required
equipment before administering sedatives or muscle
- Assess for difficult laryngoscopy and intubation. relaxants.
o Intubation success correlates directly with how visible the vocal 4) Preoxygenate the patient with 100% high-flow O2 for at least 3-
cords are. 4 min to prevent desaturation during the intubation
o Certain patient characteristics result in poor upper airway
geometry, difficult laryngoscopy, poor cord view, and
Preoxygenate the patient
subsequently higher failed intubation rates. These
characteristics include poor mouth opening, large tongue, - If the need for intubation is not immediate, preoxygenate all patients
short mandible, reduced neck mobility, and airway with 100% high flow O2by nonrebreather mask for at least 3 to 4
obstruction. minutes.
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- If the patient does not have effective ventilation to begin with, or the o Occasionally, the application of cricoid pressure may obscure
oxygen saturation does not increase above 90% with supplemental the view of the glottis. In that case, partially or completely
oxygen, use bag and mask ventilation rather than a face mask. release the cricoid pressure.
- Clinical Pearls:
o IF possible, pre-oxygenate the patient without bagging, in order
to limit gastric insufflation and aspiration
o Proper alveolar saturation with 100% oxygen allows a longer
period of safe apnea before desaturation (SaO2<90%) occurs.
In general, if you are able, you should preoxygenate the
patient without bagging (to limit gastric insufflation and
aspiration). If the patient desaturates during the intubation
sequence and an ETT is not in place, stop the attempt and
initiate two-person bag ventilation supported by insertion of an
oral airway.

Figure 13. Instruct an assistant to perform the Sellick maneuver.

Laryngoscopy & Intubation


7) Ensure that the patient is in the sniffing position
8) Hold the laryngoscope with your left hand, regardless of which
hand is dominant.
9) Grip the proximal portion of the handle and the back of the
blade and cradle it between the pads of the fingers and thumb
as you insert it into the patient’s mouth.

Figure 12. Preoxygenation of patient.

5) Ensure monitoring equipment, including BP cuff, cardiac


monitor, and O2 Sat probe are in place and are functional

Sedate and paralyze the patient


- Rapidly acting sedatives coupled with NMBs result in the best
possible intubating conditions by creating a comatose, relaxed state
and allowing the least amount of resistance during laryngoscopy.
- The combination of etomidate or propofol with either succinylcholine
or rocuronium will achieve optimal intubating states in less than 1
minute in nearly all patients.
- Clinical Pearls:
o The use of pharmacologic adjuncts is essential in the vast
majority of endotracheal intubations
Figure 14. Hold the laryngoscope with your left hand and use your right hand to
o The use of sedatives and paralytics (i.e., rapid sequence open the mouth.
induction) is safe and highly successful with few
complications when used in appropriately selected patients. If 10) Open the patient’s mouth with your right hand using the
paralysis is contraindicated, based on the difficult airway scissor technique
assessment, then use lower doses of etomidate and Versed 11) Insert the laryngoscope on the right side of the patient’s
along with fentanyl and/or topical anesthetics to perform tongue and displace the tongue forward and to the left into the
“awake” laryngoscopy (during which the patient maintains mandibular fossa
spontaneous respirations). 12) Advance the laryngoscope and identify the epiglottis

6) Instruct an assistant to perform the Sellick maneuver Insert the laryngoscope blade into the mouth.
- Once the patient is relaxed and in good position, open the mouth
Sellick maneuver using the “scissor” technique with your right hand. Push the upper
- As soon as the paralytic medication is given, an assistant should apply and lower rows of teeth apart with your index finger and thumb. If
direct posterior pressure on the cricoid cartilage (Sellick false teeth are present, remove them.
maneuver) - Gently insert the laryngoscope blade along the right side of the
- This may help prevent aspiration and should be maintained during tongue. Make sure there is neither the lip nor tongue caught
the entire procedure until the endotracheal cuff is up and tube between the blade and the patient’s teeth.
placement is confirmed. - With gentle but firm lifting pressure, displace the tongue forward
- Clinical pearls: and to the left into the mandibular fossa.
- Clinical Pearls:

