Airway Lecture 4: Techniques of Intubation

Before intubating checklist

- Performed an adequate airway evaluation of patient

- Checked out airway equipment

- Suction is present

- Patient is positioned correctly

- ASA monitors are on

- Patient is apneic, unconscious

- Demonstrate ability to mask ventilate effectively

How many blades/handles should you have available when intubating?

Two (one for backup)

When in an OB case, what may be different about your airway equipment?

Use a shorter handle for your laryngoscope setup

What is the typical size ETT used for a male?

8.0 or 7.5 for males

What is the typical size ETT used for a female?

7.5 or 7.0 for females

What to do after opening ETT

Tighten the connector, test cuff for leaks

Oral Airways come in what sizes?

90, 100, 110 mm

What to also have handy when using oral airways

Tongue depressor

Nasal Airways are measured in what units?

french diameters

Nasal Airways come in what sizes?

28-34 french diameters

What to also have handy when using nasal airways

KY jelly/water soluble lube

LMA sizes

3-5 for adults

LMA sizing is based upon

weight/mouth opening

What other equipment may you need to use if using an LMA?

lube

20mL syringe to inflate the cuff

What instrument should be available in the case of a nasal intubation

magill forceps

What instrument should be available when using an ETT

stylet/bougie

What needs to be in every room, every case, no exception

Ambu bag

What color tape is put over the eyes

Clear

What color tape is used to anchor the ETT

pink

What is the use of the stethoscope during intubation

To hear bilateral breath sounds

Where should suction be when intubating

Within reach without looking away from vocal cords

What tip should be on the suction while intubating

Yankauer

When intubating, how should the patient be positioned?

- head at top of table

- patient centered on bed

- mattress at level of belly button

- xiphoid process aligns with patient head

Sniffing Postion includes these two motions:

atlanto-occiptal extension

cervical flexion

The sniffing position is done to achieve what?

alignment of three axes

What are the three axes?

oral, pharyngeal, laryngeal

Oral axis is the axis of the

cavity of the mouth

Pharyngeal Axis is the axis of the

cavity of the pharynx

laryngeal axis is the axis of the

larynx and trachea

Sniffing Position + Head support: two methods

double folded pillow

trifold sheet with donut pillow on top

How many cm of pillow should be the head support

10cm

Why might you run into issues when positioning a morbidly obese patient?

Fat pad at base of neck may make it harder to extend atlanto occipital joint well in the flat position

How could you relieve this potential issue w/ morbidly obese patients?

build up/ramp up bed with sheets to allow for neck extension

How does ramp up help the laryngoscopist

Displaces chest inferiorly

In addition to neck flexion and atlanto-occipital extension, what can you look at to see if the patient is aligned properly?

ear to sternal notch alignment

How do you know that a patient is adequately pre-oxygenated?

FEO2 > 90% is optimal (≥85% is acceptable)

Why do we preoxygenate?

to delay the onset of hypoxia (5-9 min delay)

When is pre-oxygenation most important

- Difficult airway (need more time)

-obese (desaturate quickly)

What should always be worn when managing airway

Gloves

How do we verify patient is unconscious by IV agents

Loss of eyelid reflex

What to do while waiting for optimal relaxation provided by paralytic agents

Mask ventilate

Onset time: Roc intubating dose

1-2 min

Onset time: Roc RSI

30 seconds

Roc RSI dose

1.2 mg/kg

Two techniques for opening mouth

no-touch

scissor

What to be careful of when inserting laryngoscope blade

Pinching the lower lip against the teeth

Where do you place the blade if using a mac blade?

in vallecula (base of tongue)

Once you are in the vallecula with a mac blade, what do you do?

push up and away tensing the hyoepiglottic ligament

How does intubating with a miller blade differ?

Push blade deep

Epiglottis is being pinned to the anterior laryngeal wall

What are the two approaches to intubating with a miller blade?

- blade coming in at center

- paraglossal approach (from the right)

What is a potential disadvantage to a miller intubation?

epiglottic trauma

What is an external technique you can use to improve your view while intubating?

