ENDOTRACHEAL TUBE

EN,

GROUP 2

GROUP MEMBERSCHESTER MAKHUWIRACHIKONDI CHALANDACHRISTINA NGULUBEDALITSO SODALAELESTINA GONDOLONIETHEL CHIKADZAGRENA MTAWALIMARIA NGULUBETIONGE SISYAVYNIDA NYIRENDA

Endotracheal tubeDefinition Endotracheal tube is a specific type of

tracheal tube that is nearly inserted through the mouth(oraltracheal) or nose(nasaltracheal).

Functions of Endotracheal Tube:

It provides a patent airway when the patient is having respiratory distress that can not be treated with simpler methods.

It is a method of choice in emergency care i.e. used for administration of drugs.e.g.atropine.

It is a mean of providing an airway for patients who can not maintain an adequate airway on their own.

Cont..The are of different sizes ranges from 2 to

10.5mm in internal diameter.The size is chosen based on the patient’s

body size with the smaller sizes being used for pediatric and neonatal patients.

indicationsComaShallow or slow respirationsCyanosisGastric lavage. Surgical patients where body positioning or

facial contours preclude the use of a mask To prevent loss of airway at a later time, i.e. a

burn patient who inhales hot gases may be intubated initially to prevent his airway from swelling shut

contraindicationsObstruction of the upper airway due to

foreign objectCervical injuries

Caution

Esophageal disease Mandibular diseaseLaryngealThermal chemical burns

ENDOTRACHEAL INTUBATION

REQUIRED EQUIPMENT:1. Endotracheal tube Size of tube is dependent on size of patient 7.5 mm is the “Universally Accepted” size for

an unknown victim Men are usually larger, therefore an 8.0 mm

tube may be appropriate Females are usually smaller, therefore a 7.0

mm tube may be appropriate

Cont…2. 10 cc Syringe – used to fill the cuff at the end

of the endotracheal tube.3. Stylet – a wire inserted into the endotracheal

tube in order to stiffen it during passage4. Water soluble lubrication – KY Jelly or

Surgilube5. Stethoscope – to check for proper placement

of the endotracheal tube6. Magill forceps – May be used to help guide an

endotracheal tube from the pharynx into the larynx

Cont..7. Laryngoscope handle8. Laryngoscope blade9.Miller blade (straight blade)10. Macintosh blade (curved blade)11. Oropharyngeal airway (bite block) – to

prevent the patient from biting down on the endotracheal tube

12. Tape – to secure the endotracheal tube in place

13. Gloves

Cont..14. Ambu-bag – to facilitate positive pressure

ventilations15. Suction Device – to clear the airway of

debris (blood, mucous, saliva)

PROCEDURAL STEPS:

Endotracheal intubation (ETI) is a rapid, simple,safe and non surgical technique that achieves all the goals of airway management, namely, maintains airway patency,protects the lungs from aspiration and permits leak free ventilation during mechanical ventilation, and remains the gold standard procedure for airway management

Cont..a. Maintain the patient’s ABC’s b. Determine that the patient requires

endotracheal intubation c. Assemble required equipmentd. Position the patient’s head – three axes,

those of the mouth, the pharynx, and the trachea must be aligned to achieve direct visualization of the vocal cords

e. Sniffing Position – the head is extended and the neck is flexed

Cont..

f. A folded towel may be placed under the patients shoulders and neck to assist with positioning

g. Suction the patient (no longer than 30 seconds) h. Oxygenate patient for 1 minute with 100%

Oxygen i. Insert the laryngoscope blade and place

endotracheal tube

Cont..j. Laryngoscope handle is held with the left

hand k. Insert the laryngoscope blade in the

patients right side of the mouth and sweep to the center of the mouth.

When a curved blade is used, the tip of the blade is advanced into the vallecula (i.e. the space between the base of the tongue and the pharyngeal surface of the of epiglottis)

Cont..When a straight blade is used, the tip of the

blade is inserted under the epiglottisl. Lift the laryngoscope blade in an upward

motion m.The handle must not be used with a prying

motion, and the upper teeth must not be used as a fulcrum

n.Visualize the vocal cords

Cont..o. Using the right hand, insert the

endotracheal tube until you see the cuff pass through the vocal cords. Advance the tube an additional ½ to 1 inch for proper placement.

p. Remove the laryngoscope carefully from the patients mouth

q. Remove the stylet from the endotracheal tube

Cont..** NOTE: The insertion of the endotracheal

tube should be no longer than 30 seconds from the time you stop ventilating the patient until the time you remove the stylet. If you are unable to place the endotracheal tube within 30 seconds, withdraw the endotracheal tube and laryngoscope, ventilate the patient (Step f.) and start again

Cont.r. Ventilate the patient with two breaths s. Check for proper placement with these

first two ventilation’s by: t. Observing the chest rise and fall with

each ventilation: Proper placement will cause both lungs to

inflate with each ventilation

Cont..Auscultating for bilateral breath sounds:Breath sounds will be completely absent if

placed within the esophagus. Remove the endotracheal tube and attempt placement after 1 minute of oxygenation and ventilation.

