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Intubation and Extubation Lecture Notes

INTUBATION/EXTUBATION Overview

Definition of Intubation

  • Intubation: The passage of a tube into a body aperture; in common practice, refers to the insertion of an endotracheal tube within the trachea.

Indications for Intubation

  • Relieve Airway Obstruction: To open the airway for breathing.
  • Facilitate Removal of Secretions: To assist in suctioning mucus or fluid from the airway.
  • Protect Lower Airway from Aspiration: To prevent foreign materials from entering the lungs.
  • Provide Mechanical Ventilation: For ventilatory support when the patient cannot breathe adequately.
  • Instill Medication: Specific medications can be administered via the endotracheal tube, which includes:
    • Valium/Versed: Sedative for calming the patient.
    • Atropine: Used for bradycardia.
    • Narcan: For narcotic overdose.
    • Epinephrine: For asystole.

Equipment Required for Intubation

  • Laryngoscope: Instrument used to visualize the airway.
  • Metal Stylet: A guide wire used for oral intubation only.
  • Magill Forceps (Nasal): For nasal intubation only.
  • Water Soluble, Sterile Lubricant (Nasal): To reduce friction during tube insertion.
  • Endotracheal Tubes: Various sizes available for different patient needs.
  • 10 ml Syringe: To inflate the cuff of the endotracheal tube.
  • Yankauer and Suction Source: For airway suctioning.
  • Bag/Mask Unit: For ventilation.
  • CO2 Detector: To confirm proper placement of the tube.
  • Medications for Sedation: Sedatives such as Etomidate, Ketamine, Propofol, Midazolam.
  • Stethoscope: To auscultate lung sounds.
  • Tape/Tube Holder: To secure the intubated tube in place.
  • Tongue Depressors/OPA/Bite Block: Additional aids during intubation.
  • Sterile Suction Catheter: For post-intubation suctioning.
  • Manometer: To measure cuff pressure.

History and Development of Tracheal Tubes

  • Tracheal tubes have been utilized since the 18th century but gained popularity following the advocacy of British anesthesiologist Sir Ivan Magill in the 1920s.
  • The advent of mechanical ventilation in the 1950s required more effective tube designs.
  • Inflatable Cuff Tubes: These tubes help guard against aspiration and provide effective ventilation. Proper cuff pressure is crucial to avoid damaging airway structures.
  • Posey Cufflator: A device invented by VBM Medizintechnik and marketed for monitoring cuff pressure and inflating cuffs. It can provide continuous monitoring of cuff pressure.

Laryngoscope Information

  • Handling Technique: Always hold the laryngoscope in the left hand.
  • Components:
    • Power Pack: Contains batteries.
    • Blades:
    • Miller (Straight): Fits underneath the epiglottis and directly lifts it.
    • MacIntosh (Curved): Fits into the vallecula and lifts indirectly.
  • Troubleshooting Tips:
    • If the light does not work, check batteries and tighten/change the bulb.
  • Blade Sizes:
    • Adult: Size 3.
    • Pediatric: Size 2.
    • Term Infant: Size 1.
    • Neonate: Size 0.

Magill Forceps

  • Usage: For nasal intubation only.

Yankauer Suction

  • Purpose: To suction blood, saliva, or vomit from the upper airway.

Intubation Medications

  • Pre-treatment Medications (Administered by RN):
    • Induction Agents:
    • Rapidly induce unconsciousness to facilitate easier intubation and reduce emotional distress.
    • Examples:
    • Etomidate
    • Ketamine
    • Propofol (Diprivan)
    • Midazolam (Versed)
  • Paralyzing Agents: Induced immediately after induction agents to provide neuromuscular blockade.
    • Examples:
    • Depolarizing Neuromuscular Blocker: Succinylcholine (Anectine); rapid onset (45-60 sec), short duration (8-10 min).
    • Non-depolarizing Neuromuscular Blocker: Rocuronium (Zemuron); longer onset (60-75 sec), longer duration (30-60 min).

