Overview
Definition:
Endotracheal intubation is the insertion of a specialized endotracheal tube into the trachea through the mouth or nose to secure an airway and facilitate ventilation and oxygenation
Assisting involves supporting the primary intubator, and confirmation ensures correct tube placement.
Epidemiology:
Performed in millions of surgical procedures annually worldwide
incidence varies with surgical complexity and patient comorbidities
Crucial skill for anesthesiologists and surgeons involved in airway management.
Clinical Significance:
Essential for providing controlled ventilation during general anesthesia, managing respiratory failure, protecting the airway from aspiration, and enabling certain surgical procedures
Incorrect placement or delayed confirmation can lead to severe morbidity and mortality.
Indications For Intubation
Surgical Indications:
Need for general anesthesia with controlled ventilation
Procedures requiring airway protection from blood or secretions
Head and neck surgery
Thoracic surgery
Prolonged surgical procedures.
Medical Indications:
Respiratory failure (hypoxemic or hypercarbic)
Airway obstruction (e.g., edema, trauma, foreign body)
Inability to protect airway (e.g., decreased consciousness, neurological deficits)
Need for mechanical ventilation in critical care settings.
Contraindications:
Absolute contraindications are rare
typically relate to inability to visualize vocal cords or severe facial trauma
Relative contraindications include laryngeal pathology, severe cervical spine injury, and patient refusal (if conscious and able).
Assisting The Intubator
Pre Intubation Preparation:
Ensure availability and functionality of all equipment: laryngoscope (various sizes, working light), endotracheal tubes (appropriate sizes), stylet, suction, oxygen source, ventilation bag, bite block, securing device
Confirm medication availability for induction and paralysis.
During Intubation Support:
Administer medications as directed
Apply cricoid pressure (Sellick's maneuver) if indicated to optimize visualization
Assist with positioning of the head and neck
Provide suction as needed to clear the pharynx
Manage the ventilation bag if intubation is delayed or unsuccessful.
Post Intubation Tasks:
Secure the endotracheal tube
Confirm tube placement (see confirmation section)
Connect to the breathing circuit and ventilator
Monitor vital signs and oxygenation continuously
Document procedure details.
Confirmation Of Placement
Direct Visualization:
Direct visualization of the endotracheal tube passing through the vocal cords during laryngoscopy is the gold standard for initial confirmation.
Auscultation:
Auscultate for bilateral breath sounds over the chest and absent sounds over the epigastrium
This is a crucial step but can be misleading in cases of right mainstem intubation or esophageal intubation with gas insufflation.
Capnography:
End-tidal carbon dioxide (EtCO2) detection using a colorimetric device or waveform capnography is the most reliable method for confirming tracheal intubation
Continuous waveform capnography is considered the definitive confirmation.
Other Methods:
Chest X-ray can confirm depth but is not for immediate confirmation
Condensation within the tube during exhalation
Lack of gastric distension
Symmetrical chest rise.
Potential Complications
Airway Trauma:
Tooth damage
Lip lacerations
Pharyngeal or laryngeal trauma
Vocal cord injury
Esophageal perforation (rare).
Tube Misplacement:
Esophageal intubation leading to hypoxia and gastric distension
Right mainstem bronchial intubation leading to left lung atelectasis and hypoxia
Blind nasotracheal intubation can lead to nasal or pharyngeal complications.
Post Intubation Issues:
Subglottic stenosis
Tracheal injury
Vocal cord paralysis
Cuff-related tracheal damage
Postoperative sore throat
Hoarseness
Coughing
Laryngospasm.
Key Points
Exam Focus:
Know the primary and secondary methods of confirming endotracheal tube placement
Understand the role of capnography as the gold standard
Recognize complications of intubation and how to prevent them
Be prepared for scenarios involving difficult airways.
Clinical Pearls:
Always have a backup plan and backup equipment readily available
Prepare for the worst-case scenario, especially in emergency intubations
Effective communication with your team is paramount
Never assume correct placement
always confirm with multiple methods.
Common Mistakes:
Failure to confirm tube placement adequately
Relying solely on one confirmation method
Incorrect tube size selection
Insufficient suctioning
Failure to monitor EtCO2 continuously
Aggressive attempts leading to airway trauma.