If the tube is placed too far down the tracheal tree, a right mainstem intubation can occur. This prevents air from going into the left lung.

Cont..To correct this problem, continue to ventilate

patient and slowly withdraw endotracheal tube ¼ - ½ inch or until bilateral breath sounds are heard.

Auscultating over epigastrium for gastric sounds: Placement of the endotracheal tube into the

stomach / esophagus will produce gurgling sounds in the epigastric area. Remove the endotracheal tube and attempt placement after 1 minute of oxygenation and ventilation.

Cont..u. Inflate the endotracheal tube’s cuff with

10 cc’s of air: v. Inflation of the balloon serves two

purposes: Holds tube in place Acts as a barrier and prevents fluids from

entering the lungs w. Ventilate the patient with two breaths x. Insert oropharyngeal airway

Cont..aa.Ventilate the patient with two breaths bb.Tape endotracheal tube securely in place cc.Continue to ventilate patient (1 breath

every 5 seconds) and suction as necessary

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Immediate care of intubationA. Check symmetry of chest expansion : auscultate breath sounds of anterior and

lateral chest bilaterally. Obtain order for chest x-ray to verify

proper tube placement. Check cuff pressure every 8-12 hours. Monitor for signs and symptoms of

spiration

Cont…B. Ensure high humidity ; a visible mist

should appear in the T.piece or ventilator tube.

C. Administer oxygen prescribed by the doctors.

D. Secure the tube to the patient’s face with tape, and mark the proximal end for position maintance

Cut proximal end of tube if it islonger that 7.5cm(3 inches) to prevent kinking.

Cont..• Insert an oral airway or mouth device to

prevent the patient from biting and obstructing the tube.

E.Use sterile suction technique and airway to prevent iatrogenic contamination and infection .

F.Continue to reposition patient every 2 hours and as needed to prevent atelectasis and to optimize lung expansion.

Cont..G. Provide oral hygiene and suction the

oropharynx whenever necessary.H. Explain to the patient and family the

purpose of the tubeI. Distract the patient through one to one

interaction with the nurse and family.J. Close monitoring of the patient is

essential to ensure safety and prevent harm.

Extubation1. Determine that endotracheal intubation is no

longer required 2. Patient begins spontaneous respiration’s3. Explain procedure to patient to gain

cooperation4. Have a self inflating bag and mask ready in

case ventilator assistance is required immediately after extubation.

5. Suction the endotracheal tree and oropharynx,remove tape and then deflate the cuff.

Cont.4. Withdraw the endotracheal tube with one smooth

motion 5. Monitor the patient for signs / symptoms of

respiratory distress or difficulty 6. Give 100% oxygen for a few breaths, then insert a

new, sterile suction catheter inside tube.7. Have the patient inhale at peak inspiration, remove

the tube, suctioning the airway through the tube as it is pulled out.

Care of patient following extubation• Give heated humidity and oxygen by face

mask and maintain the in a sitting or high fowler’s position.

• Monitor respiratory rate and quality of chest excursions, note stridor ,color change and change in mental alertness or behavior.

• Monitor the patient’s oxygen level using a pulse oximeter.

• Keep NPO or give only ice chips for next few hours.

Cont.Provide mouth care.Teach patient how to perfom coughing and

deep breting exercises.

ADVANTAGES OF ENDOTRACHEAL INTUBATION

Provides an unobstructed airway when properly placed

Prevents aspiration of secretions (blood, mucous, stomach / bowel contents) into the lungs

Can be easily maintained for a lengthy period of time

Decreases anatomic dead space by approximately 50%

Cont..Facilitates positive pressure breathing

without gastric inflation Facilitates body positioning and movement

of the patient May be utilized to pass medications

Atropine Epinephrine Lidocaine

DISADVANTAGES OF ENDOTRACHEAL INTUBATION:

Need advanced training to properly perform procedure

By passes the nares function of warming and filtering the air

Increased incidence of trauma due to neck manipulation when spinal cord injury is suspected

May increase respiratory resistance Improper placement

complications1. Due to high cuff pressure: Tracheal bleeding Ischemia Pressure2. Due to low cuff pressure: Aspiration pneumonia Trauma Missed intubation Failed intubation

HaemorrhageAirway obtructionDisconnection and dislocationSwallowed ETT

Prevention of complications 1. Administer adequate humidity2. Maintain cuff pressure at appropriate

level.3. Auscultate lung sound4. Monitor for signs and symptoms of

infection including temperature and WBC5. Administer prescribed oxygen and

monitor oxygen saturation.6. Monitor for cynanosis

Cont..7. Maintain adequate hydration of the

patient.8. Use sterile technique when suctioning

Reference

Brunner and Suddaths a text book for medical surgical nursing 2009

Indian journal for Anesthesia, 2005