airway in ot

8/2/2019 Airway in OT

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ENDOTRACHEAL

INTUBATION IN THE

OPERATION THEATRE

DR. RAJESH T EAPEN

SPECIALIST - ANESTHESIA

ATLAS HOSPITAL

RUWI


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Indications forendotracheal intubation

1. Provides relative protection againstpulmonary aspiration.

2. Maintains a patent conduit for respiratorygas exchange.

3. Provides a means for coupling the lungs tomechanical ventilators.

4. Establishes a route for clearance ofsecretions.

5. Provides a route for drug administration.


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Detailed physical examination ofthe airway

The range of motion of the cervical spine: the subject should beable to tilt the head back and then forward so that the chintouches the chest.

The range of motion of the jaw (the temporomandibular joint):

three of the subject's fingers should be able to fit between theupper and lower incisors.

The size and shape of the upper jaw and lower jaw, lookingespecially for problems such as maxillary hypoplasia (anunderdeveloped upper jaw), micrognathia (an abnormally small

jaw), or retrognathia (misalignment of the upper and lower jaw).

The thyromental distance: three of the subject's fingers shouldbe able to fit between the Adam's apple and the chin.

The size and shape of the tongue and palate relative to the sizeof the mouth.

The teeth, especially noting the presence of prominentmaxillary incisors, any loose or damaged teeth, or crowns.


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Classification systems to predictdifficulty of tracheal intubation

Cormack-Lehane grading system

Intubation Difficulty Scale (IDS)

Mallampati score

The Mallampati score most commonly used - is drawn fromthe observation that the size of the base of the tongueinfluences the difficulty of intubation.

Determined by looking at the anatomy of the mouth, and in

particular the visibility of the base of palatine uvula, faucialpillars and the soft palate.

Such medical scoring systems may aid in the evaluation ofpatients but no single score or combination of scores can betrusted to detect all patients who are difficult to intubate.


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Equipment- in Intubation Trolley

Drugs

Difficult intubation

equipment - nearbyMonitors:

Pulse Oximeter

Capnograph

Laryngoscope - 2

Tubes

Anesthetic Machine:

Breathing circuitOxygen source

Bag & Mask

Working Suction

Lubricant / LA sprayForceps (Magill)

Adhesive tape

Stylet / Gum elastic bougie


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Monitors

Electrocardiograph

Pulse Oximeter Capnograph

Shygmomanometer


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Mnemonic for rememberingthe necessary equipment

SOAPME:

S = suction

O= oxygen

A = airway equipment (tracheal tube, oralairway, laryngoscope

P = positioning and pre- oxygenation

M= monitors (cardiac monitor and pulseoximetry)

E = esophageal detection device (end-tidal carbon dioxide [CO2] detector)


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Laryngoscope Blades


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Cuffed Tracheal Tube

Most endotracheal tubes today are constructed of polyvinyl chloride Specialty tubes are constructed of silicone rubber, latex rubber, or

stainless steel. ET Tubes have an inflatable cuff to seal the trachea and bronchial

tree against air leakage and aspiration of gastric contents, blood,secretions, and other fluids.

Cuff inflationtube with pilotballoon

Cuff


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Uncuffed Tracheal Tube

Use is limited mostly to pediatric patients (in small children, thecricoid cartilage, the narrowest portion of the pediatric airway,often provides an adequate seal for mechanical ventilation).


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Intubation


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ETT sizes

Male: No. 8 + 0.5

Female: No. 7 + 0.5

Children: No = + 4 (or 3, for cuffed)Age4


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ETT : sizes (Pediatrics)


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ETT Depth of insertion

Depth(cm) = + 12(children)

Male: 21-24 cm

Female: 20-22 cm

Age

2


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ETT : Depth of insertion


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Sniffing position


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Sniffing Position


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Incorrect position


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Mask ventilation and intubation


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Sellicks maneuver


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Intubation


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Laryngoscope handling

The main lifting force of the laryngoscope is parallel to thehandle. Under no circumstances should the handle of thelaryngoscope be levered backwards.

The handle is gripped down at the base.


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Difficult airway


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But for this we need a capnograph!


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Oral Airway


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Oral Airways


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Rusch Color Coded GuedelAirways


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Nasopharyngeal Airway


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Nasopharyngeal Airway

Flared end


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Rusch Latex-Free NasopharyngealAirway


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Mask and airway tools


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Laryngeal Mask Airway


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LMA-Fastrach


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LMA- Fastrach


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LMA-Fastrach


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Characteristics of the LMA

Sizes Weight (Kg) Cuff Vol.(ml)

#1


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Disadvantages of LMA over theETT

Lower seal pressure

Higher frequency of gastric

insufflation

Increased Aspiration risk


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LMA Complications

Aspiration

Coughing

Sore Throat


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Fiber optic scope intubation

Laryngoscopy may be contraindicated in a patientwho requires intubation and mechanicalventilation.

Often the case in trauma patients who may have

an unstable cervical spine or in patients with poorrange of motion of the temporo-mandibularjoint.

In such patients, flexible fiber optic bronchoscopyallows for indirect visualization of the larynx.

The endoscope is introduced through the mouthor nose.

Once anatomic structures are recognized, andthe larynx or trachea are entered under direct

visualization.


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Fiber optic scope intubation

OTHER WAYS TO INTUBATE


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OTHER WAYS TO INTUBATE- Nasotracheal Intubation

ETT is advanced through the nose intothe oropharynx before laryngoscopy.

Via laryngoscopy, the tube is thenadvanced in between the abductedvocal cords.


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Bougie

- A straight, semi-rigid stylette-likedevice with a bent tip that can beused when intubation is (or ispredicted to be) difficult often helpful when the tracheal

opening is anterior to the visual field.- During laryngoscopy, the bougie is

carefully advanced into the larynxand through the cords until the tipenters a main stem bronchus.

- While maintaining thelaryngoscope and Bougie inposition, an assistant threads anETT over the end of the bougie,into the larynx. Once the ETT is inplace, the bougie is removed.


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Light Wand

When inserted into anendotracheal tube, useful forblind intubations of thetrachea (when the laryngeal

opening cannot be visualized) End of the ET tube is at the

entrance of the trachea whenlight is well trans-illuminated

through the neck The tube can then be

threaded off the light wandand into the trachea in a blindfashion


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Drugs

A- Neuromuscular blocking drugs (NMBDs):

1- Depolarizing NMBDs-

Succinylcholine (1

1.5 mg/Kg IV)2- Non Depolarizing NMBDs-

Vecuronium (0.25 mg/Kg IV)

Cis-atracurium (0.2 mg/Kg IV)


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Drugs

B- Sedative-hypnotics:

Sodium Thiopental

PropofolC- Benzodiazepines:

Midazolam (0.5 1 mg IV)

Diazepam (2 mg IV)D- Opioids:

Morphine, Fentanyl, Remifentanil


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Drugs

E- Beta-adrenergic blocking drugs:

Esmolol (10 20 mg IV)

F- Local anesthetics agents:Lidocaine ( 1 1.5 mg/Kg IV or

aerosol anesthetic sprays)

G- Nerve blocksH- Reversal agent- Neostigmine 0.05mg/kg

+Glycopyrrolate 0.004mg/kg


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Drugs

Induction agent- Thiopentone, Propofol,Ketamine, Midazolam

Muscle Relaxant Suxamethonium

Consider Rocuronium if Suxcontraindicated

Burns > 3 days

Chronic Spinal injuriesChronic Neuromuscular diseaseHyperkalemia

states (Se. K+ > 5.5)


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Thanks

For YourAttention

airway in ot

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