Basic Airway Management & Endotracheal Intubation

(Note: Rapid sequence and use of pharmacologic adjuncts for intubation are not specifically covered in this section)

Indications:

1.       Treatment of symptomatic hypercapnia.

2.       Treatment of symptomatic hypoxemia.

3.       Airway protection against aspiration.                                   

4.       Pulmonary toilet.                

Contraindications:

1.       Awake patient.

2.       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.

 

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.
• Heimlich maneuver as needed.
• Use artificial airways if needed: oropharyngeal, nasopharyngeal.  (See Figure 1)
• 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.                                                                                                 

                                                                                                                                                                                               

 

 

 

 

 

 

 

Complications: Prevention and Management

 

Complication:	Prevention:	Management:
Missing/broken teeth:	Remove loose teeth prior; avoid using upper teeth as fulcrum for laryngoscope blade.	Check chest x-ray to rule out aspiration.
Clenched teeth:		Paralytic medication.
Air leak:	Check cuff prior to beginning procedure.	Inject more air or change tube over guide wire.
Inability to visualize vocal cords:	Proper patient positioning, proper laryngoscope blade size, proper suctioning.	Reposition, choose a different blade, adequate suction, cricoid pressure by assistant.
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.

 

 

Documentation:

Procedure note describes indications, equipment and technique, number of attempts and how placement was confirmed, as well as complications and their management.

 

Items for Evaluation:

• Understands indication.
• Appropriate preparation and pretreatment.
• Successful airway management.
• Understands and manages complications.
• Proper documentation in the medical record.