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endotracheal intubation

Indications: 1) respiratory failure - failure of less invasive measures 2) general anesthesia 3) inability to protect airway a) cardiac arrest - need for prolonged chest compressions b) coma or absent reflexes c) head & neck injuries d) severe facial burns e) aspiration of gastric contents 4) severe upper airway obstruction - obstruction may preclude endotracheal intubation & require cricothyrotomy Contraindications: 1) hypoxic patient - during emergency or elective intubations, ventilate patient with oxygen face mask & breathing bag before attempting intubation - methemoglobinemia - carbon monoxide poisoning - cyanide poisoning 2) cervical spine injury - establish airway with circothyroidotomy to avoid head extension required for endotracheal intubation 3) if unable to intubate trachea due to airway obstruction, emergency tracheostomy is indicated Complications: 1) local trauma - late complications of local trauma - tracheal stenosis [4] 2) cardiac arrhythmias - increased vagal or sympathetic stimulation in the presence of hypoxia or hypercarbia 3) aspiration of gastric contents a) vomiting or passive reflux of gastric contents with aspiration b) avoid prolonged mask ventilation with risk of gastric distension 4) esophageal intubation 5) bronchial intubation - tube pushed too far beyond cords entering right main-stem bronchus 6) risk factors for difficult intubation a) obstructive sleep apnea b) cervical spine limitation c) opening mouth <3 cm d) coma e) hypoxemia f) operator being a non-anesthesiologist [5] Procedure: Equipment: 1) laryngoscope (curved or straight blade) [3] 2) endotracheal tubes (estimated size & one smaller) 3) stylette for endotracheal tube (malleable) 4) basin with sterile water 5) sterile lubricant, water soluble 6) syringe, 10 mL 7) scissors 8) clamp, straight mosquito 9) oropharyngeal airway 10) succinylcholine 20 mg/mL 1.5 mg/kg 11) atropine 0.4 mg/mL, 0.6 mg in adults Endotracheal tube: 1) average size: a) adult male: 9 mm diameter b) adult female: 8 mm diameter c) neonate 3.5 mm diameter 2) preparation a) check cuff for leaks by inflating cuff under water b) lubricate tube & stylette c) indert stylette into tube & bend into appropriate curve d) do not allow stylette to protrude from tube Give atropine: 1) 0.6 mg adults 2) helps reduce secretions & avoid vasovagal bradycardia Technique: 1) etomidate vs ketamine for rapid sequence intubation [7] - neuromuscular blockade as needed - remifentanyl inferior to neuromuscular blockers [11] 2) insert laryngoscope & advance blade to groove between tongue & epiglottis 3) do not cover epiglottis with blade 4) lift laryngoscope upward & forward a) elevates base of tongue & epiglottis b) brings larynx into view 5) do not lever laryngoscope 6) visualize the vocal cords 7) pressure on the cricoid cartilage may help bring the vocal cords into view 8) insert endotracheal tube so that proximal end of cuff is immediately below vocal cords 9) 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] 10) use of a bougie compared with an endotracheal tube + stylet may facilitate first-pass intubation in difficult patients during emergencies [9] 11) 1st pass intubation similarly successful with stylet or bougie (80%) [10] * reserve for difficult intubuations [8] Confirm tube position: 1) attach tube to ventilation bag 100% O2 2) apply intermittent positive pressure 3) confrim bilateral chest expansion 4) confirm bilateral air entry by auscultation 5) assess for cyanosis Secure position of endotracheal tube 1) inflate cuff sufficiently to stop reflux around tube 1) 4 mL is genereally maximum in adults 2) clamp cuff inflation tube distal to observation balloon 3) cut endotracheal tube so that no more than 3 cm protrudes beyond lips 4) insert oropharyngeal airway 5) apply tincture of benzoin & tape tube to cheeks 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

Related

endotracheal extubation endotracheal tube (ETT, tracheal tube) mechanical ventilation (assisted ventilation)

General

clinical procedure

References

  1. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 56
  2. 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: 16418085
  3. 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: 16732082
  4. Medical Knowledge Self Assessment Program (MKSAP) 16, American College of Physicians, Philadelphia 2012
  5. 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: 23348979
  6. 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: 26253608
  7. 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: 27993308
  8. 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: 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: 28118656
  9. 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: 29800096 https://jamanetwork.com/journals/jama/fullarticle/2681717
  10. 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: 34879143 PMCID: PMC8655668 (available on 2022-06-08) https://jamanetwork.com/journals/jama/fullarticle/2787158
  11. 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: 36594947 https://jamanetwork.com/journals/jama/fullarticle/2800025
  12. 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: 37326325 https://www.nejm.org/doi/10.1056/NEJMoa2301601
  13. Gibbs KW et al. Noninvasive ventilation for preoxygenation during emergency intubation. N Engl J Med 2024 Jun 13; [e-pub] PMID: 38869091 https://www.nejm.org/doi/10.1056/NEJMoa2313680