ENDOTRACHEAL TUBE INTUBATION

DEFINITION :
Endotracheal tube (ETT) is a tube that is inserted into the trachea.

 Introduction
These guidelines are the synthesis of available evidence at the time of writing.
Endotracheal intubation is a commonly performed procedure in the ICU. It is potentially
dangerous, even life-threatening, and therefore must not be undertaken lightly.

 Choice of Route
The oral translaryngeal route is usually the route of choice because of familiarity, speed, and
ease of technique

 Choice of Endotracheal Tube (ETT)

Generally, polyvinylchloride ETTs are chosen which are inert, smooth and provide best
resistance to the development of biofilm and tube obstruction.
Occasionally, reinforced silicone ETTs are chosen for greater resistance to ETT compression
and obstruction, and for greater ease of insertion with the fibreoptic bronchoscope. However,
these silicone ETTs are harder to source, more difficult to insert, and are prone to greater
incidence of sputum adherence and subsequent ETT obstruction. Thus, silicone ETTs are not
the first choice of ETT in the ICU.
 As a general guide (numbers reflect the internal diameter):
o Adult females: 7.5mm, cuffed
o Adult males: 8mm, cuffed
o Children at or above the age of puberty: as per adults
o Children below the age of puberty: Size according to (Age/4) + 4mm, uncuffed )
 Preparation : Remember, every intubation in the ICU is potentially a difficult airway. This
relates to the critically ill nature of the patient and the relative infrequency of intubation in
the ICU (compared to the Operating Theatre).
• Identify need for definitive airway
• Assess the airway. Is there likely to be a difficult airway with potential problems in
successfully and safely securing the airway (see Appendix A)? If so, seek help early from
the ICU consultant and Anaesthetist.
• Provide ventilatory assistance to patient as needed whilst preparations are being made for
Intubation

INDICATION :
Acute respiratory failure, central nervous system (CNS) depression, neuromuscular disease,
pulmonary disease, or chest wall injury.
• Upper airway obstruction (tumor, inflammation, foreign body, or laryngeal spasm).
• Anticipated upper airway obstruction from edema or soft tissue swelling due to head and
neck
trauma, some postoperative head and neck procedures involving the airway, facial or airway
burns, and decreased level of consciousness (LOC).
• Need for airway protection (vomiting, bleeding, or altered mental status).
• Aspiration prophylaxis.
• Fracture of the cervical vertebrae with spinal cord injury; requiring ventilatory assistance

EQUIPMENT

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 • Gloves (Non sterile)
• Goggles
• Ask MO's choice / size of the following:
a) Adult and paediatric endotracheal tubes (2.5 to 9.0mm)
b) Adult and paediatric laryngoscopes
c) Inserting stylets, bougies and exchange catheters
d) Airway aids (oropharyngeal or guedel, nasopharyngeal)
e) Adult and paediatric Magill forceps
f) Adult and paediatric laryngeal masks (LMAs, sizes 2 to 5)
• Self inflating resuscitation bag (Ambu, Laerdal or similar) with mechanism to provide
supplemental oxygen
• PEEP valve for the resuscitation bag if necessary
• Masks (sealing face mask)
• Suction device with Yankeur
Skilled assistant (preferably two)
• 10 ml syringe to inflate the cuff (50 ml for laryngeal mask).
• Lubricant
• Tape of other device for securing the ETT
• Adhesive brown tape
• Convatec wipes.
• Small artery forceps / scissors
• Gauze, mouth tray
• Sputum trap
• Lanolin
• Y Suction catheters
• CO2 detector device ( eg “easycap, End Tidal CO2 monitoring)
• Stethoscope
• Emergency trolley at the bedside
• Difficult Airway trolley at the bedside.
• Ensure that the bronchoscope is on the ICU.
• Drugs to facilitate intubation (not all will be used):
o Propofol 20ml syringe of 10mg/ml
o Midazolam 5 ml syringe of 1 mg/ml
o Fentanyl 2 ml syringe of 50 mcg/ml
o Suxamethonium 2 ml syringe of 50 mg/ml
o Rocuronium 5 ml syringe of 10 mg/ml
o Metaraminol 20ml of 0.5mg/ml
• IV access with IV fluid eg Normal Saline or Hartmann’s solution through a “pump set”.
• Monitoring facilities for HR, BP and O2 saturation.
• Ventilator (ventilator tubing, pall filter and flex tube, closed suction catheter).
• Nasogastric tube of appropriate size.

ADVERSE EFFECTS
• Hypoxia
• Oesophageal or right main stem bronchus intubation
• Aspiration
• Vagal stimulation with severe bradycardia and hypotension
• Laryngospasm
• Vocal cord damage
• Trauma to oropharyngeal structures (teeth, etc.)

