ACLS:Airway Management:

Endotracheal IntubationDr. Linda Frasca

Edward Via Virginia College of Osteopathic Medicine

Block 12

Indications: Endotracheal Intubation

• Respiratory Failure: Hypoxia, Hypercapnia, tachypnea, or apnea ; ie. ARDS, asthma,

pulmonary edema, infection, COPD exacerbation

• Inability to ventilate unconscious patient• Maintenance or protection of an intact airway• Cardiac Arrest• Medication administration

Contraindications:

• Inability of patient to extend head• Moderate to severe trauma to the cervical

spine or anterior neck• Infection in the epiglottal area• Mandibular fracture or trismus• Mild hypoxia• Uncontrolled oropharyngeal hemorrhage• Intact tracheostomy

Equipment

• Laryngoscope• Blades: curved (MacIntosh) and straight

(Miller)• Endotracheal tubes of various sizes:

– Neonates and full term infants: no. 0 and 1– Adult women: 7.0 mm i.d. tube– Adult men: 8.0 to 8.5 mm i.d. tube– Pediatric size: (age in years/4) + 4 or width of

fingernail of the fifth digit

Continue Equipment for ET intubation:

• Lubricant, Malleable stylet• 10-ml syringe (to inflate ET cuff)• Oxygen and manual bag valve mask• Suction apparatus• Stethoscope• Sterile gloves and goggles• Oropharyngeal airway• CO2 Detector

How do you confirm the correct placement of the ET Tube?

• Primary Confirmation• Secondary Confirmation

Primary Confirmation By Physical Exam

• Confirm tube placement immediately• Listen over the epigastrium and observe the

chest wall for movement• If stomach gurgling and no chest wall

expansion, esophagus intubated:remove ET tube

• Reattempt intubation after reoxygenation

Primary Confirmation: cont.

• If chest wall rises and stomach not gurgling, perform 5-point auscultation• If still doubt, use laryngoscope to see the tube

passing through the vocal cords (best)• Secure the tube • Look for moisture condensation on the inside

of the tracheal tube (not 100%: false + with esophageal intubations)

Secondary Confirmation

• End-Tidal CO2 Detectors– Commercial device that reacts with a color change

to CO2 exhaled from the lungs: MELLO YELLOW– Qualitative detection device indicates exhaled

CO2 indicates proper tracheal tube placement– Absence of CO2 (unless prolonged CPR), indicates

esophageal intubation– False+: Distended stomach, carbonated beverages– False-: Low or no blood flow state ( as above)

Endotracheal tube(ET) trachea, endotracheal tube (arrows) and location of carina (^).

University of Virginia

Complications

• Hypoxia– Long duration of procedure– Esophageal intubation ( not visualizing vocal

cords)– Intubation of a bronchus ( right more common)– Failure to secure the placement– Failure to recognize misplacement of tube– Aspiration – Pneumothorax

Complications: continued

• Trauma and adverse effects– Broken teeth– Oral lacerations– Vocal cord injury– Pharyngeal-esophageal perforation– Short-term laryngeal edema– Release of high levels of epinephrine and norepinephrine

stimulated by tracheal intubation: can cause elevated blood pressure, tachycardia,

arrhythmias