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Endotracheal Intubation

Endotracheal Intubation. Birth. Term Gestation? Clear of Meconium? Breathing or crying? Good Muscle Tone?. Routine Care Provide warmth Clear Airway if needed Dry Assess color. Yes. No. 30 seconds. Provide warmth Position clear airway  (as necessary) Dry, stimulate, reposition.

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Endotracheal Intubation

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  1. Endotracheal Intubation

  2. Birth • Term Gestation? • Clear of Meconium? • Breathing or crying? • Good Muscle Tone? • Routine Care • Provide warmth • Clear Airway if needed • Dry • Assess color Yes No 30 seconds • Provide warmth • Position clear airway • (as necessary) • Dry, stimulate, reposition Evaluate Resp, HR and Color Observational Care Breathing, HR>100, Pink Breathing, HR>100, Cyanotic Pink Give Supplementary Oxygen 30 seconds 30 seconds HR < 100 Apnea Persistent cyanosis • Provide positive pressure ventilation  Ventilating HR < 60 HR > 60 Post resuscitation Care HR > 100 & Pink • Provide positive pressure ventilation  • Administer Chest Compressions HR < 60  Endotracheal intubation may be considered at several steps Medications, continue PPV, CC

  3. Endotracheal Intubation • Indications • How to select and prepare equipment needed • How to use laryngoscope • How to determine tube is in trachea • How to use ET tube to suction trachea • How to use ET tube to administer PPV

  4. Indications • Prolonged PPV required • Bag & mask ineffective: Inadequate chest expansion • If chest compressions required: Intubation may facilitate coordination and efficiency of ventilation • Tracheal suction required : e.g. MSAF • Diaphragmatic Hernia • Use of Drugs through ET tube

  5. Prerequisites for Intubation • Pre oxygenate before intubation PPV with 100% oxygen • Deliver Free Flow oxygen during intubation • Not more than 20 sec per attempt : Not more than 3 attempts • Ventilate with Bag and mask with 100% oxygen in between attempts

  6. Equipment Required

  7. Type of Endotracheal Tubes

  8. Characteristics of Endotracheal Tubes

  9. 2.2cm 2.4cm 2.6cm 2.8cm Length of Trachea : PT = 3 cm, FT = 5-6cm Characteristics of Endotracheal Tubes

  10. Characteristics of Endotracheal Tubes

  11. Characteristics of Endotracheal Tubes

  12. Size of ET tube Tube size Weight Gestational ( ID -mm) (gms) Age 2.5 <1000 < 28 wks 3.0 1000-2000 28-34 3.5 2000-3000 34-38 4.0 > 3000 >38

  13. Suction Catheter Size for ET tube of Various inner diameter Endotracheal Catheter Tube Size Size 2.5 5 F or 6 F 3.0 6 F or 8 F 3.5 8 F 4.0 8 F or 10 F

  14. Anatomy you need to know before inserting tube

  15. Sagittal Section of Airway with Laryngoscope in place

  16. Sagittal Section of Airway with Laryngoscope in place

  17. Vallecula Epiglottis Glottis Vocal cords Esophagus Anatomy

  18. Position Neck Slightly Extended

  19. Position Neck Hyperextended

  20. Position Neck Flexed

  21. How to Hold Laryngoscope

  22. Before Starting to Intubate

  23. Preparing to insert the Laryngoscope

  24. Landmarks for Placement of Laryngoscope

  25. Landmarks for Placement of Laryngoscope

  26. Technique to Lift the Laryngoscope to expose Larynx

  27. Improving Visualization

  28. Suctioning of Secretions

  29. Insertion of ET tube • Insert ET tube holding in the right hand • Introduce through the right angle of the mouth • Keep glottis in view • Insert when vocal cords are apart • Do not push through vocal cords • If cords are together wait, if do not open within 20 sec stop and ventilate with Bag & mask

  30. Insertion of ET tube

  31. Insertion of ET tube

  32. Stabilizing ET tube while Laryngoscope is withdrawn

  33. Removing of Stylet

  34. Insertion of ET tube

  35. ET Suctioning

  36. Check Placement

  37. Check Placementwith CO2 Detector • Two types of CO2 Detectors: • Colorimetric: Change Color • Capnographs • Babies with poor cardiac output may exhale insufficient CO2

  38. What Can go Wrong

  39. What Can go Wrong

  40. What Can go Wrong

  41. What Can go Wrong

  42. What Can go Wrong

  43. What Can go Wrong

  44. What Can go Wrong

  45. What Can go Wrong

  46. Signs of ET Tube in Esophagus • Poor response to intubation (cyanosis, bradycardia etc • CO2 detector fails to show presence of Expired CO2 • No audible breath sounds • Air heard entering stomach • Gastric distension may be seen • No Mist in tube • Poor chest movements

  47. ET Tube Too Far in Trachea • Heart rate or color shows no improvement • Breath sounds heard over right and not on left side of chest • Breath sounds are louder on right side of chest than on left side

  48. How to know Tip of tube is in right location Tip to Lip Distance * Babies weighing less than 750 gms may require only 6 cm insertion

  49. 15 mm Connector Inflation Line Airway Tube Cuff Inflation Pilot Balloon Valve Aperture Bar Alternatives to ET Intubation Laryngeal Mask Airway (LMA)

  50. Laryngeal Mask Airway (LMA) • Airway device: can be used to provide PPV • The size-1 Neonatal Device • Elliptical mask with inflatabale rim • Flexible airway tube • Inserted into baby’s mouth with index finger • Guided along hard palate till it reaches esophagus • The rim is inflated • Pilot balloon to monitor mask’s inflation

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