endotracheal intubation
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Indications
- respiratory failure
- failure of less invasive measures
- general anesthesia
- inability to protect airway
- cardiac arrest
- need for prolonged chest compressions
- coma or absent reflexes
- head & neck injuries
- severe facial burns
- aspiration of gastric contents
- cardiac arrest
- severe upper airway obstruction
- obstruction may preclude endotracheal intubation & require cricothyrotomy
Contraindications
- hypoxic patient
- during emergency or elective intubations, ventilate patient with oxygen face mask & breathing bag before attempting intubation
- methemoglobinemia
- carbon monoxide poisoning
- cyanide poisoning
- cervical spine injury
- establish airway with circothyroidotomy to avoid head extension required for endotracheal intubation
- if unable to intubate trachea due to airway obstruction, emergency tracheostomy is indicated
Procedure
Equipment:
- laryngoscope (curved or straight blade)[3]
- endotracheal tubes (estimated size & one smaller)
- stylette for endotracheal tube (malleable)
- basin with sterile water
- sterile lubricant, water soluble
- syringe, 10 mL
- scissors
- clamp, straight mosquito
- oropharyngeal airway
- succinylcholine 20 mg/mL 1.5 mg/kg
- atropine 0.4 mg/mL, 0.6 mg in adults
- average size:
- adult male: 9 mm diameter
- adult female: 8 mm diameter
- neonate 3.5 mm diameter
- preparation
- check cuff for leaks by inflating cuff under water
- lubricate tube & stylette
- indert stylette into tube & bend into appropriate curve
- do not allow stylette to protrude from tube
Give atropine:
- 0.6 mg adults
- helps reduce secretions & avoid vasovagal bradycardia
Technique:
- etomidate vs ketamine for rapid sequence intubation[7]
- neuromuscular blockade as needed
- remifentanyl inferior to neuromuscular blockers[11]
- neuromuscular blockade as needed
- insert laryngoscope & advance blade to groove between tongue & epiglottis
- do not cover epiglottis with blade
- lift laryngoscope upward & forward
- elevates base of tongue & epiglottis
- brings larynx into view
- do not lever laryngoscope
- visualize the vocal cords
- pressure on the cricoid cartilage may help bring the vocal cords into view
- insert endotracheal tube so that proximal end of cuff is immediately below vocal cords
- video laryngoscopy*
- similar 1st pass intubation rates but more complications than direct laryngoscopy[8]
- 1st pass intubation more likely successful in critically-ill patients[12]
- particularly helpful for operators learning to intubate[12]
- use of a bougie compared with an endotracheal tube + stylet may facilitate first-pass intubation in difficult patients during emergencies[9]
- 1st pass intubation similarly successful with stylet or bougie (80%)[10]
* reserve for difficult intubuations[8]
Confirm tube position:
- attach tube to ventilation bag 100% O2
- apply intermittent positive pressure
- confrim bilateral chest expansion
- confirm bilateral air entry by auscultation
- assess for cyanosis
Secure position of endotracheal tube
- inflate cuff sufficiently to stop reflux around tube
- 4 mL is genereally maximum in adults
- clamp cuff inflation tube distal to observation balloon
- cut endotracheal tube so that no more than 3 cm protrudes beyond lips
- insert oropharyngeal airway
- apply tincture of benzoin & tape tube to cheeks
Complications
- local trauma
- late complications of local trauma
- cardiac arrhythmias
- increased vagal or sympathetic stimulation in the presence of hypoxia or hypercarbia
- aspiration of gastric contents
- vomiting or passive reflux of gastric contents with aspiration
- avoid prolonged mask ventilation with risk of gastric distension
- esophageal intubation
- bronchial intubation
- risk factors for difficult intubation
- obstructive sleep apnea
- cervical spine limitation
- opening mouth <3 cm
