Tubes, Lines, and Vents in the ICU:Endotracheal IntubationMechanical Ventilation

Central Venous CatheterizationArterial Catheterization

Swan Ganz Catheterization

Curt Sessler, MDProfessor of Medicine

Medical Director of Critical CareVirginia Commonwealth University Health System

May 4, 2004

Endotracheal Intubation: Outline

AnatomyPreparation» Patient evaluation» Equipment / Medications

Pre-intubation patient managementProcedure of intubationDifficult airway

Goals of EndotrachealIntubation

Secure and protect airwayVentilationOxygenation

Anatomy for Tracheal Intubation

Pathway to vocal cords: mouth, pharynx, larynxGlottis: vocal cords, epiglottis, valeculae, esophagus

Pre-Intubation Patient Evaluation: Critical Issues

Difficult mask fit / bag-mask ventilationDifficult intubationMedical conditions which influence choice of medicationsAlternative airway options

Pre-Intubation Evaluation:‘NDOTRAC’

Parameter Abnormality ActionN Neck Short Difficult*D Dentition Loose teeth Caution w bladeO Oral cavity Small, limited view Difficult*T Tongue Large Difficult, curved bladeR ROM Limited FiberopticA Adam’s apple Prominent (anterior) straight bC Chin Receding Difficult** consider awake intubation, alternatives, backup

Equipment for Intubation

Laryngoscope: handle, straight & curved bladesEndotracheal tubesAirwaysWater soluble lubricantStyletSyringe

Suction equipmentOxygenBag and maskPulse oximetryET CO2 detectorTape / benzoinCardiac monitorDefibrillatorMedications

Patient Preparation

Open airway by placing patient in sniffing positionLift at chin or angles of jaw

Patient Preparation

Towel / blanket beneath head / upper shouldersProvide effective mask ventilation with 100% O2» May need oral airway» May need PEEP valve

Apply pressure to cricoid cartilage

Visualize Vocal CordsAlign axes of pharynx, larynx, mouthPlace towels beneath head to align larynx & pharynxUsing laryngoscope, hyperextend at C1-C2 vertebra

Orotracheal Intubation

Position patient in sniffing position, hyper-extend at C1-C2Laryngoscope blade is inserted into the right corner of the mouth and advanced halfway as

moved to the midline» Tongue swept out of the way» Epiglottis visualized

Orotracheal Intubation

Curved blade: tip of blade advanced above epiglottisStraight blade: tip of blade advanced under epiglottisLaryngoscope lifted to visualize cords

Orotracheal Intubation

ET tube tip is passed between cords until cuff is beyond cords

How to Hold the Endotracheal Tube?

Steps in OrotrachealIntubation

Insert bladeVisualize epiglottisReposition blade and visualize vocal cordsInsert ET tube

Rapid Sequence Intubation(RSI)

Short acting sedatives and neuromuscular blocking agent to facilitate immediate intubation in unstable patientFeatures» Adequate sedation and amnesia» Rapid muscle relaxation» Reduced risk of aspiration» Reduced rise in ICP

Induction Agents

Smooth rapid amnesticShort duration of actionStable hemodynamicsFew side effects

Etomidate (Amidate)Midazolam (Versed)Thiopental (Pentothal)Methohexital (Brevitol)Ketamine (Ketalar)

Nasotracheal Intubation

Patient selection» Must be spontaneously breathing

Useful alternative to orotracheal intubation» Cervical spine injury» Avoid IV sedatives and NMBA

Contra-indications: apnea, upper airway foreign body, bleeding diathesis, epiglottitis, CSF rhinorrhea / head trauma, nasal polyp or abscess

Nasotracheal Intubation: Technique

Determine nasal patency, consider applying vasoconstricting agentInsert nasal airway coated

with topical anesthetic / lubricant

Nasotracheal Intubation: Technique

With patient sitting upright, ET tube is inserted and advanced towards the back of the head above the hard palletET tube advanced toward cords while listening for breath sounds

Nasotracheal Intubation: Technique

Endotracheal position confirmed by breath sounds through ET tube, cough.Methods to improve successful placement» head in sniffing position» protrude tongue» cricoid pressure» maintain slight downward pressure if meeting

resistance and patient cannot speak: tip likely is against cords and will pass when pt breathes

Endotracheal Intubation: Complications

Trauma: teeth, mouth, pharynx, nasopharynx, tracheaEsophageal intubation» Avoid by measuring

exhaled CO2 (bag for 5-10 breaths to confirm)

Endotracheal Intubation: Complications

Bronchial intubation» Confirm bilateral = BS » Confirm ET tube position

Reflex response to airway stimulation:» Tachycardia, hypertension,

increased ICP resulting in MI, Aspiration of gastric contentsHypotension: dehydration, poor LV function

22 cm

27 cm

Difficult Airway:Esophageal Tracheal Tube

Manually (blindly) inserted. Double lumen tube with 2 cuffs. One tube (arrow) opens to multiple holes between cuffs and is used to ventilate if tip is in esophagus. Other lumen opens beyond distal cuff and is used to ventilate if tip is placed in trachea.

Blanda. J Crit Illness 2000

Difficult Airway:Laryngeal Mask

Manually (blindly) inserted. Slightly inflate cuff and insert to fit over the larynx. Inflate tube and bag.

Cricothyroidotomy / Transtracheal Ventilation

Endotracheal Intubation: Summary

Preparation for intubation» Patient assessment» Equipment» Intubation

Endotracheal intubation procedure» Pre-intubation» Procedure

Difficult airway management