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o Correct positioning of the blade depends on whether a curved - Occasionally, there is a poor view of the glottic opening and the vocal
or straight blade is used cords cannot be visualized. You may make one attempt to place the
▪ Mackintosh blade: tube just under the very middle of the epiglottis.
• Place the tip of the curved blade into the vallecula - Clinical Pearls:
→ lift anteriorly to expose the vocal cords o Avoid rotating the blade handle backward, because this can
▪ Miller blade: damage both the teeth and structures near the blade tip
• Place the tip of the straight blade under the and does not improve the view of the glottis
epiglottis → lift anteriorly to expose vocal cords o In some cases, you can see the laryngeal inlet on the first
o This maneuver is contraindicated in patients with suspected or attempt without the use of excessive lifting force or external
known cervical trauma manipulation. If this does not occur, confirm that the blade is
midline, then search for identifiable structures.
Visualize the glottis structures. ▪ Are the epiglottis, arytenoid cartilages, or part of the
13) Once the tip of the blade has been correctly positioned, lift the vocal cords seen? If so, you may need to advance the
laryngoscope forward and upwards. laryngoscope, reposition the patient’s head, or apply
14) Direct the force along the axis of the laryngoscope blade, extra lifting force.
aimed at the ceiling over the patient’s feet (Fig. 16). o Having an assistant apply backward, upward, rightward
pressure to the larynx (the “BURP” maneuver) may be useful
if midline structures are identified but cords are not seen.
▪ This pushes the larynx inferiorly and has been shown to
improve laryngoscopic view during most intubations.

15) Once you see the vocal cords, do not take your eyes off the
target.

Figure 15. Displace the tongue to the left.

Figure 18. Insert the ETT into the right side of the mouth, along the laryngoscope
blade.

Insert the endotracheal tube.


16) Instruct another assistant to place the endotracheal tube into
your right hand
17) Introduce the endotracheal tube into the right side of the
patient’s mouth, and along the course of the laryngoscope
Figure 16. Epiglottis as it appears during orotracheal intubation
blade towards the larynx

- Clinical Pearls:
o Do not insert the tube along the midline, because this will
obstruct your view of the glottis

Figure 17. Direct the force along the axis of the laryngoscope blade.

- It may be helpful to have an assistant retract the patient’s right cheek


in order to improve visualization of the glottis

Figure 19. Visualize the tube transverse the chord.


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18) Watch the tube pass through the vocal cords and into the - Clinical Pearls:
trachea. Advance it so that the tip of the tube lays about 4 cm o End-tidal CO2detection may be inaccurate during
distal to the cords cardiopulmonary resuscitation because of impaired
19) Remove the stylet and inflate the endotracheal cuff with air pulmonary gas exchange.

- Clinical Pearls: Troubleshooting


o Use only enough air to prevent air leaks during tidal volume
Poor glottic exposure
respiration
o This usually requires <10 mm of air - If you have difficulty obtaining a view of the cords during direct
o Use of a malleable stylet that is shaped in either a gentle curve laryngoscopy, there are several things that can help.
or straight with a 20- to 30-degree angle proximal to the cuff - Patient position:
(i.e., “hockey-stick”) will facilitate intubation. o Make sure the patient is in the sniffing position, if appropriate.
o Having an assistant pull gently outward on the right cheek may Maintain a neutral position in patients with cervical spine
improve working space and visualization in the oral cavity. precautions.
- Blade choice:
o A curved blade may not be as good as a straight blade in
situations where the epiglottis is large and excessively mobile.
Switching to a straight blade may provide a better view.
- BURP maneuver:
o This maneuver can improve the laryngoscopic view and should
be applied if the initial view is poor. You can also manipulate
the larynx with the right hand during direct laryngoscopy to
determine the best positioning of the larynx for optimal view
(OELM: Optimal External Laryngeal Manipulation).
- Paralysis: Allow adequate time after giving a paralytic to achieve full
relaxation. Premature attempts at laryngoscopy before paralysis can
be difficult or impossible.
o If more than 3 minutes has elapsed and paralysis is
incomplete, then make sure the IV is working and the dose of
paralytic was correct. More medication may be required.
- Release of cricoid pressure may improve the view.

Figure 20. Inflate the balloon with air.


