SUBJECT:- ADVANCE NURSING PRACTICE

PROCEDURE ON ENDOTRACHEAL INTUBATION

SUBMITTED TO:- SUBMITTED BY:-

SINGNATURE OF EVALUATOR:-
ENDOTRACHEAL TUBE INTUBATION
Endotracheal intubation is the placement of a tube into the trachea
(windpipe) in order to maintain an open airway in patients, who are
unconscious or unable to breathe on their own. Oxygen, anesthetics or
other gaseous medications can be delivered through the tube. Nurses
assist in passing of a slender hollow tube, endotracheal tube into the
trachea through nose or mouth using aseptic technique to facilitate
artificial ventilation and resuscitation.
PURPOSES
➢ To treat acute respiratory failure, persistent hypoxemia and
persistent rise in PCO2.
➢ To maintain patent airway.
➢ To ensure adequate oxygenation.
➢ To provide ventilatory assistance when indicated.
INDICATIONS
1. CNS depression
2. Neuromuscular disease
3. Chest wall injury
4. Upper airway obstruction.
5. Aspiration prophylaxis.
6. Fracture of cervical vertebrae and spinal cord injury.
7. Respiratory arrest.
8. Respiratory failure.
9. Need for prolonged ventilatory support.
10. Class III or IV hemorrhage with poor perfusion.
11. Severe flail chest or pulmonary contusion.
12. Multiple traumas, head injury and abnormal mental status.
13. Inhalation injury with erythemal edema of the vocal cords.
 14. Protection from aspiration.
15. Anticipated upper airway obstruction (edema, soft tissue
swelling due to head and neck trauma. Postoperative head and
neck surgeries, decreased level of consciousness).
COMPLICATIONS
• Laryngeal/tracheal injury.
• Pulmonary infection and sepsis.
• Dependence on artificial airway.
DESCRIPTION
To begin the procedure, an anesthesiologist or physician opens the
patient's mouth by separating the lips and pulling on the upper jaw with
the index finger. Holding a laryngoscope in the left hand, he or she
inserts it into the mouth of the patient with the blade directed to the
right tonsil. Once the right tonsil is reached, the laryngoscope is swept
to the midline, keeping the tongue on the left to bring the epiglottis into
view. The laryngoscope blade is then advanced until it reaches the angle
between the base of the tongue and the epiglottis. Next, the
laryngoscope is lifted upwards towards the chest and away from the
nose to bring the vocal cords into view. Often an assistant, nurse has to
press on the trachea to provide a direct view of the larynx. The
anesthesiologist or physician then takes the endotracheal tube, made of
flexible plastic, in the right hand and starts inserting it through the
mouth opening. The tube is inserted through the cords to the point so
that the cut may rest just below the cords. Finally, the cuff is inflated to
provide a minimal leak, when the bag is squeezed. Using a stethoscope,
the anesthesiologist listens for breathing sounds to ensure the correct
placement of the tube.
ARTICLES
 ✓ Towel roll.
✓ Suction apparatus with tubing
✓ Suction catheter
✓ AMBU bag and mask.
✓ Oxygen source and tubing.
✓ Laryngoscope with appropriate size blade.
✓ Magill's forceps.
✓ Endotracheal tubes of appropriate size
✓ Stilette.
✓ Xylocaine gel.
✓ Disposable syringe 10 ml.
✓ Cotton tape/Dynaplast.
✓ Sterile gloves.
✓ Facemask.
PREPARATION
For endotracheal intubation, the patient is placed lying on the back with
a pillow under the head. The anesthesiologist or physician wears gloves,
a gown and goggles.
STEPS FOR PROCEDURE
1. Step I: Check the equipment laryngoscope, curved (Macintosh type)
and straight (Miller type) blades of an appropriate size for the patient
and assure that the light works, check ETT cuff for leaks).
2. Step II: Assemble all materials close at hand (laryngoscope handle,
blades, assorted ET tube sizes, 10 ml syringe, water-soluble lubricant,
securing device, BVM, suction equipment, stethoscope).
3. Step III —Position of the Patient; unless contraindicated-i.e. trauma,
elevating the patient's head about 10 cm with pads under the occiput
and extension of the head into the sniffing position serves to align the
oral, pharyngeal and laryngeal axis, so that the passage from the lips to
the glottic opening may be almost a straight line. This position permits
better visualization of the glottis and vocal cords and allows easier
passage of the endotracheal tube.
NURSES PROCEDURE WHILE ASSISTING ENDOTRACHEAL INTUBATION
1. Explain procedure to the patient if conscious and get consent from
patient and relatives.
2. Place patient in supine position with head extended by keeping
towel roll under neck.
3. Check for loose teeth/dentures or foreign body in throat, if so,
remove with Magill's forceps.
4. Seal mouth and nose with mask and Ambu bag and initiate
bagging with oxygen.
5. Provide laryngoscope to doctor.
6. Suction oral cavity.
7. Provide lubricated endotracheal tube with stilette in situ.
8. Press cricothyroid cartilage with thumb and index finger against
esophagus.
9. Assist while endotracheal tube is introduced into trachea and
remove stilette. The tube when inserted should have the 22 cm
marking at the incisor teeth
10. Verify placement of tube by auscultation, listening/feeling
for airflow through tube and observe for bilateral chest
movements.
11. Connect AMBU bag with oxygen attached to endotracheal
tube and continue bagging.
12. Inflate cuff of the endotracheal tube with 10 ml of air.
13. Insert an oral airway and apply endotracheal suctioning if
necessary.
 14. Fix endotracheal tube in position by using adhesive tape.
Tube should be fixed at the midline to prevent pressure ulcer at
the angle of mouth.
15. Connect to ventilator if needed.
POSTPROCEDURAL CARE
1. Place patient in lateral position.
2. Arrange for chest X-ray to be taken in order to check placement of
ET tube.
3. Apply endotracheal suctioning if secretions are present.
4. Watch for chest movements, ET tube kinking, obstruction with
secretion and blood, leakage of tube cuff, change in position of
tube and over inflation of cuff.
5. Document type and size of tube used, chest movements, vital
signs and patient's tolerance of procedure.
6. Check ABGs periodically.
RISKS
Complications may include edema; bleeding: tracheal and esophageal
perforation: pneumothorax (collapsed lung); and aspiration. The patient
should be advised of the potential signs and symptoms associated with
life-threatening complications of airway problems. These signs and
symptoms include, but are not limited to sore throat, pain or swelling of
the face and neck, chest pain, subcutaneous emphysema and difficulty
in swallowing.
NORMAL RESULTS
The endotracheal tube inserted during the procedure maintains an
open passage through the upper airway and allows air to pass freely to
and from the lungs in order to ventilate them.