Endotracheal Intubation

What is endotracheal intubation?

Endotracheal intubation is a procedure by which a tube is inserted through the mouth down into the trachea (the large airway from the mouth to the lungs). Before surgery, this is often done under deep sedation. In emergency situations, the patient is often unconscious at the time of this procedure.

What kind of tube is used?

The tube that is used today is usually a flexible plastic tube. It is called an endotracheal tube because it is slipped within the trachea

What is the purpose of endotracheal intubation?
Specifically, endotracheal intubation is used for the following conditions:

• 
  respiratory arrest
  


• respiratory failure
  


• airway obstruction
  


• need for prolonged ventilatory support
  


• Class III or IV hemorrhage with poor perfusion
  


• severe flail chest or pulmonary contusion
  


• multiple trauma, head injury and abnormal mental status
  


• inhalation injury with erythema/edema of the vocal cords
  


• protection from aspiration

TECHNIQUE OF ENDOTRACHEAL INTUBATION

• Position of the patient: Supine


• Pillow under head


• Flexion of the neck.


• Extension of the atlanto-occipital joint. (This is the position sometimes called "sniffing the morning air")


• Open the mouth by separating the lips and pulling on the upper jaw with the index finger.


• Hold the laryngoscope in the left hand. Insert the laryngoscope into the mouth with the blade directed to the right tonsil. Once the right tonsil is reached, sweep the blade to the midline keeping the tongue on the left.


• This brings the epiglottis into view. DO NOT LOSE SIGHT OF IT.


• Advance the laryngoscope blade till it reaches the angle between the base of the tongue and the epiglottis.


• Lift the laryngoscope upwards and away from the nose - towards the chest. This manoeuvre should bring the vocal cords into view, but it may be necessary for an assistant to press on the trachea to improve the direct view of the larynx.


• Take the endotracheal tube in the right hand. Keep the concavity of the tube facing the right side of the mouth. This causes least interruption to the view of the vocal cords. Watch the tube entering the larynx and insert it through the cords only till the cuff is just below the cords.


• Inflate the cuff to provide a minimal leak when the bag is squeezed.


• Listen for air entry at both apices and both axillae to ensure correct placement, using a stethoscope.

Precautions:

• Wear protective clothing: gloves; gowns; goggles.
• Disposal of apparatus:
  (Face masks, Guedel airways, contaminated laryngoscopes, suction nozzles should be put into a "dirty dish" and removed from the theatre promptly for cleaning. Used endotracheal tubes should be discarded into a container for contaminated waste)

What are the complications of endotracheal intubation?

If the tube is inadvertently placed in the esophagus (right behind the trachea), adequate respirations will not occur. Brain damage, cardiac arrest, and death can occur. Aspiration of stomach contents can result in pneumonia and ARDS. Placement of the tube too deep can result in only one lung being ventilated and can result in a pneumothorax as well as inadequate ventilation. During endotracheal tube placement, damage can also occur to the teeth, the soft tissues in the back of the throat, as well as the vocal cords.
It is no wonder that this procedure should be performed by a physician with experience in intubation. In the vast majority of cases of intubation, no significant complications occur.