- Intubation equipment
- Laryngoscope: used to hold the mouth and epiglottis open, and shine a light into the airway so an endotracheal tube can be inserted.
- Straight blade: directly lifts the epiglottis.
- Curved blade: indirectly lifts the epiglottis by lifting the base of the tongue next to the epiglottis.
- Tracheal tubes
- Adult male 8-8.5 mm.
- Adult female 7-8 mm.
- Infants and children 2.5-6 mm.
- A generic size is 7.5 mm. When in doubt, use the smaller size.
- The distal side contains an inflatable cuff that holds it in position after a successful intubation.
- Stylet: pliable metal wire that is initially inside the tracheal tube to keep it from kinking.
- Tracheal tube insertion
- Ventilate patient for 2 minutes before intubation attempt.
- Assemble and test equipment:
- Pick the right sized tube.
- Insert stylet into the tube.
- Lubricate distal end.
- See if cuff inflates.
- Visualize the vocal cords and glottic opening and insert tube through the vocal cords.
- Tube should go down halfway between the carina (where the trachea branches) and the vocal cords.
- Hold the tube in position all the time until the cuff is inflated.
- Remove laryngoscope, stylet, and inflate the cuff.
- Confirmation of successful intubation:
- Air sounds in lungs, but not the stomach
- CO2 detected in exhaled breath
- Equal breath sounds to both sides. If unequal, you've inserted the tube too far.
- An esophageal detection device - the esophagus will collapse in response to negative pressure and give you resistance.
- Exhaled condensation in the tracheal tube.
- Puls-ox reading should show that the patient is getting oxygen with the tube in place and not deteriorating into hypoxia.
- Mark the position of the successful intubation on the tracheal tube.
- Maximum time spent intubating a patient = 30 seconds. If you exceed it, stop, and ventilate the patient for 2 minutes before re-attempting intubation.
- Always have a suction device ready during intubation in case of vomiting. Also, suction any fluids in the airway before intubation.
- Nasalgastric insertion in infants and children: used to extract air from the stomach in case of gastric distention that threatens to stimulate vomiting or compromise PPV.
- Orotracheal suctioning: this type of suctioning can go beyond the base of the tongue and into the trachea up to the carina. Used for removing secretions that could block the airway. Suction for a maximum of 15 seconds at a time for adults and ventilate the patient for 2 minutes before repeating. Suction on the way out with twisting motion of the catheter.
- Sellick maneuver: closes off the esophagus by applying pressure to the cricoid cartilage to prevent aspirations. Also called cricoid pressure. Applied to unresponsive patients without a gag reflex. Applied during an intubation attempt if enough personnel available.