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 STEPS OF PROCEDURE

Action Steps
Inform patient of procedure and / or To alleviate anxiety.
significant others.
Pre-oxygenate the spontaneously To reduce the risk of hypoxia.
breathing patient with high flow oxygen via
a non-rebreathing mask
Gather all intubation equipment. To facilitate procedure.
Wash hands. To reduce the spread of infection.
Don gloves & goggles. To protect yourself / OH&S.
Attach resuscitation bag to oxygen and To check that it is in working order.
test.
Attach suction tubing and Yankeur sucker To remove excess secretions and reduce
to high volume suction - (ensuring that it is the risk of aspiration.
working correctly). To allow the cords to be more visible
Note: Do not set suction pressure above without the excess fluid and sections
120mmHg. To prevent airway trauma.
Set up the ventilator.
The ventilator should be checked prior to To ensure that the ventilator is operating
use. correctly.
When test is completed the Pall filter will Reduce the spread of infection.
be placed after the Y connector to protect
the patient from infections, and the closed
suction device attached to the flexi tubing.
Attach laryngoscope blade to laryngoscope Check performance and test light.
handle. Check bulb light and blade
engages properly.
Check cuff on ETT while maintaining Use a 10 ml syringe to check seal.
sterility of tube.
Apply lubricant to the tip of ETT while To protect mucosa and facilitate insertion
maintaining sterility of tube in the of tube
packaging.
Position the bed to be flat and at an OH&S
appropriate height for you to perform the
intubation
Position patient supine. Do not remove OH&S
pillow from under the head.
Position the bed to be flat and at an • To prevent any OH & S problems and
appropriate height for the procedure: further damage in spinal patient .
o Trauma patient: neutral position with inline neck
stabilisation;
o Non trauma patient: “Sniffing the morning air”
position.
The M.O. will pre-oxygenate the patient To ensure optimal O2 delivery
with 100% O2 via the mask and airviva
before intubation.

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Insert intubating stylet into ETT with the To give the operator more control of the
stylet tip recessed within the distal end of ETT.
the ETT and bend the ETT/stylet into a
“Lazy J”
Attempt assisted ventilation with self-
inflating bag and mask with high flow To pre-oxygenate and prevent hypoxia.
oxygen, if able continue preoxygenation
with sealing facemask for 3 minutes.
MO may require nursing staff to apply To prevent aspiration.
cricoid pressure before paralysing patient.
Monitor the patient throughout the To prevent complications.
procedure.
Consider IV anaesthetic for hypnosis To induce skeletal muscle relax
Low dose Propofol 5ml (50mg), or
Midazolam 2-5 ml (2-5mg) and Fentanyl
2ml (100mcg)
Consider IV muscle relaxation
Suxamethonium 2ml (100mg) EXCEPT in
patients with hyperkalemia ) or risk of, such
as end stage renal failure), burns and
neurological injury between 3 days and 6
months after initial injury, or
Recuronium 4-5ml (40-50mg)

PROCEDURE DURING INTUBATION

Action Rationale
Ventilate until the patient is asleep and To facilitate procedure
muscle relaxed (if used , fasciculations
subsided after Suxamethonium, 2-3
minutes after Rocuronium) .
Pass laryngoscope into the oropharynx. To facilitate view of the glottic opening
Exert traction along the axis of the
laryngoscope handle until the glottic
opening is exposed. Do not use the upper
teeth as a fulcrum.
Insert ETT/Stylet into the glottic opening. Note the CM marking of the ETT at the
Pass the ETT until all of the cuff is gums or teeth.
approximately 1 cm below the cords.
Hold the ETT firmly at the lips. To prevent dislodgement
Assistant to remove the intubating stylet. To facilitate hand ventilation
Inflate the cuff with 10 ml of air. To create a seal and prevent an air leak.
Ventilate the patient with the resuscitation -To prevent hypoxia and ascertain the
bag using the end tidal CO2 detector if presence of CO2.
available.

Suction patient's mouth. -To remove secretions/ prevent aspiration

and decrease risk of infection.
Monitor cardiac status. -Assess haemodynamic effects of drugs

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 and initial mechanical ventilation.
Increased intrathoracic pressure decreases
venous return and decreases C.O.
Maintain cricoid pressure until instructed To decrease the chance of vomiting and
not to do so any longer. (Usually after the facilitate the view.
cuff is inflated and position verified with
auscultation).
Confirm the ETT position To assess accurate placement and air
-Watch for chest expansion and fall entry.
-Look for the condensation within the ETT Unilateral chest rise indicates that the ETT
-CO2 detector to change appropriately was misplaced.
-Auscultate the lung fields If abdomen rises = failed intubation.

