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ENDOTRACHEAL INTUBATION

DEFINITION The insertion of a tube into the trachea to allow air to enter the lungs.
INDICATIONS:
Cardiopulmonary Arrest
Patient in deep coma or unresponsive
Shallow or slow respirations (less than 8 per minute)
Progressive cyanosis
Gastric lavage / gavage
Surgical patients where body positioning or facial contours preclude the use of a mask
To prevent loss of airway at a later time, i.e. a burn patient who inhales hot gases may
be intubated initially to prevent his airway from swelling shut
ADVANTAGES:
a. Provides an unobstructed airway when properly placed
b. Prevents aspiration of secretions (blood, mucous, stomach / bowel contents) into the
lungs
c. Can be easily maintained for a lengthy period of time
d. Decreases anatomic dead space by approximately 50%
e. Facilitates positive pressure breathing without gastric inflation
f. Facilitates body positioning and movement of the patient
g. May be utilized to pass medications like Narcan, Atropine, Epinephrine ,Lidocaine .
DISADVANTAGES:
o Need advanced training to properly perform procedure

o Bypasses the nares function of warming and filtering the air


o Increased incidence of trauma due to neck manipulation when spinal cord injury is
suspected
o May increase respiratory resistance
o Improper placement
REQUIRED EQUIPMENT:
1. Endotracheal tube
a. Size of tube is dependent on size of patient
b. 7.5 mm is the Universally Accepted size for an unknown victim
c. Men are usually larger, therefore an 8.0 mm tube may be appropriate
d. Females are usually smaller, therefore a 7.0 mm tube may be appropriate
2. 10 cc Syringe used to fill the cuff at the end of the endotracheal tube
3. Stylet a wire inserted into the endotracheal tube in order to stiffen it during passage
4. Water soluble lubrication KY Jelly or Surgilube
5. Stethoscope to check for proper placement of the endotracheal tube
6. Laryngoscope handle
7. Laryngoscope blade
8. Straight blade
9. Curved blade
10. Oropharyngeal airway (bite block) to prevent the patient from biting down on the
endotracheal tube
11. Tape to secure the endotracheal tube in place
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12. Gloves
13. Ambu-bag to facilitate positive pressure ventilations
14. Suction Device to clear the airway of debris (blood, mucous, saliva)
FARMOLA FOR ENDOTRACHEAL TUBE INSERTION:
Predicted Size uncuffed tube = (age/4)+4
Predicted Size cuffed tube= (age/4) +3
Internal diameter of tube (mm) = (patient age in years/4) + 6
Depth of insertion (cm) =12+(patient age in years/2)
Patient preparation Administer medication as ordered to decrease respiratory secretions, induce amnesia
analgesia and help calm and relax conscious patient.
Remove dentures if present.
Administer oxygen until tube is inserted to prevent hypoxia.
Place patient supine in sniffing position so that his mouth, pharynx and trachea are
extended.
Put on gloves.
For oral intubation spray local anaesthetic deep into patient posterior pharynx to
diminish gag reflex and reduce patients discomfort.
If necessary suction patients pharynx just before tube insertion
Time each intubation attempt, limiting attempts to less than 30 seconds.
Stand at head of patients bed. Using your right hand hold patients mouth open by
crossing your index finger, hold patients mouth open by crossing your index finger
over your thumb on patients upper teeth and your index finger on his lower teeth.

