Intubation

The most definitive way of achieving complete control of an airway

- Takes time

- Takes practice

- Can be difficult to achieve

Basic airways failed

Long term ventilation required

Airway burns/anaphylaxis

Suction of bronchial tree

Inhalation risk

CPR - asynchronous

Also Intermittent positive pressure ventilation (IPPV) and loss of airway reflexes

Airway maintained by basic techniques

Patient maintains own airway

Epiglottitis

Unable to intubate within 15 secs

- Receding lower jaw, obtuse angle @mandible

- Short muscular neck

- Full set of teeth

- Prominent upper incisors

- Long narrow mouth with high arched palate

- Carious/insecure teeth

- C-spine abnormality

- Late pregnancy

Looks bad? probably is!

Evalute. 3-3-2 score

Mallampati score

Obesity

Neck mobility

Use patients own fingers

3 - between upper and lower incisors

3 - between mentum and hyoid bone (chin-neck junction)

2 - between hyoid bone and thyroid notch

- The degree to which the mouth opens revealing the posterior oropharynx with tongue extended.

- Grade I = easy

- Grade IV = hard

Upright seated patient who is able to fully open their mouth.

LIMITED VALUE IN UNRESPONSIVE PATIENTS WHO CANNOT FOLLOW COMMANDS

- Anything that might interfere with visualisation or ET tube placement.

- Foreign bodies

- Obesity

- Haematoma

- Masses

- Muffled voice (hot potato)

- Difficulty swallowing

- Stridor

Difficulties achieving sniffing the morning air position.

- Neck trauma

- Elderly patients (osteoporosis, arthritis)

Total airway blockage

Oesophageal intubation

Patient resists; reflex activity present

Induced bradycardia

Clenched teeth due to cerebral irritation

Airway burns

Facial trauma

Regurgitation and swallowing

Intubation of right main bronchus

Cervical spine injury

Attachments too heavy

- Use initial basic techniques, back slaps etc. Forceps (guided by laryngoscope)

- Attempt intubation

- Consider needle crichothyroidotomy

- Deflate cuff

- Remove tube

- Re-oxygenate patient

- Re-attempt intubation

- Abandon attempt

- Use basic airway techniques

- Hyperventilate with 5 breaths of bag valve mask, 1/3 of the bag, 1 second a go.

- Suction

- Remove airway adjunct.

- Careful laryngoscopy to avoid problem.

- Atropine (600micrograms initial dose - every 3-5mins up to 3 milligrams max dose)

- Cerebral irritation, tetanus

- Abandon irritation

- Basic airways

- Oxygenation to relieve cerebral irritation

- Early intubation

- Uncut tube

- Use bougie for all pre-hospital intubations

- Consider smaller tube

- Consider needle crichothyroidotomy

- Careful suctioning

- Careful laryngoscopy

- Suction using wide bore catheter (measure from the corner of mouth to tragus of ear)

- Discard and replace tube if becomes blocked during intubation

- Revert to basic techniques if unsuccessful.

- Deflate cuff

- Withdraw to correct position

- Re-inflate cuff

- Re-check positioning with stethescope

- Apply in-line immobilisation immediately

- Intubation attempted only if attempts to maintain airway failing

- Minimal neck movement

- Displacement of tube due to equipment or rough handling

- Check tube position

- Re-intubate if tube dislodged

- Stabilise head and neck (consider collar)

Sniffing the morning air

Neutral

- Is all equipment there?

- Does the cuff on the tube inflate?

- Bulb working on laryngoscope?

- 2 of everything

When a Thomas Mount with bite block is not available....OPA acts as a bite block.

Suction prior to?

Point of maximal inspiration. Vocal cords are widest apart, then withdraw as they exhale.

Patient on their side.

1.Position the patient

2. Blade insertion

3. Visualisation of glottic open

4. Tube insertion

5. Ventilation

6. Confirmation of tube placement

8

7

- Gastric channel

- Forms an anatomical seal with the pharyngeal, laryngeal and perilaryngeal structures

- Epiglottic rest prevents epiglottis from down folding

- Integral bite block

All anatomical airway structures above the level of the vocal cords.

An anatomical space or pocket located between the base of the tongue and the epiglottis

Sniffing the morning air position

The application of posterior pressure to the cricoid cartilage to minimise the risk of regurgitation during positive pressure ventilation

Backwards, upwards, right pressure manoevre used to improve the view of vocal cords during intubation

Larynx

9

6/9

3

- arytenoid

- corniculate

- cuneiform

- Thyroid

- Cricoid

- Epiglottis

- Hyaline

- Largest cartilage

- Adams apple

- Most inferior

- Forms the base of larynx

- First ring of the trachea, only one the is circumferential

- Elastic

- Attached to the thyroid cartilage and projects superiorly as a free flap towards the tongue.

- Articulate with the posterior superior border of the cricoid cartilage.

- Posterior attachment for the vocal cords.

- Attached to the superior tips of the arytenoid cartilages.

- Contained in a mucous membrane anterior to the corniculate cartilages.

Vocal folds and opening between them.

- Insert blade into right side of mouth

- Use the flange of the blade to sweep the tongue gently to the left side of the mouth while moving the blade into the midline

- Slowly advance the blade

–Vocal cords are white fibrous bands thatlie vertically within the glotticopening

–If you are having difficulty seeing theopening, consider cricoid pressure

–Insert the tube from the right corner ofthe patient’s mouth through the vocal cords

- insert the tube until the proximal end ofthe cuff is 1 to 2 cm past the vocal cords

- Blade is not designed as a guide for thetube

- Remove the blade. Remove the boujie

- Inflate cuff with 5-10ml air

- Attach bag valve mask and ventilate

- Monitor chest for full respiratory cycle

- Ascultation at apex and base of each lung and over the epigastric region

- Capnography

- If breath sounds heard only on right side then tube advanced into right bronchus

- False vocal cords

- Superior pair of ligaments that extend from anterior surface of the arytenoid cartilages to the posterior surface of the thyroid cartilage.

- Covered by mucus membrane

- True vocal cords

- Inferior pair of ligaments that extend from the anterior surgace of the arytenoid cartilages to the posterior surface of the thyroid cartilage

- Covered by mucus membrane

Two pockets of tissue on the lateral borders of the larynx. Airway devices are occasionally inadvertently inserted into these pockets.

Groove between the base of the tongue and the epiglottis

Lips-teeth-tongue-hard palate-soft palate-palentine tonsil-uvula-pharynx-epiglottis-epiglottic vallecula.

Thyrohyoid ligament

Laryngeal prominence

(Adams apple)

Cricothyroid membrane

Trachea

Hyoid bone

Thyroid cartilage

Cricoid cartilage

size 5

90+kg

size 4

50-90kg

size 3

30-60kg

epiglottis

vestibular folds

glottis

vocal folds

Cuneiform cartilages

Corniculate cartilages

Trachea

Base of tongue

Vocal cord

Vestibular fold

Pyriform fossae

Trachea

Glottic opening

epiglottic valleculae

Epiglottis

Tubercle of epiglottis

Aryepiglottic fold

Cuneiform cartilage

Corniculate cartilage

- "I visualised the tube passing the cords"

- Rise and fall of chest

- Auscultate

- ETCO2

- Capnography

- Oesophageal detector

- Not cyanosed/improved perfusion

94-98%

To avoid vasoconstriction as a result of myogenic response.

4-6 kPa

35-40 mmhg