- coma
- hypoxemia
- operator being a non-anesthesiologist[5]
Notes
- maximize oxygen reserves during emergency airway management with high-flow nasal cannula oxygenation[6]
- preoxygenation with non-invasive ventilation safely lowers incidence of hypoxemia in critically ill adults[13]
- no increased incidence of pulmonary aspiration
More general terms
Additional terms
- endotracheal extubation
- endotracheal tube (ETT, tracheal tube)
- mechanical ventilation (assisted ventilation)
References
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 56
- ↑ Bozeman WP et al, A comparison of rapid-sequence intubation and etomidate-only intubation in the prehospital air medical setting. Prehosp Emerg Care 2006; 10:8 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16418085
- ↑ 3.0 3.1 Tripathi M and Prandy M Short thyromental distance: A predictor of difficult intubation or an indicator for small blade selection. Anesthesiology 2006; 104:1131 PMID: https://www.ncbi.nlm.nih.gov/pubmed/16732082
- ↑ 4.0 4.1 Medical Knowledge Self Assessment Program (MKSAP) 16, American College of Physicians, Philadelphia 2012
- ↑ 5.0 5.1 De Jong A et al. Early identification of patients at risk for difficult intubation in the intensive care unit. Am J Respir Crit Care Med 2013 Apr 15; 187:832 PMID: https://www.ncbi.nlm.nih.gov/pubmed/23348979
- ↑ 6.0 6.1 Badiger S et al. Optimizing oxygenation and intubation conditions during awake fibre-optic intubation using a high-flow nasal oxygen-delivery system. Br J Anaesth 2015 Aug 7 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26253608
- ↑ 7.0 7.1 Upchurch CP et al. Comparison of etomidate and ketamine for induction during rapid sequence intubation of adult trauma patients. Ann Emerg Med 2017 Jan; 69:24 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27993308
- ↑ 8.0 8.1 8.2 Lascarrou JB, Boisrame-Helms J, Bailly A et al. Video laryngoscopy vs direct laryngoscopy on successful first-pass orotracheal intubation among ICU patients: A randomized clinical trial. JAMA 2017 Feb 7; 317:483. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28118659
O'Gara B, Brown S, Talmor D Video laryngoscopy in the intensive care unit: Seeing is believing, but that does not mean it's true. JAMA 2017 Feb 7; 317:479. PMID: https://www.ncbi.nlm.nih.gov/pubmed/28118656 - ↑ 9.0 9.1 Driver BE, Prekker ME, Klein LR et al Effect of Use of a Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients With Difficult Airways Undergoing Emergency Intubation. A Randomized Clinical Trial. JAMA. Published online May 16, 2018 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29800096 https://jamanetwork.com/journals/jama/fullarticle/2681717
- ↑ 10.0 10.1 Driver BE, Semler MW, Self WH et al. Effect of use of a bougie vs endotracheal tube with stylet on successful intubation on the first attempt among critically ill patients undergoing tracheal intubation: A randomized clinical trial. JAMA 2021 Dec 28; 326:2488 PMID: https://www.ncbi.nlm.nih.gov/pubmed/34879143 PMCID: PMC8655668 (available on 2022-06-08) https://jamanetwork.com/journals/jama/fullarticle/2787158
- ↑ 11.0 11.1 Grillot N, Lebuffe G, Huet O et al Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration. A Randomized Clinical Trial. JAMA. 2023;329(1):28-38. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36594947 https://jamanetwork.com/journals/jama/fullarticle/2800025
- ↑ 12.0 12.1 12.2 Prekker ME et al. Video versus direct laryngoscopy for tracheal intubation of critically ill adults. N Engl J Med 2023 Jun 16; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/37326325 https://www.nejm.org/doi/10.1056/NEJMoa2301601
- ↑ 13.0 13.1 Gibbs KW et al. Noninvasive ventilation for preoxygenation during emergency intubation. N Engl J Med 2024 Jun 13; [e-pub] PMID: https://www.ncbi.nlm.nih.gov/pubmed/38869091 https://www.nejm.org/doi/10.1056/NEJMoa2313680