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ENDOTRACHEAL INTUBATION

ENDOTRACHEAL INTUBATION. Indication for endotracheal intubation. 1) For supporting ventilation in patient with some pathologic disease. : U pper airway obstruction. : R espiratory failure. : L oss of conciousness. Indication for endotracheal intubation (con’t).

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ENDOTRACHEAL INTUBATION

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  1. ENDOTRACHEAL INTUBATION

  2. Indication for endotracheal intubation 1) For supporting ventilation in patient with some pathologic disease : Upper airway obstruction : Respiratory failure : Loss of conciousness

  3. Indication for endotracheal intubation (con’t) • 2) For supporting ventilation during general anesthesia • Type of surgery : Operative site near the airway : Abdominal or thoracic surgery

  4. Indication for endotracheal intubation (con’t) : Prone or lateral position : Long period of surgery • Patient has risk of pulmonary aspiration • Difficult mask ventilation

  5. ANATOMY OF AIRWAY

  6. AIRWAY ASSESSMENTS • 1) Condition that associated with difficult intubation • : Congenital anomalies ---> Pierre Robin syndrome , Down’s syndrome • : Infection in airway--> Retropharyngeal abscess, Epiglottitis • : Tumor in oral cavity or larynx

  7. AIRWAY ASSESSMENT • 1) Condition that associated with difficult intubation (con’t) • : Enlarge thyroid gland • trachea shift to lateral or compressed tracheal lumen

  8. AIRWAY ASSESSMENT 1) Condition that associated with difficult intubation (con’t) • : Maxillofacial ,cervical or laryngeal trauma • : Temperomandibular joint dysfunction • : Burn scar at face and neck • : Morbidly obese or pregnancy

  9. AIRWAY ASSESSMENT • 2) Interincisor gap : normal -> more than 3 cms

  10. Soft palate Uvula AIRWAY ASSESSMENT • 3) Mallampati classification: Class 3,4 -> may be difficult intubation

  11. AIRWAY ASSESSMENT Laryngoscopic view grade 3,4 -> risk for difficult intubation

  12. AIRWAY ASSESSMENT • 4) Thyromental distance : more than 6 cms

  13. AIRWAY ASSESSMENT • 5) Flexion and extension of neck

  14. AIRWAY ASSESSMENT • 6) Movement of temperomandibular joint (TMJ) Grinding

  15. Equipment preparation

  16. 1) Laryngoscope : handle and blade

  17. Miller blade Macintosh blade LARYNGOSCOPIC BLADE • Macintosh (curved) and Miller (straight) blade • Adult : Macintosh blade, small children : Miller blade

  18. 2) Endotracheal tube

  19. Endotracheal tube • 1) Size of endotracheal tube : internal diameter (ID) • Male: ID 8.0 mms . Female : ID 7.5 mms • New born - 3 months : ID 3.0 mms • 3-9 months : ID 3.5 mms • 9-18 months : ID 4.0 mms • 2- 6 yrs : ID = (Age/3) + 3.5 • > 6 yrs : ID = (Age/4) + 4.5

  20. High volume Low pressure cuff Low volume High pressure cuff • 2) Material : Red rubber or PVC • 3) Endotracheal tube cuff

  21. 4) Bevel • 5) Murphy’s eye

  22. 6) Depth of endotracheal tube : Midtrachea or below vocal cord ~ 2 cms • Adult -> Male = 23 cms ,Female = 21 cms • Children • Oral endotracheal tube = (Age/2) + 12 (cm) • Nasal endotracheal tube = (Age/2) + 15 (cm)

  23. 7) Tube markings • Z-79 • Disposible (Do not reuse) • Oral/ Nasal • Radiopaque marker

  24. 3) Other equipments 3.1 Stylet

  25. Oral airway Nasal airway • 3.2 Oropharyngeal or nasopharyngeal airway

  26. 3.3) Suction catheter • 3.4) Slip joint

  27. 3.5) Face mask and self inflating bag • 3.6) Magill forcep

  28. Syringe Lubricating jelly Plaster for strap endotracheal tube Monitoring success of endotracheal intubation Stethoscope Endtidal - CO2 Pulse oximeter

  29. Sniffing position Flexion at lower cervical spine Extension at atlanto-occipital joint

  30. Sniffing position

  31. Steps of oroendotracheal intubation

  32. Steps of oroendotracheal intubation

  33. Steps of oroendotracheal intubation

  34. Steps of oroendotracheal intubation

  35. Steps of oroendotracheal intubation

  36. Nasoendotracheal intubation

  37. Nasoendotracheal intubation • Advantage • 1) Comfortable for prolong intubation in postoperative period • 2) Suitable for oral surgery : tonsillectomy , mandible surgery • 3) For blind nasal intubation • 4) Can take oral feeding • 5) Resist for kinking and difficult to accidental extubation

  38. Disadvantage • 1) Trauma to nasal mucosa • 2) Risk for sinusitis in prolong intubation • 3) Risk for bacteremia • 4) Smaller diameter than oral route -> difficult for suction

  39. Contraindication for nasoendotracheal intubation • 1) Fracture base of skull • 2) Coagulopathy • 3) Nasal cavity obstruction • 4) Retropharyngeal abscess

  40. Complication of endotracheal intubation • 1) During intubation • : Trauma to lip, tongue or teeth • : Hypertension and tachycardia or arrhythmia • : Pulmonary aspiration • : Laryngospasm • : Bronchospasm

  41. Complication of endotracheal intubation (Con’t) • 1) During intubation • : Laryngeal edema • :Arytenoid dislocation -> hoarseness • : Increased intracranial pressure • : Spinal cord trauma in cervical spine injury • : Esophageal intubation

  42. Complication of endotracheal intubation(Con’t) 2) During remained intubation : Obstruction from klinking , secretion or overinflation of cuff : Accidental extubation or endobronchial intubation : Disconnection from breathing circuit

  43. Complication of endotracheal intubation(Con’t) • 2) During remained intubation • : Pulmonary aspiration • : Lib or nasal ulcer in case with prolong period of intubation • : Sinusitis or otitis in case with prolong nasoendotracheal intubation

  44. Complication of endotracheal intubation(Con’t) • 3) During extubation • Laryngospasm • Pulmonary aspiration • Edema of upper airway

  45. Complication of endotracheal intubation(Con’t) 4) After extubation • Sore throat • Hoarseness • Tracheal stenosis (Prolong intubation) • Laryngeal granuloma

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