Bag/Mask Unit (Bag Valve Mask)

  • Function: To ventilate and oxygenate the patient.

CO2 Detector

  • Purpose: To confirm tracheal vs. esophageal intubation.
  • Device Example: EZ-Cap - indicates 5% CO2 with a color change to yellow (pH sensitive).

Tube Holders and Tape

  • Endotracheal Tube Holder: Essential for securing the endotracheal tube in place.

Sterile Suction Catheter

  • Usage: For suctioning through the endotracheal tube once positioned.
    • Design Features:
    • "Ballard" inline suction catheter.
    • Irrigation port for saline lavage.
    • Removable plug and thumb control for suction operation.
    • Includes a catheter sheath for connecting to the ventilator circuit.

Manometers

  • Function: For checking and managing cuff pressures during intubation.

Role of the Respiratory Care Practitioner (RCP) in Intubation

  • Primarily assists the physician throughout the intubation process, including:
    • Gathering supplies and checking their functionality.
    • Positioning the patient’s head appropriately.
    • Pre-oxygenating the patient using a bag/mask unit.
    • Ensuring suction is available.
    • Checking breath sounds for proper tube placement.
    • Securing the tube once placed.
    • Setting up the ventilator for the patient.

Intubation Procedure Steps

  • Preparation: Ensure equipment is ready and functional.
  • Patient Positioning: Place the patient in the “sniff” position, potentially using a pillow or towel under their shoulders.
  • Ventilation and Oxygenation: Use bag/mask to deliver breathing support before procedure.
  • Assisting Physician: Provide necessary tools once intubation starts.
  • Cricoid Pressure: Apply pressure to the cricoid membrane, which collapses the esophagus to improve visualization.
  • Insertion Depth:
    • Oral Intubation: 21-25 cm from the lips.
    • Nasal Intubation: 26-29 cm from the nares.
  • Timing: Not exceed 30 seconds per attempt; re-oxygenate in between attempts.
  • Cuff Inflation: Inflate cuff using a syringe (5-7cc) and confirm bilateral chest movement while bagging.

Patient Position for Intubation

  • Utilize rolled towels or a pillow under the patient’s shoulders to maintain the sniff position during intubation.

Mallampati Classification of Airway Assessment

  • Class I: Visualization of soft palate, uvula, and tonsillar pillars.
  • Class II: Visualization of soft palate and uvula, but not the tonsillar pillars.
  • Class III: Visualization of the soft palate and the base of the uvula.
  • Class IV: Only the hard palate is visible.

Airway Anatomy Components

  • Structures Involved:
    • Tongue
    • Vallecula
    • Epiglottis
    • Vocal Cords
    • Glottis
    • Arytenoid cartilage

Pre-oxygenation Protocol

  • Administer 100% Oxygen for at least 5 minutes to saturate alveoli.
  • Use either Non-Rebreather (NRB) or Bag-Valve-Mask (BVM) methods.
  • Positive pressure assistance may be required.
  • Adhere to 30-second limit per intubation attempt and re-oxygenate for 3 to 5 minutes after failed attempts.

Cricoid Pressure

  • Also known as the Selleck Maneuver, cricoid pressure is applied to collapse the esophagus, facilitating easier visualization of vocal cords for intubation. Note that this is indicated only for adults as children's tracheae are too soft.

Tube Position Assessment Post-Intubation

  • Steps include:
    • Inspection: Observing for chest movement.
    • Auscultation: Listening for bilateral breath sounds.
    • Capnography: Using the EZ-Cap (ETCO2 detector) to confirm placement.
    • CXR Requirement: The tube tip should be positioned 2 cm (1 inch) above the carina on chest X-ray.

Hazards of Intubation

  • Potential complications include:
    • Tracheal damage.
    • Vocal cord damage.
    • Right mainstem intubation observed through asymmetrical chest movement.
    • Cuff rupture or aspiration, especially if the patient is not adequately sedated.
    • Hypoxemia, patient tachycardia, or arrhythmias.
    • Nosocomial infections, esophageal intubation, potential hemorrhage, broken teeth, laryngospasm, and bradycardia from vagal stimulation.
    • Nasal route risks include bleeding, ulceration, and sinusitis.

