1.09 (Surgery-CK) Orotracheal Intubation
1.09 (Surgery-CK) Orotracheal Intubation
1.09 (Surgery-CK) Orotracheal Intubation
Orotracheal Intubation
ClinicalKey
August 10, 2020
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
1 of 9
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.
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.
3 of 9
Surgery | Orotracheal Intubation
• 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.
Figure 11. Place the patient into the sniffing position and preoxygenate.
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:
6 of 9
Surgery | Orotracheal Intubation
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 18. Insert the ETT into the right side of the mouth, along the laryngoscope
blade.
- 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.
8 of 9
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.
Further steps
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.
9 of 9