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Endotracheal Intubation by Direct Laryngoscopy


Rendell W. Ashton, MD
Christopher M. Burkle, MD

Indications
Inability to oxygenate patient
(SpO2 < 90%, PaO2 < 55)
Inability to ventilate patient
(rising PaCO2, respiratory acidosis, mental status change or other symptoms)
Patient unable to protect the airway

Contraindications
Neck immobility or increased risk of neck trauma (e.g. rheumatoid arthritis, cervical spine injury,
etc.)-consider beroptic intubation (beroptic-endotracheal-intubation-procedure.php)
Inability to open mouth (e.g. trismus, scleroderma, surgical wiring, etc.)-consider nasal intubation,
either blind or beroptic, or surgical airway

Equipment
NOTE: check beforehand to make sure everything works
Patient positioning equipment
Bed or procedure table that can be raised and lowered
Pillows or blankets that can be rolled and placed under patient for optimal positioning
(discussed below)
Monitoring equipment
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Pulse oximeter
Blood pressure gauge
Cardiac monitor
Oxygenation equipment (Slide1.jpg)
Oxygen source and tubing
Face mask
Anesthesia bag or self-inating ambu-bag
Suction catheter with Yankauer tip
Premedication and induction equipment
Intravenous access
Premedication agents (discussed below)
Induction agents (discussed below)
Paralytic agents (discussed below)
Intubation equipment (Slide2.jpg)
Laryngoscope handle and blades of dierent sizes and shapes (remember to check light
bulb on each blade):
Curved blades (e.g. Macintosh blades)
Straight blades (e.g. Miller or Wisconsin blades)
Endotracheal tubes (Slide3.jpg)
Have several dierent sizes available
Remember to check cu for leaks
Means of securing tube in place
Commercial products specically designed for this purpose are recommended
Alternatives include tape or ties
Equipment for verifying tube position after placement
Stethoscope
Carbon dioxide detector or end-tidal CO2 monitor
Esophageal syringe or bulb syringe
Chest x-ray to verify position is also required
Click image to enlarge.

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(cxr1.jpg)

(cxr2.jpg)

Preparation and Anesthesia (Slide8.jpg) ( See rapid sequence timeline


(Slide4.jpg))
Assemble equipment
Calculate doses and draw medications into syringes
Check IV access and ush uid
Do you predict a dicult airway (Slide10.jpg)?
Is the patient unresponsive or near death (Slide9.jpg)?
Position patient (Slide5.jpg)
Bed at comfortable height for laryngoscopist
Patient aligned without lateral deviation of head or neck
Shoulders and/or neck supported with rolls or pillows to allow positioning of head
Neck exed approx. 15 degrees on chest
Head hyperextended on neck to maximum comfortable degree (may be best done after
induction)
Preoxygenate patient 5 minutes on 100% oxygen via mask (straps or person holding in place)
Consider premedications, optional for most patients-usually given 2-3 minutes prior to induction
Defasciculating drug (for patients who will get succinylcholine, but may not tolerate
fasciculation, e.g. elevated intracranial or intraocular pressure)
Succinylcholine 0.15 mg/kg (10% of paralyzing dose)
Vecuronium 0.01 mg/kg (10% of paralyzing dose)
Prevention of vagal response (especially children younger than age 5 often have
bradycardic response to laryngoscopy)
Atropine 0.02 mg/kg
Prevention of worsening intracranial pressure or bronchospasm
Lidocaine 1.5 mg/kg
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Prevention of hypertensive response in patients with elevated intracranial pressure, heart


disease or aneurysm
Fentanyl 3 mcg/kg
Administer a precalculated dose of an induction agent:

Etomidate

Dose

Advantages

Cautions

0.3

Good for low blood

Nausea and vomiting on

mg/kg

pressure; okay in

emergence

hypovolemia
Ketamine

1.5

Good for low blood

Caution in elevated intracranial

mg/kg

pressure, hypovolemia;

pressure or heart disease

good in asthma
Propofol

Thiopental

2 - 2.5

Rapid onset and recovery

Caution if hypovolemic or risk of

mg/kg

hypotension

3-5

Multiple drug interactions; caution

mg/kg

if hypovolemic or risk of
hypotension

Administer a precalculated dose of a paralytic agent

Succinylcholine

Rocuronium

Dose

Characteristics

Cautions

1 - 1.5

Rapid onset,

Contraindicated in hyperkalemia, crush injury,

mg/kg

rapid recovery;

renal failure, extensive burns, elevated

fasciculation

intracranial or intraocular pressure

0.6 -

No

Longer acting-may be problematic if intubation

1.2

fasciculation

attempt fails

mg/kg
Vecuronium

0.08 0.1
mg/kg

Atracurium

0.4 0.5
mg/kg

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FROM THIS POINT UNTIL THE ENDOTRACHEAL TUBE IS VERIFIED AND SECURED, AN ASSISTANT
MUST APPLY PRESSURE TO THE CRICOID CARTILAGE (Slide6.jpg) TO PREVENT ASPIRATION
(SELLICK MANEUVER).

