Don Hudson, D.O.

, FACEP, ACOEP


Advanced Airway
Management & Intubation
The Difference Between
Life and Death
Topics For Discussion
Basic anatomy and
physiology.
Advantages of
endotracheal intubation.
Indications of intubation.
Contraindications of
intubation.
Complications of
intubation.
Equipment required for
intubation.
Technique of
endotracheal intubation.
Rules of endotracheal
intubation.
Tube sizes.
Rules and principals of
suctioning.
Other airway adjuncts.
Conclusion.
Difficult intubations.


Anatomy and Physiology
The airways can be divided in to parts namely:
The upper airway.
The lower airway.
The Upper Airway
The Lower Airway
Advantages of Endotracheal
Intubation
Cuffed E.T tubes protect the airway from
aspiration.
E.T tube provides access to the
tracheobronchial tree for suctioning of
secretions.
E.T tube does not cause gastric distention and
associated danger of regurgitation.
E.T tube maintains a patent airway and assists
in avoiding further obstruction.
E.T tube enables delivery of aerosolized
medication.
Indications for Intubation
Inadequate oxygenation(decreased arterial
PO2) that is not corrected by supplemental
oxygen via mask/nasal.
Inadequate ventilation (increased arterial
PCO2).
Need to control and remove pulmonary
secretions.
Any patient in cardiac arrest.
Indications for Intubation
Ant patient in deep coma who cannot protect his
airway.(Gag reflex absent.).
Any patient in imminent danger of upper airway
obstruction (e.g. Burns of the upper airways).
Any patient with decreased L.O.C, GCS <= 8.
Severe head and facial injuries with
compromised airway.
Indications Cont
Any patient in respiratory arrest
Respiratory failure
1. Hypoventilation/Hypercarbia
A. Paco2 > 55mmhg
2. Arterial hypoxemia
refractory to O2
A. Paco2 < 70 on 100% O2

Contraindications for Intubation
Patients with an intact gag reflex.
Patients likely to react with laryngospasm
to an intubation attempt. e.g. Children
with epiglottitis.
Basilar skull fracture avoid naso-tracheal
intubation and nasogastric/pharyngeal
tube.
Complications Associated With
Intubation
Trauma of the teeth, cords, arytenoid cartilages, larynx
and related structures.
Nasotracheal tubes can damage the turbinates, cause
epistaxis, and even perforate the nasopharyngeal
mucosa.
Hypertension and tachycardia can occur from the
intense stimulation of intubation; This is potentially
dangerous in the patient with coronary heart disease.
Transient cardiac arrhythmias related to vagal
stimulation or sympathetic nerve traffic may occur .
Complications Continued
Damage to the endotracheal tube cuff, resulting
in a cuff leak and poor seal.
Intubation of the esophagus, resulting in gastric
distention and regurgitation upon attempting
ventilation.
Baro-trauma resulting from over ventilating with
a bag without a pressure release valve(
phneumothorax).
Complications Continued
Over stimulation of the larynx resulting in
laryngospasm, causing a complete airway
obstruction.
Inserting the tube to deep resulting in unilateral
intubation (right bronchus).
Tube obstruction due to foreign material, dried
respiratory secretion and/or blood.
Equipment Required for
Successful Intubation
Equipment Cont
Laryngoscope with relevant size blades.
Magill forceps.
Flexible introducer.
10-20 ml syringe.
Oropharangeal airways all sizes.
Tape or adhesive plaster.
E.T tubes relevant sizes.
Bag-valve-mask with oxygen connected.
Suction unit with Yankauer nozzle and endotracheal
suction catheter.



Technique of Endotracheal
Intubation (in a ideal setting)
Technique Cont
Position the patient supine, open the airway with
a head-tilt chin-lift maneuver.(Suspected spinal
injury, attempt naso-tracheal intubation, spine in
neutral position.).
Open mouth by separating the lips and pulling
on upper jaw with the index finger.
Hold laryngoscope in left hand, insert scope into
mouth with blade directed to right tonsil.
Once right tonsil is reached, sweep the blade to
the midline keeping the tongue on the left.

Technique Cont
This brings the epiglottis into view. DO NOT LOOSE
SIGHT OF IT!
Advance the blade until it reaches the angle between the
base of the tongue and epiglottis.( volecular space)
Lift the laryngoscope upwards and away from the nose
towards the chest. This should bring the vocal cords into
view. It may be necessary for a colleague to press on
the trachea to improve the view of the larynx.
Place the ETT in the right hand. Keep the concavity of
the tube facing the right side of the mouth.
Insert the tube watching it enter through the cords.
Technique Cont
Insert the tube just so the cuff has passed the
cords and then inflate the cuff.
Listed for air entry at both apices and both
axillae to ensure correct placement using a
stethoscope.




Rules of Intubation
Always have a suction unit available.
An intubation attempt should never exceed
30 seconds.
Oxygenate the patient pre and post
intubation with a bag-valve-mask.(100% O2).
Have sedative medication available if
needed. (e.g. Midazolam 15mg/3ml)
Always recheck tube placement manually
guided by oxygen saturation
readings.(Spo2).
Tube sizes
Newborn to 4 kg - 2.5 mm (uncuffed).
1-6 months 4-6 kg 3.5 mm (uncuffed).
7-12 months 6-9 kg 4.0 mm (uncuffed).
1 year 9 kg 4.5 mm (uncuffed).
2 years 11 kg 5.0 mm (uncuffed).
3-4 years 1416 kg - 5.5 mm (uncuffed).
5-6 years 1821 kg 6.0 mm (uncuffed).
7-8 years 22-27 kg 6.5 mm ( uncuffed).
Tube Sizes
9-11 years 28-36 kg 7.0 mm(cuffed).
14 to adults 46+ kg 7.0 80 mm (cuffed).
Adult female 7.0 8.0mm (cuffed).
Adult male 7.5 8.5 mm (cuffed).
The size of the tube may also be determined by
the size of the patients little finger.
N.B patients below the age of 8 require uncuffed
ETT due to damage caused by the cuff in
younger patients. Always monitor the ECG
activity during intubation.
4 Rules of Suctioning
Never suction further than you can see.
Always suction on the way out.
Never suction for longer than15 seconds.
Always oxygenate the patient before and
after suctioning.

Other Airway Adjuncts
Kombi-tube.
Oropharangeal airways/tubes.
Nasopharyngeal airways/tubes.
Oro-tracheal tubes.
Naso-tracheal tubes.


Conclusion
Always oxygenate patient before and after
intubation.
Do not attempt intubation unless you are
totally skilled, rather perform bag-valve-
mask ventilation.
Always monitor the spo2 readings.
Always reconfirm tube placement from
time to time.

This is some information as a base line
only.
The additional Power Points will expand
on this information.