Grasp the laryngoscope handle in your left hand and gently slide the blade into right
side of patients mouth.
Center the blade and push the patients tongue to left. Hold patients lower lip away
from his teeth to prevent lip from being traumatized.
Advance the blade to expose epiglottis.
Lift laryngoscope handle upward and away from your body at a 45-degree angle to
reveal vocal cords.
If desired, have an assistant apply pressure to cricoid cartilage to occlude esophagus
and minimize gastric regurgitation.
When performing an oral intubation, insert ET tube into right side of patients mouth.
When performing a nasotracheal intubation, insert ET tube through nostril and into
pharynx.
Guide tube into vertical openings of larynx between the vocal cords .If vocal cords are
closed because of spasm wait a few seconds them to relax and then gently guide tube
past them to avoid traumatic injury.
Advance tube until cuff disappears beyond the vocal cords
Holding the ET tube in place, quickly remove stillet if present.
Blind nasotracheal intubation
Pass the ET tube along the floor of nasal cavity. If necessary use gentle force to pass
tube through nasopharynx and into the pharynx.
Listen and feel for air movement through tube as it is advanced to ensure that tube is
properly placed in airway.
Slip the tube between vocal cords when patient inhales
Once the tube is past the vocal cords, the breath sounds become louder. If at any time
during advancement breath sounds disappear, withdraw the tube until they reappear.

After intubation Inflate tubes cuff with 5-10 cc of air until you feel resistance.
Remove the laryngoscope.if patient was intubated orally,insert an oral airway to
prevent patient from obstructing airflow or puncturing tube with his teeth.
To ensure correct tube placement observe for chest expansion and auscultate for
bilateral breath sounds feel tubes tip for warm exhalations and listen for air
movement.
If you dont hear any breath sounds, auscultate over stomach while ventilating with
resuscitation bag. If you dont hear any breath sounds auscultate over stomach while
ventilating with resuscitation bag. Stomach distension, belching or gurgling sound
indicates esophageal intubation. Immediately deflate cuff and remove the tube.
Auscultate bilaterally to exclude possibility of endotracheal intubation.
Once you have confirmed correct tube placement administer oxygen or initiate
mechanical ventilation. And suction if indicated.
To secure tube position applies benzoin tincture to each cheek and let it dry for
enhanced tape adhesion.
Inflate the cuff with minimal leak technique or minimal occlusive volume technique.
Clearly note centimetre marking on tube at point where tube exits patients mouth or
nose.
Make sure that chest X ray is taken to verify tube position.
Place patient on his side with his head in a comfortable position to avoid tube kinking.
Auscultate both sides of chest and watch chest movement as indicated by patient
condition
Give frequent oral care to orally intubated patient position ET tube
Suction secretions through ET tube to clear secretions and prevent mucus plugs from
obstructing tube.
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COMPLICATIONS Apnea
Aspiration of blood, secretions or gastric contents
Bronchospasm
Injury to lips,mouth, pharynx or vocal cords
Laryngeal edema and erosion
Tooth damage or loss
Tracheal stenosis, erosion and necrosis
CONTRAINDICATIONS: Obstruction of the upper airway due to foreign objects
Cervical fractures
The following conditions require caution before attempting to intubate:
Esophageal disease
Ingestion of caustic substances
Mandibular fractures
Laryngeal edema
Thermal or chemical burns
NURSING CONSIDERATIONS
Maintain exact tube placement and tube must be well secured to avid kinking and
prevent bronchial obstruction and accidental extubation.
Use the minimal leak technique to avoid tracheal erosion and necrosis.
Always record volume of air needed to inflate cuff
-gradual increase in volume indicates tracheal dilatation or erosion
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-sudden increase in volume indicates rupture of cuff and requires immediate


reintubation.
Once the cuff has been inflated, measure its pressure at least every 8 hours to avoid
overinflation (normal cuff pressure is about 18 mmHg)
Record date and time of procedure, its indications and success or failure. Tube type
and size, cuff size, amount of inflation, initation of supplemental oxygen or ventilator
therapy and results of chest x ray
Record any complications and nursing action taken.
Note patient reaction to procedure

BIBLIOGRAPHY
Brunner and suddarth ,Textbook of medical Surgical Nursing. Edition 10th . Page No985-987
Lewis Heitkemper.Medical Surgical Nursing.Assessment &management of clinical
problems.7th Edition.Page No.-1750-1752
Cathy goldberg, Peter Johnson handbook of clinical skills:edition 7th ;page no-299-306
http://www.brooksidepress.org

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