Airway Management – Intubation

Laryngoscope modifications
1. oxygen and suction ports available on some models (especially on infant sizes i.e. 1 Mac)
2. handle size
3. disposable blades (cheap alum. or hard plastic)
Viewing the laryngeal structures
1. patient in sniffing position
2. position of intubators head should be far enough away from patient’s mouth to allow binocular vision. If the arm holding the laryngoscope is 90 degrees at the elbow, eye distance should be correct
3. use of stylet (hockey stick)
4. Endotrol ET tube – ring on side of tube that can bend/move the tube
Endotracheal Tube Guides
1. Intubating introducer catheter
2. Gum Elastic Bougie
3. Eschmann Stylet
Misc. Intubation Adjuncts
1. Light Wand
2. Flexible Fiberoptic bronchoscopy
3. Retrograde Wire Intubation
Video Laryngoscopy Devices
1. AKA King Intubating Devices
2. Provides a digitally produced real-time view of the larynx without having to directly view through the patient’s open mouth
3. Image viewed on separate monitor
4. useful for situations such as difficult intubations, compromised mouth opening or neck positioning
5. Most facilities have at least one
Brand names of video laryngoscopy devices
1. Airtraq by King Systems
2. Glidescope and Glidescope Ranger
3. McGrath
4. Bullard scope
5. Optical Stylet
Drugs used to facilitate intubation
Phase 1 – Pretreatment (airway preparation and sedation)
1. Lidocaine (irritable airway) {RT can administer}
2. Opioid analgesic – sedation in order to intubate (fentanyl, sufentanil, alfentanil) {IV admin}
3. Atropine (parasympathetic – dry secretions) {IV admin}
4. Defasciculating agents – paralytics (use with Opioids) impairs your ability to breathe {IV admin}
Drugs used to facilitate intubation
Phase 2 – Induction (agents that provide rapid loss of consciousness)
1. Etomidate (most common)
2. Propofol
3. Midazolam (Versed)
4. Sodium thiopental
5. Ketamine (often used with kids w/ epiglottitis)
Drugs used to facilitate intubation
Phase 3 – Paralysis
1. Depolarizing agents – Succinylcholine (short acting 5-15 minutes)

2. Nondepolarizing agents – Rocuronium (lasts about an hour) “euonium” means nondepolarizing

Nasal Intubation
Possible Indications
1. Access to the mouth is not available
2. Oral surgery or oral trauma
3. When the mouth cannot be opened adequately (i.e. trauma, TMJ, Mandibular fixation
Nasal Intubation
Advantages
1. tube stability enhanced
2. oral hygiene facilitated
3. better tolerated in semi-conscious patients (no gag)
4. smaller tube size may cause less pressure on the glottis and therefore fewer complications than oral intubation (approx. 1/2 size smaller Nasotube than ET tube)
Nasal Intubation
Relative Contraindications
1. suspected basilar skull fracture
2. nasal fracture
3. nasal polyps
4. epistaxis (nosebleeds)
5. coagulopathy
6. planned thrombolysis (Coumadin, Heparin)
Nasal Intubation
Disadvantages
1. requires smaller and longer tube
2. necrosis of nasal septum and external meatus
3. sinusitis
4. otitis media
5. epistaxis
6. feeding remains problematic
Nasal Intubation
Blind Technique
1. pt. must be breathing spontaneously and be able to support ventilation (can be semi-conscious)

2. follow step 1 – Oral intubation

3. position patient supine or siting

4. preoxygenate with supplemental oxygen as appropriate

5. anesthetize nasal passages with 2% Lidocaine and vasoconstrict with 0.25% racemic epinephrine

6. insert the tube through the nose, as the tip approaches the larynx listen for air movement. Advance on inspiration. As breath sounds become louder and more tubular, the tube is probably passing through the larynx. successful intubation – usually harsh cough followed by vocal silence. If all sounds disappear, probably esophageal placement. Reposition head as necessary if intubation attempt is unsuccessful.

7. confirmation of tube placement same as oral intubation

8. stabilization of tube same as oral intubation

Nasal Intubation
Direct Visualization Technique
1. equipment same as oral intubation with the addition of Magill forceps

2. patient is positioned same as oral intubation

3. preoxygenate as appropriate

4. anesthetize and lubricate nasal passage

5. insert tube with bevel positioned towards the septum. Once advanced to the oropharynx, insert laryngoscope, use Magill forceps to guide tube through glottis (grab the tube, not the cuff)
Avg. depth for males is 23-25 cm
Avg. depth for females 21-23 cm
May use rigid or flexible laryngoscope or flexible bronchoscope

6. confirm placement

7. stabilize the tube

Nasal Intubation
Complications/Hazards
1. damage to nasal septum resulting in bleeding
2. trauma to nasopharynx, oropharynx, larynx
3. hypoxemia, hypercapnia, bradycardia and cardiac arrest (less likely than with oral intubation)
Specialty Tubes
1. Hi-Lo Evac tube – has port for suctioning subglottic secretions (can suction the top of the cuff)

2. ET tubes with instillation ports for medication delivery

3. Double lumen endotracheal tubes (DLET) – separate ventilation lumens. Only use when ventilation 1 lung. RT does not place these

4. Rae Tubes – proximal end curves up towards the forehead (i.e. face surgery)

5. Wire reinforced tubes for laser surgery