Contraindications for Oral Intubation

  • Situations where ORAL intubation is not suitable include:
    • Significant cervical spine injury (preventing neck extension).
    • Lower facial injuries.
    • Recent oral surgery.

Complications of Endotracheal Tubing (ETT)

  • Other complications may include:
    • Kinked airway requiring manipulation or suctioning.
    • Ruptured cuff needing reintubation.
    • Pilot line cut requiring securement and reintubation.
    • Patient biting the tube necessitating immediate replacement.
    • Excess mucus buildup requiring Mucomyst treatment.
    • Continuous coughing due to sensitivity or close proximity to carina, needing repositioning.

EXTUBATION Overview

  • Definition: The removal of the endotracheal tube from the trachea.
  • Equipment Needed for Extubation:
    • Suction catheter and Yankauer.
    • 10 ml syringe.
    • Oxygen setup and towel.
    • Cool aerosol setup and racemic epinephrine if necessary.
    • Bag/Mask unit and reintubation equipment ready.

Extubation Procedure Steps

  • Explain the procedure to the patient clearly beforehand.
  • Position the patient in High Fowler’s (or as upright as possible).
  • Suction the airway and mouth thoroughly.
  • Cut and remove any securing tape.
  • Deflate the cuff prior to removal of the tube.
  • Have the patient take a deep breath to prevent vocal cord damage while pulling the tube during peak inspiration.
  • After removal, encourage coughing to clear secretions, conduct more suctioning, and administer O2/humidity as needed.
  • Monitor for potential complications such as stridor or obstruction, vital signs, and document the procedure.

Complications and Management Post-Extubation

  • Mild Complications:
    • Distress/stridor/sore throat management includes administration of oxygen and cool mist.
  • Moderate Complications:
    • Moderate distress or stridor may require oxygen, cool mist aerosol, and 2.25% racemic epinephrine.
  • Severe Complications:
    • Marked inspiratory stridor should prompt reintubation.

Other Hazards of Extubation

  • Complications include:
    • Tracheal or vocal cord damage if cuff is inflated during extubation.
    • Vomiting if the NG tube is removed too early.
    • Laryngospasm or nasal bleeding with nasal tube use.

Self-Extubation Protocol

  • If a patient self-extubates, immediately bag the patient if they can't sustain their own ventilation and notify the physician.
  • If the patient can ventilate on their own and is stable, place them on 100% NRB and evaluate. For tracheostomy patients, cover the stoma with sterile gauze.

Weaning Parameters for Extubation

  • Essential criteria include:
    • NIF or MIP ≥ -20 mmHg.
    • Vital Capacity (VC) > 10 ml/kg.
    • Tidal Volume (VT) > 5 ml/kg.
    • Respiratory Rate (RR) = 8-30 bpm.
    • Minute Ventilation (MV) < 10 LPM.
    • Rapid Shallow Breathing Index (RSBI) < 100, calculated as the ratio of frequency (RR) to tidal volume (f/VT).

Example of RSBI Calculations

  • Patient A: Rate (f): 32, VT: 0.30 L, calculated RSBI = ( rac{32}{0.30} = 107).
  • Patient B: Rate (f): 28, VT: 0.40 L, calculated RSBI = ( rac{28}{0.40} = 70).
  • Candidate Evaluation: Patient B is a better candidate for extubation due to a lower RSBI.

Additional Considerations for Weaning

  • Factors to consider include:
    • Resolving chest X-ray.
    • Stable vital signs.
    • Adequate oxygenation status.
    • Improved arterial blood gas (ABG) values.
    • Satisfactory nutrition levels.
    • Proper electrolyte and fluid balance.
    • Stable cardiovascular performance (hemodynamic stability).
    • Functional integrity of other organ systems (renal, gastrointestinal).
    • Evidence of reversal or partial reversal of the original reason for instituting mechanical ventilation.