BURP

Backwards, Upwards, and Rightwards Pressure on external larynx region

Misleading alternate name of optimal external laryngeal manipulation

Cricoid pressure

Who performs the initial cricoid pressure (BURP)

Laryngoscopist

How far in do you push the ETT tube?

x3 ETT size at level of teeth

After you are through the glottis with the ETT tube, how much further do you advance?

2-3cm into the trachea

What may happen if you insert the Mac blade too deep?

may only see the esophagus

What is the purpose of the flange on a blade?

to keep the tongue off to the left

How to hold ETT tube after intubating

Braced against the patient's cheek

How much air should you push into the cuff? ml and cmh20

6ml of air or 20-30cm H2O

Why is the first attempt at intubation typically the best?

- Airway is relatively dry

- Patient is pre-oxygenated

- drugs are active

How do you confirm that the tube is actually in the trachea? (2)

sustained etco2 using capnography

chest rise

How do you confirm where in the trachea the tube is? (2)

Bilateral breath sounds

Lack of sound over epigastric area

What are the two ways to monitor end tidal carbon dioxide

- capnography (waveform, more common)

- capnometry (number)

What would your capnograph display if you were in the stomach/esophagus?

EtCO2 diminishing over time

Although carbon dioxide measurement is the gold standard, why is not infallible?

if there is no pulmonary circulation to produce co2, none may be detected

EtCO2 is proportional to...

Cardiac output

A quick EtCO2 drop could be indicative of

cardiac arrest or pulmonary embolism

Ngeative Pressure devices to check confirmation of tube placement is based on the theory that

the tracheobronchial tree is semi rigid, and the esophagus is collapsable

Negative pressure device example

Self-inflating bulb (SIB)

Negative Pressure Devices: If you are in the trachea, what would happen to your bulb?

bulb would reinflate

Negative Pressure Devices: If you are in the esophagus, what would happen to your bulb?

No inflation of bulb

Advantages of using negative pressure devices

Practical and cheap

Immediately following intubation, where should you listen while manually ventilating the patient

Bilateral axillae

In what situations may chest rise be diminished ?

barrel chested, obese patients

Which fiberoptic device may be used to confirm ETT tube placement?

fiberoptic bronchoscope

Disadvantages of using fiberoptic bronchoscope

Expensive, impractical

Which types of intubations always require you to use an fiberoptic bronchoscope?

double lumen enodbronchial tube

Can you verify tube placement with a pulse oximeter?

NO, but serves as a warning device is patient is desaturating due to hypoventialtion

Mainstem intubation occurs when:

The tube is advanced too far and therefore enters the mainstem bronchus

Mainstem intubation may also occur if...

Patient's head is repositioned

Which bronchus is the tube more likely to go into?

right

Outside of the OR, how can you confirm tube position?

chest x-ray

Minimum check of tube placement

Continuous capnography

Auscultation of lungs and stomach

Test to check tube placement outside the OR

Negative presssure test

Where should you tape the tube on patients face?

Maxilla to maxilla

In a prone positioned patient, what might you consider to REALLY secure the airway

- using two pieces of tape secured from 2 diff. positions

What to do if the tape is not sticking well

Benzoin

What should you be mindful of when securing the tube? (2)

- do not tape all the way around head (will restrict venous return)

- be sure not to catch the lip

If tape on the face is not desirable, how can the tube be secured?

wire tube to upper incisors via sutures

BIte blocks are used to accomplish what?

- To reduce chances of patient biting/occluding the tube

What can happen is the tube is occluded?

negative pressure pulmonary edema (NPPE)

When nasally intubating, what should you ask the patient prior to intubation?

which nostril is more patent

When nasally intubating sprays can be utilized to vasodilate or vasoconstrict?

vasocontstrict

Nasal Vasoconstrictors examples

-Oxymetazoline spray

-Phenylephrine spray

What side of the nose is the spray used with nasal intubation

both

In comparison to a oral tube, how do you size nasal tube?

1/2 size smaller than normal

7 for women, 7.5 for men

Two things that you can do to tube itself to facilitate easier movement?

warm tube up, and lube tip

Methods to warm up nasal tube?

soak in warm saline

wrap in warm blankets

When do you always use lube

When inserting anything through the nose