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Endotracheal Intubation

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INDICATIONS

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  • Respiratory

    • Apnea

    • Hypoventilation

    • Severe respiratory distress/respiratory muscle weakness

    • Acute respiratory failure (PaO2 <50 mmHg in patient with FiO2 >0.5 and PaCO2 >55 mmHg acutely)

    • Need to control oxygen delivery (e.g., institution of positive end-expiratory pressure [PEEP], accurate delivery of FiO2 >0.5)

    • Need to control ventilation (e.g., to decrease work of breathing, to control PaCO2, to provide muscle relaxation)

  • Neurologic

    • Inadequate chest wall function (e.g., in patient with Guillain-Barre syndrome, poliomyelitis)

    • Absence of protective airway reflexes (loss of cough, gag)

    • Glasgow Coma Score <8

  • Airway

    • Upper airway obstruction

    • Infectious processes (epiglottis, croup)

    • Trauma to the airway

    • Burns (concern for airway edema)

  • Cardiac

    • Cardiopulmonary failure/arrest

    • Low cardiac output states (reduced oxygen demand/consumption)

  • Other

    • Transport of a patient with potential for respiratory failure

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CONTRAINDICATIONS

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  • Absolute

    • Nasotracheal intubation is contraindicated in patients with nasal fractures or basilar skull fractures

  • Relative

    • None

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RISKS

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  • Bradycardia

  • Hypoxemia/desaturation

  • Hypotension

  • Inability to intubate

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EQUIPMENT-SEE FIGURES 6-1 AND 6-2

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  • Suction – source, catheters; should have a tonsil-tipped suction device or a large-bore suction catheter, as well as a suction catheter of appropriate size that fits into the endotracheal tube (ETT)

  • Oxygen – source

  • Ventilation bags – flow inflating bags and self-inflating bags

  • Masks – appropriate sizes for ventilation

  • Laryngoscope – blade (straight or curved), handle, bulb, battery

    • Handle with battery and blade with light source

    • Adult and pediatric handles fit all blades and differ only in handle diameter

  • Video laryngoscope if available

  • Endotracheal tubes – appropriate sizes, cuffed, uncuffed

  • Forceps

  • Oropharyngeal airway

  • Tongue blade

  • Bite block

  • Tape – to secure tube or tube securement device

  • Stylet – appropriate sizes

  • CO2 detector device – colorimetric detection device or capnography

  • Syringe to inflate the endotracheal tube balloon on cuffed tubes

  • Laryngeal mask airways (LMA) – appropriate sizes

  • Medications (see medication section later)

  • Normal saline or Lactated Ringer’s for fluid resuscitation

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FIGURE 6-1

Intubation equipment.

Graphic Jump Location

Reproduced with permission from Chapter 27. Oral Endotracheal Intubation. In: Hanson C, III. eds. Procedures in Critical Care New York, NY: McGraw-Hill; 2009.

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FIGURE 6-2

Laryngoscope blades and handle. Top: straight blade, middle: curved blade.

Graphic Jump Location

Reproduced with permission from Klock A, et al, Airway Management. In: Longnecker DE, et al, eds. Anesthesiology, 3e New York, NY: McGraw-Hill, 2018.

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GUIDELINES FOR LARYNGOSCOPE, ETT, SUCTION CATHETERS BASED ON AGE AND WEIGHT – SEE TABLE 6-1

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  • Historically, uncuffed tubes were recommended for children <8 years of age; however, current research shows that cuffed tubes are safe in all patients except in the newborn period.

  • If a difficult intubation is anticipated due to altered supraglottic anatomy, absolutely no irreversible anesthetics or muscle relaxants should be administered.

  • Such patients should generally be intubated awake or in the operating room with inhaled anesthetic.

  • For difficult intubations, other techniques, such as ...

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