Laryngoscopy technique
Check to verify eect of induction and paralytic agent
Optimize patient position, if needed
With suction available at hand, hold laryngoscope in left hand and endotracheal tube in right
hand
Open the patient's mouth with a right-handed scissor technique
Insert the laryngoscope blade on the right side of the mouth and use it to sweep the tongue to
the left
Advance the blade until landmarks (Slide7.jpg) are recognized-usually the tip of the epiglottis or
the arytenoid cartilages
Lift (not lever) the laryngoscope in the direction of the handle to lift the tongue and posterial
pharyngeal structures out of the line of sight, bringing the glottis into view (Mac or Miller
Technique)
Miller Blade Visualization

Mac Blade Visualization

When the vocal cords or the arytenoid cartilages are clearly seen, advance the tube down the
right side of the mouth, keeping the vocal cords in view until the last possible moment, then
advance the tube through the vocal cords (Mac or Miller Technique).
Mac Blade Intubation

Miller Blade Intubation

Insert the tube to 23 cm (at incisors) in men and 21 cm in women, then inate the cu
Attach bag ventilator to tube and verify tube position immediately
Listen for breath sounds over epigastrium (one breath), then to each hemithorax in the
midaxillary line (one breath on each side)
Attach CO2 detector to tube or use end-tidal CO2 monitor to verify return of carbon dioxide
with each breath
Use esophageal syringe or bulb syringe to verify tube is in noncollapsing trachea (cautionthis technique may be falsely negative if tube is in esophagus and stomach is full of air)
Secure tube in position and request chest x-ray to conrm position.
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Ensure proper attachment to mechanical ventilator and review ventilator settings.


Consider ongoing sedation, particularly if induction agent may wear o before paralytic agent.

Complications
Can't intubate, but can ventilate with mask (Slide10.jpg) -- continue mask ventilation until more
experienced laryngoscopist arrives, defer intubation or consider alternative technique, such as
beroptic intubation.
Can't intubate, can't ventilate -- see " failed airway (Slide11.jpg)" algorithm.
Aspiration-avoidable if Sellick maneuver done properly and maintained throughout procedure.
Trauma from laryngoscope
Teeth-avoidable with proper laryngoscopy technique.
Soft tissues (bleeding)-usually avoidable with proper laryngoscopy technique.
Edema-usually due to repeated attempts at laryngoscopy; key is to optimize something with
each new attempt, not simply repeat procedure without addressing a possible reason for
failure.
Equipment failure-have backup equipment nearby and verify that everything works beforehand.

Quiz Questions
1. Which of the following techniques is most reliable to insure that the endotracheal tube has
been properly placed?
visualizing the ETT passing through the vocal cords
CO2 return
bilateral breath sounds
chest rise
None of the above
2. Preoxygenation prior to rapid sequence induction is considered adequate when:
the patient's oxygen saturation is greater than 90%
the patient displays no clinical signs of hypoxemia
the patient has been breathing 100% oxygen for at least 5 minutes
Routine ECG

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AmericanThoracicSocietyEndotrachealIntubationbyDirectLaryngoscopy

the patient's saturation is 100%


3. The larygoscope blade is used to:
sweep the tongue from left to right
A compress the midline of the tongue
sweep the tongue from right to left
knock the teeth out of your eld of vision
4. As compared to a straight blade, a curved blade may:
allow you to sweep a large tongue out of the way more easily
allow you pick up a large, oppy epiglottis more easily
be more dicult to tolerate for a conscious or semi-conscious patient
cause more damage to the teeth

Get Score

Start Over

Prepared by:
Rendell W. Ashton, MD

Mayo Clinic, Rochester, MN

May 2004

Reviewed by:
Christopher M. Burkle, MD

Mayo Clinic, Rochester, MN

May 2004

References
1. Hagberg, CA. Handbook of Dicult Airway Management. Churchill Livingstone. New York. 2000.
2. Benumof, JL. Airway Management Principles and Practice. Mosby. St Louis. 1996

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