IF ETT POSITION IS CONFIRMED

• Assistant may cease providing cricoid pressure
• Reassess the ETT position at the lips and secure ETT in place with tape or ties (rough
guide for position at lips: male 23 cm, female 22 cm, child Age/2+12cm)
• Reassess adequacy of ventilation with chest expansion and auscultation
• Order and review CXR

IF ETT POSITI ION IS NOT CONFIRMED

• Consider repeat attempts x 2, if successful confirm (above)

IF NOT SUCCESSFUL AFTER TWO ATTEMPTS:

Continue bag/mask ventilation with self-inflating bag
Urgent call for help to ICU consultant, anaesthetic registrar, surgical registrar

PROCEDURE POST INTUBATION

Action Rationale
Re-check ventilation settings with RMO Medico legal documentation
and connect to ventilator.
Check continuously and record the To maintain accurate documentation of
following observations on the flow chart the patients ongoing care and condition
hourly:
1. Haemodynamic status.
2. Oxygen saturation.
3. Chest auscultation - air entry/breath
sounds.
4. Ventilation parameters - RR, TV, MV,
AP, PEEP etc.
5. Ventilator alarms.
6. Physical assessment.
Secure tube with white tape as per To prevent movement of the ETT and
protocol. tracheal damage.
Change ETT tapes once per shift and To reduce Ventilator Associated pneumonia
PRN. (AP)
Nasogastric tube will need to be inserted To reduce the risk of aspiration and
as per OWP policy. facilitate the decompression of the
This may be attended prior to chest X-ray. stomach while the patient is ventilated.

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Attend Chest X-ray. The tube should be positioned 3-4 cm
above the carina but inferior to the vocal
chords . Flexion and extension of the head
may move the tube from the correct
position.

Check cuff pressure and record 4/24 on To minimise damage to tracheal tissue.
flow chart. This will provide adequate seal to permit
safe mechanical ventilation.
The cuff should be inflated just beyond the Regular addition of air to cuff to maintain
point where an audible air leak occurs an acceptable cuff pressure may indicate
aiming for the lowest possible cuff the cuff or pilot tube may have a hole in it,
pressure. or the pilot tube valve is broken or cracked
2/24 suction. This may be performed less Maintain ET tube patency and remove
frequently in long term patients. secretions.

Record on the flow chart the point at which To assess any displacement of the ETT in
the tube meets the lips or nostrils. Place the future.
brown tape around ETT for future
reference.
Record size of ETT used, name of ventilator, date
and time of intubation.

2/24 Mouth care and eye care as per unit To maintain patient hygiene and comfort.
policies. Eye and mouth tray to be changed
each night.

Change NGT tapes daily and PRN. Clean Maintains nasal hygiene and prevents
nares with swab sticks. Check for pressure pressure areas on the nose.
areas and rotate tube around nares. Wipe
with convatec before applying nasofix tape.

Laryngeal or tracheal injury:

o Sore throat, hoarse voice.
o Glottis edema
o Trauma (damage to teeth or mucous membranes, perforation or laceration of pharynx, larynx,
or trachea).
o Aspiration.
o Laryngospasm, bronchospasm.
o Ulceration or necrosis of tracheal mucosa.
o Vocal cord ulceration, granuloma, or polyps.
o Vocal cord paralysis.
o Postextubation tracheal stenosis.
o Tracheal dilation.
o Formation of tracheal-esophageal fistula.
o Formation of tracheal-arterial fistula.
o Innominate artery erosion.
• Pulmonary infection and sepsis.

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• Dependence on artificial airway.

BIBLIOGRAPHY:

1. Basavanthappa BT, Medical Surgical Nursin1 st edi.2005. New Delhi;

Jaypee Brother Pp. 340-345.

2. Black J.M. Medical Surgical Nursing. 5th edition, W. B. Saunders;

Company, Philadelphia, 1999.Pp. 450-460.

3. Brunner’s and Siddhartha’s. Textbook of Medical Surgical Nursing. 10th;

Edition, Lippincott- Raven Publishers, India : 1996. P.g.346-362.

4. Luckmann and Sorenson’s. Medical Surgical Nursing. 4th edition, W. B;

Saunders Company, Philadelphia: 1993. Pp.545-560.

5. Philips S. and Philips W.J. Medical Surgical Nursing. 7th edition, B.I;

Publication (P) Ltd, Delhi: 1995. Pp. 345 – 359.

WEBSITE:

- www.google.com/endotrachealintubation
- www.wikipediya.com/endotrachealintubation