Inability to pass an ETT through the cords
Confirm the placement (Fig. 21) - Obstruction or edema may make passage of an ETT difficult or
impossible despite an adequate view of the vocal cords.
20) Place the end-tidal CO2 detector in-line between the bag-valve
- Try a smaller ETT
mask and the ETT
o If an 8.0 tube does not fit, attempt intubation with a 7.0 tube.
- Make sure a malleable stylet is in the ETT
- Most end-tidal CO2 detectors will change color when exposed to
o This provides shape and stiffness that is helpful in navigating
exhaled carbon dioxide.
mild laryngeal narrowing.
- Auscultate over each lung and assess for symmetrical breath sounds
- Make sure the shape of the stylet is either a gentle curve or straight
- Also auscultate over the epigastrium to assess for gurgling →
with a 20- to 30-degree angle placed proximal to the cuff.
indicates esophageal tube placement.
o Exaggerated angles will make placement of the ETT into a
- Although visualization of tube placement and auscultation are
narrow, straight tube like the trachea more difficult.
important steps in confirmation of ETT placement, the most
accurate way to confirm tracheal tube placement is by end-tidal
POST-PROCEDURE
CO2 detection.
o If lung sounds are heard on the right side but not the left, right Post-procedure Care
main-stem bronchus intubation has likely occurred, and the 21) Secure the tube to the patient with tape/prefabricated
tube should be withdrawn until symmetrical sounds are endotracheal holder
heard. 22) Once the tube is secured, obtain a chest radiograph to evaluate
the depth of tube insertion

Secure the ETT.


- Once the ETT placement is confirmed by end-tidal CO2
measurement and auscultation, secure the tube to the patient.
- A variety of commercially manufactured endotracheal tube holders
are available and should be used preferentially over tape.
- Endotracheal tube tape may be used if an ETT holder is not
available. First secure the tape to the patient’s cheek, then wrap it
circumferentially around the tube, and finally secure it to the other
cheek.
- The tip of the ETT should be positioned in the midtrachea, with the
tip several centimeters above the carina.
- The radiograph may be useful in detecting intubation of a main stem
bronchus or complications of mechanical ventilation, such as
Figure 21. Confirm proper placement with an end-tidal CO2 detector. pneumothorax

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Surgery | Orotracheal Intubation
- Clinical Pearls: Dental, pharyngeal, and airway trauma
o The method of securing the tube will depend upon institutional - The rate of dental and airway trauma is unknown but likely correlates
protocol inversely with experience and directly with intubation difficulty.
- Dental trauma is often seen when backward rotation is placed on the
laryngoscope, resulting in cracking or fracture of the upper incisors
from the proximal part of the blade.
- Pharyngeal and upper airway trauma from the blade tip can occur
during difficult laryngoscopic attempts, when excessive force can
cause blunt trauma, bleeding, cord edema, or pharyngeal
perforation.

Figure 22. Post-intubation chest radiograph.

Further steps

These steps are no longer included in the video.

- Insert a nasogastric or orogastric tube after intubation and place it on


continuous low wall suction.
o Even with a cuffed endotracheal tube in place, aspiration is
possible.
o Although most aspiration pneumonias are from oropharyngeal
(not gastric) secretions, paralyzed patients do not have
esophageal sphincter tone and may have stomach dilatation
resulting in reflux of gastric contents.
- Check arterial blood gases.
o This is not required immediately after intubation but should be
checked within 10 to 15 minutes, and periodically thereafter,
to assess the effectiveness of ventilation.
- Continue sedation and pain control.
o Maintain adequate sedation, pain control, and, if necessary,
paralysis.
o Infusions of Versed and fentanyl are commonly used to
maintain sedation and control pain.

Complications
Unrecognized esophageal intubation
- Intubation of the esophagus, if undetected, results in gastric
insufflation, vagal nerve stimulation with severe bradycardia, and
possibly perforation.
- More importantly, failure to intubate the trachea results in hypoxia,
hypercapnia, and eventually death.
- Esophageal intubation is easily recognized through the routine use of
end-tidal CO2 detectors, pulse oximetry, and auscultation.
- Esophageal intubation should normally be immediately apparent and
corrected. Failure to detect and correct esophageal intubation
constitutes malpractice.

Main-stem intubation
- There are no data to suggest that main-stem intubation is immediately
dangerous, but it should be recognized quickly and corrected.
- Assess for main-stem intubation via auscultation to confirm bilateral
breath sounds and confirm appropriate ETT placement with a
portable chest radiograph.

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